Hip fracture on apixaban: block choice and LAST76-year-old woman, 64 kg, with a displaced right hip fracture after a fall; theatre is booked for tomorrow morning

The patient

The examiner asks

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1. Consider

   What are your considerations?

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   • A 76-year-old, 64 kg, with a hip fracture, on full-dose apixaban for AF, needing early fixation. Patient
   • Already forgetful at 76: I record her baseline cognition now, as delirium risk climbs after 60.
   • Fixing her hip within 48 hours lowers her inpatient mortality and pressure sores. Surgery
   • Her age puts her among those at higher risk of local anaesthetic toxicity. Patient

2. Prepare

   Is her heart a reason to delay surgery?

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   • Urgency: her fixation should happen within 48 hours, so assessment mustn't delay it. Stem trigger
   • Active cardiac conditions? None: her AF is rate-controlled at 88, with no failure, ischaemia or severe valve disease. Disease
   • RCRI 0: hip surgery isn't high-risk, and she has no coronary disease, failure, stroke, insulin or creatinine over 2.
   • Functional capacity: a broken hip stops her walking; any disability counts as under 4 METs.
   • Decision: RCRI 0 is low risk, so no stress testing; I proceed.

3. Prepare

   Can she have a spinal tomorrow morning?

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   • Full-dose apixaban needs at least 72 hours off before a spinal or a deep block. Disease
   • Her last dose was this morning, so tomorrow is only about 24 hours: too soon.
   • Her clearance of 38 mL/min makes timing alone less reliable, so I'd rather measure a level.
   • Earlier only if a drug level shows apixaban below 30 ng/mL; an anti-Xa no higher than 0.1 IU/mL also works.
   • Without that level, no spinal: she has general anaesthesia rather than a delayed operation. Surgery

4. Plan

   How do you manage her pain and her anaesthetic?

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   • Fascia iliaca block in the emergency department now, for her pain before surgery. Surgery
   • It's a superficial block, so apixaban doesn't delay it; deep blocks follow spinal timing. Disease
   • Ropivacaine well under 3 mg/kg; her age justifies a cautious dose. Patient
   • Nerve blocks may also reduce her delirium, so it helps twice.
   • GA with less propofol: in older adults, more than 1.5 mg/kg causes severe hypotension.

5. Crisis

   Fifteen minutes after the fascia iliaca block she becomes confused, then has a broad-complex tachycardia at 150 with BP 70/35. What do you do?

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   • LAST algorithm: confusion then a broad-complex arrhythmia after her large-volume block. (Crisis)
   • Help called, LAST kit fetched, and the bypass team warned early.
   • 100% oxygen and airway support; hypoxia and acidosis make the toxicity worse.
   • Lipid 20% now: under 70 kg, 1.5 mL/kg over 2–3 minutes, then 0.25 mL/kg/min.
   • Arrhythmia: amiodarone if needed; never lidocaine, beta-blockers, calcium blockers or vasopressin.
   • If pulseless, CPR with adrenaline under 1 mcg/kg; still unstable, repeat the bolus, double the infusion.
   • Resuscitation may be long; cardiopulmonary bypass if lipid and CPR fail.