Elderly Hip Fracture With Severe Aortic Stenosis
An 84-year-old woman (62 kg, 158 cm) is admitted with a displaced femoral neck fracture after a mechanical fall 38 hours ago. She has severe aortic stenosis (valve area 0.7 cm², mean gradient 44 mmHg, peak velocity 4.3 m/s), preserved LVEF of 55%, hypertension, and CKD stage 3 (eGFR 36). She reports exertional dyspnea and one episode of syncope 5 months ago, but no chest pain, orthopnea, or resting dyspnea. Medications: aspirin 81 mg, amlodipine, atorvastatin. BP 148/72 mmHg, HR 68 in sinus rhythm, SpO2 96% on room air. NT-proBNP is 2,150 pg/mL. A fascia iliaca catheter provides partial analgesia (NRS 5/10). The orthopedic team wants to operate tomorrow morning; the cardiology fellow suggests waiting for an outpatient echo and stress test.
1. Should surgery proceed tomorrow or be delayed for further cardiac evaluation? Justify your recommendation with the specific risks you are weighing.
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Proceed tomorrow and complete the workup in parallel rather than delaying for the cardiology plan.
Risks of delay: In elderly hip fracture patients, waiting beyond 48 hours is associated with higher 30-day mortality, delirium, pressure injury, VTE, pneumonia, and deconditioning. This patient is already at 38 hours. An outpatient echo and stress test would not return in time to change management, and no stress test is safe or useful while she is bed-bound with a fracture. Aortic valve replacement (surgical or TAVR) requires a stability and recovery period incompatible with an unrepaired femoral neck fracture.
Risks of proceeding: Severe AS carries perioperative risk of hypotension, myocardial ischemia, and heart failure. However, she has no decompensated features (no resting dyspnea, no orthopnea, no ischemia symptoms). The syncope was months ago and is consistent with her known AS. The elevated NT-proBNP is partly explained by acute fracture and CKD.
Decision drivers: What would change my mind is active pulmonary edema, hemodynamic instability, or new ischemia at rest. None is present. The safest course is early surgery with an anesthetic plan built around her fixed-stroke-volume physiology, plus continued aspirin, avoidance of nephrotoxins, and a monitored bed postoperatively.
2. Describe your anesthetic plan, including technique, monitoring, and hemodynamic targets.
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Preop: Continue aspirin, correct hypovolemia (slow crystalloid; avoid large boluses that cause pulmonary edema), place an arterial line before induction, have phenylephrine and vasopressin immediately available, and type and screen.
Technique: Either a titrated low-dose spinal or a carefully controlled general anesthetic is acceptable; the physiology matters more than the label. I would favor a low-dose spinal (hyperbaric bupivacaine about 7.5–9 mg) combined with a fascia iliaca block, dosed incrementally, with a phenylephrine infusion started before the block. This avoids the sympathetic surge of laryngoscopy and permits continuous neurologic assessment. If she is uncooperative or the block is inadequate, general anesthesia with an endotracheal tube and the same hemodynamic targets is reasonable.
Hemodynamic targets: Severe AS means stroke volume is fixed. Maintain sinus rhythm, HR 60–80, adequate preload, and, critically, afterload. Avoid vasodilators such as nicardipine or nitroprusside; avoid tachycardia from ephedrine or light anesthesia. Treat hypotension with phenylephrine first, escalate to vasopressin, and if cardiac output is low, add inotropy. Avoid aortocaval compression and sudden position changes.
Postop: Step-down or ICU with continuous ECG and arterial monitoring for 24 hours, serial troponins, and early mobilization.
3. What postoperative disposition and monitoring would you arrange, and what findings would trigger escalation?
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Disposition: A monitored step-down or ICU bed for at least 24 hours. Severe AS plus major orthopedic surgery plus CKD justifies continuous ECG, arterial pressure monitoring (or frequent cuff), hourly urine output, and daily electrolytes and creatinine.
Escalation triggers:
- Hypotension (MAP below 65 mmHg or systolic below 90 mmHg) unresponsive to a fluid challenge
- New atrial fibrillation or any tachyarrhythmia; loss of atrial kick is poorly tolerated
- Chest pain, new ST changes, or a rising troponin
- Pulmonary edema, falling SpO2, or orthopnea from over-resuscitation
- Oliguria or a creatinine rise of more than 0.3 mg/dL
- Delirium or new confusion
Other measures: Continue aspirin, avoid NSAIDs because of CKD, use acetaminophen and the fascia iliaca catheter (check its site daily), give VTE prophylaxis per orthopedic protocol, and mobilize early with physical therapy. Aortic stenosis does not contraindicate the surgery; it mandates disciplined hemodynamics and a monitored setting.