Beyond Pain Control: Perioperative Optimization Through Multimodal Anesthesia and Analgesia in a Geriatric Patient With Hip Fracture Following Acute Ischemic Stroke: A Case Report.

Abstract

Introduction

Hip fracture in geriatric patients is associated with severe pain, functional decline, postoperative delirium, and increased morbidity and mortality. A history of stroke further increases neurological vulnerability and may hinder functional recovery. Multimodal regional anesthesia has emerged as a strategy to optimize perioperative analgesia, reduce opioid exposure, and facilitate early recovery.

Objective

To describe the use of a multimodal anesthetic and analgesic strategy consisting of a pericapsular nerve group (PENG) block, lateral femoral cutaneous nerve block, spinal anesthesia, and systemic multimodal analgesia to provide effective pain control and promote functional recovery in a geriatric patient with hip fracture and a history of stroke.

Case Presentation

A female patient presented with an acute ischemic stroke characterized by altered level of consciousness and sudden-onset left-sided faciocorporeal hemiparesis. As a consequence of the neurological deficit, she experienced a fall resulting in severe pain and deformity of the left hip. Subsequent medical evaluation confirmed a hip fracture. Her medical history was significant for hypertension, type 2 diabetes mellitus, and chronic kidney disease.

During the preanesthetic assessment, the patient reported severe pain with a Visual Analog Scale (VAS) score of 8/10 and was considered at high risk for functional deterioration due to immobility and preexisting neurological vulnerability. Spinal anesthesia was selected as the primary anesthetic technique. Perioperative analgesia was achieved using ultrasound-guided PENG and lateral femoral cutaneous nerve blocks, complemented by systemic multimodal analgesia.

The procedure was completed without anesthetic or surgical complications. Hemodynamic stability was maintained throughout surgery, and no significant systemic opioid requirements were observed. No new neurological deficits were identified in the immediate postoperative period. At 24 hours postoperatively, the patient reported a VAS pain score of 0/10, demonstrated good tolerance to treatment, and actively participated in early rehabilitation activities. No manifestations suggestive of postoperative delirium or thromboembolic events were documented during hospitalization.

Discussion

Perioperative optimization in geriatric patients with hip fracture should focus not only on anesthetic safety but also on preserving cognitive function and promoting functional recovery. In this case, the combination of PENG block, lateral femoral cutaneous nerve block, and spinal anesthesia provided effective analgesia, as evidenced by the reduction in pain intensity from a VAS score of 8/10 to 0/10. Adequate pain control and minimal opioid exposure may have contributed to reducing risk factors associated with postoperative delirium, while the absence of pain facilitated early mobilization and rehabilitation.

Conclusions

The combination of spinal anesthesia and multimodal regional analgesia may represent an effective perioperative optimization strategy for geriatric patients with hip fracture and a history of stroke. In this case, it provided effective analgesia, enabled early rehabilitation, and was associated with a favorable clinical course without postoperative delirium or new neurological events, highlighting the role of regional anesthesia as a comprehensive tool for improving functional outcomes in high-risk geriatric patients.