Pericapsular nerve group block for hip fracture is feasible, safe and effective in the emergency department: A prospective observational comparative cohort study

Alan Fahey, Elinor Cripps, Aloysius Ng, Amy Sweeny, Peter J Snelling, Alan Fahey, Elinor Cripps, Aloysius Ng, Amy Sweeny, Peter J Snelling

Abstract

Objectives: The pericapsular nerve group (PENG) block was first described for analgesia of hip fracture in 2018. We hypothesised that the PENG block is safe and effective for patients with hip fracture when provided by emergency physicians and trainees in the ED.

Methods: This was an observational study of routine care. Consecutive patients receiving regional anaesthesia for hip fracture at a single ED were prospectively enrolled. Pain scores were assessed prior to regional anaesthesia then at 15, 30 and 60 min after administration. Maximal reduction in pain scores within 60 min were assessed using the Visual Analogue Scale (at rest and on movement) or the Pain Assessment IN Advanced Dementia tool (at rest). Patients were followed for opioid use for 12 h after regional anaesthesia and adverse events over the duration of admission.

Results: There were 67 eligible patients during the enrolment period, with 52 (78%) prospectively enrolled. Thirty-three received femoral blocks (19 fascia iliaca compartment blocks, 14 femoral nerve blocks) and 19 received a PENG block. Inexperienced providers were able to successfully perform the PENG block. There was no difference in maximum pain score reduction between the groups. There was no difference in adverse effects between groups. Opioid use was similar between the groups. More patients were opioid-free after a PENG block.

Conclusions: The present study demonstrated that the PENG block can be provided safely and effectively to patients with hip fracture in the ED. On the basis of this pilot study, a larger randomised controlled study should now be designed.

Keywords: PENG block; hip fracture; neck of femur; regional anaesthesia; ultrasound.

© 2022 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for Emergency Medicine.

Figures

Figure 1
Figure 1
(a) Ultrasonographic view of right sided anatomical landmarks for the pericapsular nerve group block, with superimposed needle trajectory (arrows) and target injection site (*). (b) Demonstration of patient and probe positioning with needle insertion site indicated. AIIS, anterior inferior iliac spine; FA, femoral artery; FV, femoral vein; IPE, iliopubic eminence; PT, psoas tendon.
Figure 2
Figure 2
Patient enrolment flow chart. FICB, fascia iliaca compartment block; FNB, femoral nerve block; NRS, numerical rating scale; PENG, pericapsular nerve group; VAS, Visual Analogue Scale; PAINAD, Pain Assessment IN Advanced Dementia.
Figure 3
Figure 3
Pain scores over time. Boxes indicate the interquartile range bisected at the median. Black whiskers show the distribution, excluding outliers. Yellow dots and lines show mean and standard deviation. Blue dots are individual data points. Femoral block, femoral nerve block or fascia iliaca compartment block; PENG, pericapsular nerve group.

References

    1. Dyer SM, Crotty M, Fairhall N et al. A critical review of the long‐term disability outcomes following hip fracture. BMC Geriatr. 2016; 16: 158.
    1. Lystad RP, Cameron CM, Mitchell RJ. Mortality risk among older Australians hospitalised with hip fracture: a population‐based matched cohort study. Arch. Osteoporos. 2017; 12: 67.
    1. Australian Commission on Safety and Quality in Health Care . Hip Fracture Care Clinical Care Standard. Sydney: Australian Commission on Safety and Quality in Health Care, 2016.
    1. Guay J, Parker MJ, Griffiths R, Kopp SL. Peripheral nerve blocks for hip fractures: A Cochrane review. Anesth. Analg. 2018; 126: 1695–704.
    1. Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth. Analg. 2010; 111: 1552–4.
    1. Xing JG, Abdallah FW, Brull R et al. Preoperative femoral nerve block for hip arthroscopy: A randomized, triple‐masked controlled trial. Am. J. Sports Med. 2015; 43: 2680–7.
    1. Cooper AL, Nagree Y, Goudie A, Watson PR, Arendts G. Ultrasound‐guided femoral nerve blocks are not superior to ultrasound‐guided fascia iliaca blocks for fractured neck of femur. Emerg. Med. Australas. 2019; 31: 393–8.
    1. Newman B, McCarthy L, Thomas PW, May P, Layzell M, Horn K. A comparison of pre‐operative nerve stimulator‐guided femoral nerve block and fascia iliaca compartment block in patients with a femoral neck fracture. Anaesthesia 2013; 68: 899–903.
    1. Kukreja P, Avila A, Northern T, Dangle J, Kolli S, Kalagara H. A retrospective case series of pericapsular nerve group (PENG) block for primary versus revision total hip arthroplasty analgesia. Cureus 2020; 12: e8200.
    1. Allard C, Pardo E, de la Jonquière C et al. Comparison between femoral block and PENG block in femoral neck fractures: a cohort study. PLoS One 2021; 16: e0252716.
    1. Short AJ, Barnett JG, Gofeld M et al. Anatomic study of innervation of the anterior hip capsule: Implication for image‐guided intervention. Reg. Anesth. Pain Med. 2018; 43: 186–92.
    1. Giron‐Arango L, Peng PWH, Chin KJ et al. Pericapsular nerve group (PENG) block for hip fracture. Reg. Anesth. Pain Med. 2018; 43: 859–63.
    1. Swenson JD, Davis JJ, Stream JO, Crim JR, Burks RT, Greis PE. Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: The pattern of distribution and effects on the obturator nerve. J. Clin. Anesth. 2015; 27: 652–7.
    1. Nielsen ND, Bendtsen TF. In response: Motor blockade after iliopsoas plane (IPB) and pericapsular nerve group (PENG) blocks: A little may go a long way. Acta Anaesthesiol. Scand. 2021; 65: 137–8.
    1. 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; 46: 169–75.
    1. Jadon A, Mohsin K, Sahoo RK, Chakraborty S, Sinha N, Bakshi A. Comparison of supra‐inguinal fascia iliaca versus pericapsular nerve block for ease of positioning during spinal anaesthesia. Ind. J. Anaesth. 2021; 65: 572–8.
    1. Aliste J, Layera S, Bravo D et al. Randomized comparison between pericapsular nerve group (PENG) block and suprainguinal fascia iliaca block for total hip arthroplasty. Reg. Anesth. Pain Med. 2021; 46: 874–8.
    1. Lin DY, Morrison C, Brown B 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: 398–403.
    1. Pascarella G, Costa F, Del Buono R 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: 1492–8.
    1. Valery P, Aliaksei M. A comparison of the onset time of complete blockade of the sciatic nerve in the application of ropivacaine and its equal volumes mixture with lidocaine: A double‐blind randomized study. Korean J. Anaesthesiol. 2013; 65: 42–7.
    1. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J. Am. Med. Dir. Assoc. 2003; 4: 9–15.
    1. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional nerve blocks for hip and femoral neck fractures in the emergency department: A systematic review. CJEM 2016; 18: 37–47.
    1. Wang X, Sun Y, Wang L, Hao X. Femoral nerve block versus fascia iliaca block for pain control in total knee and hip arthroplasty: A meta‐analysis from randomized controlled trials. Medicine 2017; 96: e7382.
    1. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad. Emerg. Med. 2003; 10: 390–2.
    1. Kwun‐Tung Ng T, Chan WS, Peng PWH, Sham P, Sasaki S, Tsui HF. Chemical hip denervation for inoperable hip fracture. Anesth. Analg. 2020; 130: 498–504.
    1. Bahreini M, Safaie A, Mirfazaelian H, Jalili M. How much change in pain score does really matter to patients? Am. J. Emerg. Med. 2020; 38: 1641–6.
    1. Australian and New Zealand College of Anaesthetists . Opioid Calculator; 2020. Available from URL:
    1. Mundi S, Chaudhry H, Bhandari M. Systematic review on the inclusion of patients with cognitive impairment in hip fracture trials: a missed opportunity? Can. J. Surg. 2014; 57: 141.
    1. McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. J. Clin. Epidemiol. 2014; 67: 267–77.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera