Achieving Reliable Peripheral Nerve Blockade in Cardiogenic Shock With Distorted Femoral Anatomy: A Case Report.

Patients with cardiogenic shock and severe structural heart disease may poorly tolerate both general and neuraxial anesthesia. In selected cases, peripheral nerve blockade may reduce hemodynamic disturbance, but the block must be reliable when pain, sympathetic stimulation, or emergency conversion to general anesthesia could be poorly tolerated. We report a 62-year-old woman with cardiogenic shock, low-flow, low-gradient severe aortic stenosis, advanced dilated cardiomyopathy, pulmonary edema, orthopnea, and active femoral bleeding who required urgent femoral artery and vein repair. General anesthesia and neuraxial anesthesia were considered hazardous. Hematoma and anasarca distorted the femoral anatomy and prevented direct femoral nerve visualization. Combined ultrasound guidance and nerve stimulation were used to support safe needle advancement and functional nerve localization. Surgery proceeded with minimal sedation and without escalation of vasoactive support. This case highlights the role of reliability-focused peripheral nerve blockade when conventional anesthetic options are high risk and regional anatomy is distorted.