Background & Aims
Surgery for various hip fractures is common and often associated with significant postoperative pain that can impede rehabilitation. Regional anaesthesia is considered one of the safer modes in elderly patients to alleviate postoperative morbidity and mortality. Ultrasound-guided (USG) Lumbar plexus block (LPB) is a modality for providing pain relief in hip fracture surgeries. Continuous USG Pericapsular Nerve Group (PENG) Block is a relatively newer intervention modality that primarily targets the sensory articular branches of femoral nerve and accessory obturator nerve in the anterior capsule of the joint. There are a number of recent studies demonstrating its effectiveness in hip surgical operations.1-5 However, there is only one very recent study comparing head-to-head USG-PENG block with USG-LPB.6 Our study evaluated the efficacy and safety of continuous USG-PENG block in comparison with USG-LPB with catheter in-situ for postoperative pain management of unilateral hip fracture.
Methods
In this prospective, randomized, single-blinded controlled registered trial, after sample size calculation, 50 consenting patients of ASA grade I and II, aged 20-80 years BMI 18-35 kg/m2 posted for unilateral hip fracture surgery received either USG-LPB or USG-PENG block before operation. Exclusion criteria included patient refusal, history of drug allergy to ropivacaine and fentanyl, coagulopathy, local infection etc. Preoperatively patients were randomised 1:1 to either Group I (PENG block) or Group II (LPB). Both the groups were given 15 ml of 0.5% ropivacaine plus 2 mcg/ml fentanyl combination, along with the provision of 0.2% ropivacaine plus 2 mcg of fentanyl continuous infusion at the rate of 5 ml/h for 48h. The primary outcome was to compare the mean postoperative pain score over 48h (using 11-point numeric rating scale, NRS) in patients receiving either block. Secondary outcomes were to assess sensory and motor blockade, Patient satisfaction and other adverse effects.
Results
Baseline demographics were similar among the groups. At rest, pain scores were significantly lower in PENG block when compared to LPB at 1h [mean (SD) 0.00(0.00) vs. 0.88(0.73); p<0.001], 4h [0.20(0.65) vs. 1.60(0.96); p<0.001], 8h [0.72(0.94) vs. 2.36(0.76); p<0.001], 12h [1.28(0.79) vs. 2.72(1.02); p<0.001], 24h [1.08(0.76) vs. 1.64(0.70); p=0.008], 36h [0.48(0.65) vs. 0.80(0.58); p=0.048], 48h [0.04(0.20) vs. 0.32(0.48); p=0.011] respectively. On movement too, the pain scores were significantly lower in PENG block when compared to LPB at 1h [0.04(0.20) vs. 2.32(1.25); p<0.001], 4h [0.64(1.15) vs. 3.48(1.42); p<0.001], 8h [1.56(1.39 vs. 4.60(1.22); p<0.001], 12h [2.52(1.33 vs. 4.80(1.26); p<0.001], 24h [2.04(0.84) vs. 3.84(0.99); p<0.001], 36h [1.08(0.57) vs. 2.36(1.08); p<0.001], and 48h [0.40(0.50) vs. 1.40(0.65); p<0.001] respectively. Length of postoperative hospital stay (days) was significantly lesser in PENG block group compared to LPB [27.12(5.02) vs. 32.20(8.47); p=0.014].
Conclusions
In this prospective, randomized, controlled study, the PENG block has demonstrated effective analgesia with minimal adverse effects while allowing early postoperative mobilisation.
References
1.Giro?n-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) Block for Hip Fracture. Reg Anesth Pain Med 2018; 43(8):859-63.
2.Morrison C, Brown B, Lin DY, Jaarsma R, Kroon H. Analgesia and anesthesia using the pericapsular nerve group block in hip surgery and hip fracture: a scoping review. Reg Anesth Pain Med. 2021 Feb;46(2):169-175.
3.Pascarella G, Costa F, Del Buono R, Pulitano? R, Strumia A, Piliego C, et al. Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial. Anaesthesia 2021; 76(11):1492-98.
4.Lin DY, Morrison C, Brown B, Saies AA, Pawar R, Vermeulen M, et al. Pericapsular nerve group (PENG) block provides improved short-term analgesia compared with the femoral nerve block in hip fracture surgery: a single-center double-blinded randomized comparative trial. Reg Anesth Pain Med 2021; 46(5):398-403.
5.Kong M, Tang Y, Tong F, Guo H, Zhang XL, Zhou L, et al. The analgesic efficacy of pericapsular nerve group block in patients with intertrochanteric femur fracture: A randomized controlled trial. PLoS One 2022; 17(10):e0275793.
6.Lee TY, Chung CJ, Park SY. Comparing the Pericapsular Nerve Group Block and the Lumbar Plexus Block for Hip Fracture Surgery: A Single-Center Randomized Double-Blinded Study. J Clin Med. 2023 Dec 25;13(1):122.
Presenting Author
Sukanya Mitra
Poster Authors
Sukanya Mitra
M.D.
Government Medical College & Hospital, Chandigarh, India
Lead Author
Pelerieto Rurhia
M.D.
Government Medical College and Hospital, Chandigarh, India
Lead Author
Jasvir Singh
M.D.
Government Medical College and Hospital, Chandigarh, India
Lead Author
Sudhir Garg
M.S.
Government Medical College and Hospital, Chandigarh, India
Lead Author
Topics
- Treatment/Management: Interventional Therapies – Injections/Blocks