INTRODUCTION
The elderly patient with cardiovascular disease represents a daily challenge for the anesthesiologist. The authors present a case report of a successful use of regional techniques in a patient with hip fracture purposed for left hemiarthroplasty.

CASE REPORT
84 year male, severe depression of cardiac function (ejection fraction: 26%) with implantable cardioverter-defibrillator (ICD), low functional ability, auricular fibrillation (reverted hipocoagulation), cerebral infarction, chronic kidney disease and diabetes. 
The ICD was disabled, defibrillation pads were placed in anterior/posterior position, as well as a radial catheter to monitor direct blood pressure. The anesthesiologist performed a continuous spinal block, in lateral position under full aseptic conditions (18 G Tuohy epidural needle / 20G catheter), paramedian approach, in L4-L5 interspace. After obtaining free flow of cerebrospinal fluid, the catheter was inserted 3 cm into subarachnoid space and administered sufentanyl 2 µg and bupivacaine 0,33%, 2.6 mg (0,8 mL). The patient had two drops in BP (< 65mmHg), without any discomfort, that solved with ephedrine 10 mg. Before transfering the patient to intense care unit (ICU), the spinal catheter was removed. The procedure was ineventful. After reversion of sensitive block, the anesthesiology performed in the ICU ultrasound guided blocks of the left femoral, lateral cutaneous of thigh and the anterior branch of obturator nerve – UGPB (total ropivacaine 0,5%: 125mg). The patient became comfortable during all postoperative period. There was no report of postpuncture dural headache. 

DISCUSSION AND CONCLUSION
The continuous spinal block remains a valid technique for patients with cardiovascular disease, adding the great stability with minimum necessary dosis for an effective block(1). In this patient, combining it with the ultrasound guided peripheral blocks for postoperative pain control allowed a superior cardiovascular stability and patient comfort(2). There are several reports of successful use of UGPB for hip surgery as this case report exemplified.

(1) Saber R, Metainy S. Continuous spinal anesthesia versus single small dose bupivacaine–fentanyl spinal anesthesia in high risk elderly patients: A randomized controlled trial. Egyptian Journal of Anaesthesia (2015) 31, 233–238
(2) Jiménez MIS, Gago MB, et al. Efficacy of obturator and femoral cutaneous nerve blocks for postoperative analgesia in hip surgery. Rev. Esp. Anestesiol. Reanim. 2009; 56: 590-597

The best of both worlds! Continuous spinal anesthesia and peripheral nerve blocks for hip surgery in a patient with severe cardiac disease