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Anesthesia & Clinical Research

Anesthesia & Clinical Research
Open Access

ISSN: 2155-6148

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Research Article - (2021)Volume 12, Issue 4

The Pericapsular Nerve Group Block for Hip Fracture Surgery: A Prospective Case Report

Brigid Brown1*, D-Yin Lin1, Alex Saies2, Marthinus Vermeulen1, Hidde M. Kroon3,4, Job Doornberg2 and Ruurd Jaarsma2
 
*Correspondence: Dr. Brigid Brown, Department of Anesthesiology, Flinders University and Flinders Medical Centre, Bedford Park, Australia, Email:

Author info »

Abstract

Background:The Pericapsular Nerve Group (PENG) block is a regional analgesia technique of the hip. This prospective case series investigated the PENG block in Neck of Femur (NOF) fracture surgery.

Methods: Consecutive patients undergoing surgical repair of neck of femur fractures receiving a PENG block were included. This number was limited due to the few anesthesiologists trained in this novel block (DL, BB, MV). The primary outcome was individual patient pain score reduction. Secondary outcomes were opiate use, patient satisfaction, and perioperative complications.

Outcomes: Twenty eight patients were recruited from October 2019 to April 2020. There was a median reduction of 7 points [range -3 to 10] on an 11-point Verbal Numerical Rating Score (VNRS).

Conclusion: The PENG block provides effective pain relief in NOF surgery, and warrants further investigation by randomised controlled trial.

Keywords

PENG; Hip fracture; Regional anesthesia; Pericapsular nerve group block

Introduction

Neck of Femur (NOF) fracture is a painful condition associated with significant morbidity and mortality [1]. Femoral nerve block is commonly performed as part of multimodal analgesia [2-5]. However shows only modest reductions in pain scores and opioid requirement and results in temporary quadriceps weakness, contributing to delayed mobilization, prolonged hospital stay and in-hospital falls [6-10].

An anatomical study exploring the sensory innervation of the hip joint led to the development of the Pericapsular Nerve Group (PENG) block. This technique suggests greater improvement in pain scores and less motor weakness than the traditional femoral nerve blocks. Current literature on PENG blocks is limited to small case series and editorials only. This case series was designed to evaluate the PENG in a larger patient cohort than previously studied with a focus on pain score reduction in patients undergoing surgical NOF fracture repair.

Case Report

Study design

This is a single-center case series conducted at a large tertiary trauma centre. A prospective cohort of patients undergoing NOF fracture repair were enrolled and received a PENG block prior to their operation. The study was approved by the local ethics committee (AUD/19/SAC/197) in October 2019 and written informed consent was obtained. The primary outcome measure was individual patient pain score reduction. Secondary outcome measures were opioid consumption for the first three days postoperatively, complication rates, patient satisfaction and duration of block effect.

Participants

Three consultant anesthesiologists were trained in performing the PENG block (BB, DL, MV). Twenty-eight patients were recruited between October 2019 and April 2020. Inclusion criteria were age greater than 44 years, and planned NOF surgery. Exclusion criteria were contraindications to a regional nerve block, a distracting second injury, and patient’s refusal of a regional nerve block. Eligible patients were identified prospectively from these particular anesthesiologists’ orthopaedic operating lists. Per patient, a pain score difference was calculated by subtracting the maximum pain score postoperatively in Recovery from the maximum pre-operative pain score.

Results

Twenty eight patients were included in this study. The median age of patients was 78 years (range 59-99). Demographics are detailed (Table 1). Preoperatively, three patients (14%) had no to mild pain (VNRS 0-4), seven had moderate pain (VNRS 5-7), and 12 patients (54%) reported severe pain (VNRS 8-10).

  PENG
(n=28)
Age in years, median (range) 78(59-99)
Gender, n (%)
Male
Female
8(29)
20(71)
ASA score, n (%)
I
II
III
IV
V
0
7 (25)
15 (54)
6 (21)
0
Preoperative Mobility, n (%)
1 (Independent)
2 (Stick/Crutch)
3 (Walker/frame)
4 (Wheelchair/assisted)
14 (50)
5 (18)
8 (28)
1 (4)
Mental status, n (%)
0 (No impairment)
1-3 (Cognitive impairment)
19 (67)
9 (33)
Residence, n (%)
1 (Home)
2 (Assisted care)
3 (Nursing home)
18 (64)
2 (7)
8 (29)
Fracture side, n (%)
1 (Left)
2 (Right)
15 (54)
13 (46)
Type of fracture, n (%)
intracapsular
extracapsular
13 (46)
15 (54)
Preoperative pain score (VAS), n (%)
None
Mild (1-4)
Moderate (5-7)
Severe (8-10)
1 (5)
2 (9)
7 (32)
12 (54)a
Type of anaesthesia for surgery, n (%)
General
Spinal
15 (54)
13 (46)

Table 1: Patient and preoperative characteristics.

Postoperative outcomes are outlined (Table 2). At four hours postoperative, patients reported a median decrease in preoperative to postoperative pain of 7 points (range -3 to 10). 15 patients (65%) reported a pain scale of zero at 4 hours postoperative. The median length of stay in hospital was 6 days (range 2-49).

  PENG (n=28)
Duration of PENG block effect in hours, median (range) 12.5 (5.25 – 23)a
Maximum postoperative pain score in recovery), n (%)
None (0)
Mild (1-4)
Moderate (5-7)
Severe (8-10)
15 (65)
5 (22)
2 (9)
1 (4)b
Pain score (VAS) reduction preoperative to postoperative, median(range) 7 (-3 to 10)b
Complications, n (%)
Pneumonia
DVT
PE
Wound
UTI
Anemia
Reoperation
Delirium
Death
Other
2
0
1
0
0
3
1
10
0
6
Clavien-Dindo complications scale, n (%)
0
I
II
III
IV
V
7 (25)
6 (21)
13 (46)
1 (4)
1 (4)
0
Length of hospital stay in days, median (range) 6 (2-49)

Table 2: Postoperative outcomes.

Postoperative opioid use and patient satisfaction scores are reported (Table 3). Every patient in this study required postoperative opioids and use was relatively consistent across all three days of follow up. The median duration of the PENG block was 12.5 hours (range 5.25-23 hours) as recalled by 20 patients. All patients in this subanalysis (n=20) reported they were satisfied with the PENG block and would have it again.

  PENG
(n=27)
Postoperative opiate use in morphine equivalents, median (range)
Day 1
Day 2
Day 3
Total
30 (0-120)
23 (0-135)
15 (0-90)
65 (8-301)
Postoperative opiate use for opioid users only, in morphine equivalents, median (range)
Day 1
Day 2
Day 3
Total
30 (3-120)
27 (3-135)
23  (5-90)
65 (8-301)
Number of patients using opioids, n (%)
Day 1
Day 2
Day 3
Total
26 (93)
23 (82)
23 (82)
27 (100)
Patient satisfaction, n (%) Unsatisfied
Satisfied
Unable to assess
0
20 (74)
7 (26)

Table 3: Postoperative opiate use and patient satisfaction.

Conclusion

This PENG block case series demonstrates some potential advantages compared with the conventional nerve blocks used for analgesia in NOF fracture patients, however, further studies are required. This cohort study supports future randomised prospective trials in a larger patient group.

Acknowledgments

None

References

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Author Info

Brigid Brown1*, D-Yin Lin1, Alex Saies2, Marthinus Vermeulen1, Hidde M. Kroon3,4, Job Doornberg2 and Ruurd Jaarsma2
 
1Department of Anesthesiology, Flinders University and Flinders Medical Centre, Bedford Park, Australia
2Department of Orthopedics, Flinders University and Flinders Medical Centre, Bedford Park, Australia
3Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
4Department of Health and Medical Science, University of Adelaide, Adelaide, Australia
 

Citation: Brown B, D-Yin Lin, Saies A, Vermeulen M, Kroon HM, Doornberg J, et al. (2021) The Pericapsular Nerve Group Block for Hip Fracture Surgery: A Prospective Case Series. J Anesth Clin Res. 12:999.

Received: 19-Mar-2021 Accepted: 05-Apr-2021 Published: 12-Apr-2021 , DOI: 10.35248/2155-6148.21.12.999

Copyright: © 2021 Brown B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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