Regional anesthesia combined with esketamine analgesia and remimazolam sedation as a salvage strategy for intertrochanteric femur fracture surgery in a high-risk patient: A case report

Rationale: The anesthetic management of intertrochanteric fractures in patients with dual contraindications to neuraxial and general anesthesia is highly challenging. We illustrate a unique salvage multimodal strategy combining a comprehensive ultrasound-guided regional blockade with esketamine-based sedation to manage such complex cases. Patient concerns: A 55-year-old female (147 cm, 45 kg) was admitted following a slip-and-fall accident resulting in severe right hip pain and limited mobility. Due to her complex medical history, the patient and her family expressed significant anxiety regarding the risks of conventional anesthesia. Diagnoses: Imaging confirmed a comminuted right intertrochanteric fracture. The patient’s clinical profile was complicated by congenital spinal dysraphism (spina bifida) with a local meningocele and a history of 2 recent episodes of spontaneous pneumothorax. Interventions: The patient underwent surgical fixation under a primary ultrasound-guided supra-inguinal fascia iliaca compartment block (40 mL of 0.4% ropivacaine) supplemented by a lateral femoral cutaneous nerve block. Intraoperative management utilized a multimodal approach combining esketamine-mediated systemic analgesia and remimazolam-based sedation while strictly preserving spontaneous ventilation. Outcomes: The 70-minute procedure was successful without conversion to general anesthesia or positive-pressure ventilation. Hemodynamics remained stable throughout the surgery (systolic blood pressure: 128–151 mm Hg; heart rate: 61–78 bpm). The patient awakened fully within 3 to 4 minutes postoperatively, reported no intraoperative discomfort, and achieved excellent pain control (VAS 1/10) with an unremarkable one-month recovery. Lessons: For high-risk surgical candidates where both neuraxial and general anesthesia are relatively contraindicated, a multimodal approach centered on comprehensive nerve blocks combined with remimazolam and esketamine sedation represents a safe and effective salvage strategy. This technique minimizes physiological stress and avoids the specific risks of conventional anesthesia in complex clinical scenarios.