|LETTER TO THE EDITOR
|Year : 2020 | Volume
| Issue : 1 | Page : 58-59
Initial experience of pericapsular nerve group block for positioning during neuraxial block in patients with hip fracture
Arshad Ayub, Debesh Bhoi, Nagesh Tangirala, MR Vishnu Narayanan
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||16-Apr-2020|
Dr. Debesh Bhoi
Fta-205, 2nd Floor, Ayurvigyan Nagar, August Kranti Marg, New Delhi - 110 049
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ayub A, Bhoi D, Tangirala N, Vishnu Narayanan M R. Initial experience of pericapsular nerve group block for positioning during neuraxial block in patients with hip fracture. Indian J Pain 2020;34:58-9
|How to cite this URL:|
Ayub A, Bhoi D, Tangirala N, Vishnu Narayanan M R. Initial experience of pericapsular nerve group block for positioning during neuraxial block in patients with hip fracture. Indian J Pain [serial online] 2020 [cited 2020 Jul 6];34:58-9. Available from: http://www.indianjpain.org/text.asp?2020/34/1/58/282545
Hip fractures in elderly patients are one of the most common emergency situations and if not managed early may lead to significant morbidity or mortality. As per the British Orthopaedic Association Standards for Trauma guidelines, it should be fixed within 48 h from admission, unless there is any irreversible medical conditions. Owing to elderly age associated with multiple comorbid conditions and risk of impairment of cognitive function, the choice of anesthesia in these settings favors regional over the general anesthesia. However, neuraxial block in such patients, specifically with intertrochanteric fracture, is technically difficult, because of severe pain during positioning for the block. Conventionally, the pain during positioning is managed with short-acting opioids (fentanyl) or ketamine; however, the quality of analgesia is not so satisfactory. The various side effects such as sedation, nausea, and vomiting and urinary retention associated with opioids compel to use other alternative modalities such as femoral block or fascia iliaca block. However, it spares the articular branches from the obturator and accessory obturator nerve. Recently, pericapsular nerve group (PENG) block has been described, with promising analgesia in patients with hip fracture. We report our initial experiences in such group of patients for comfortable positioning during neuraxial block. Written informed consent was taken in all patients before the procedure.
We performed this block in five patients with intertrochanteric fracture aging more than 65 years and the eldest one was 75 year. The median numeric pain rating scale score (NRS) was 8/10. PENG block was performed in all the patients in supine position as described by Girón-Arango et al. A low-frequency (2–5 MHz) curvilinear probe (Sonosite S-nerve, Bothell, WA, USA) was placed transversely over anterior inferior iliac spine and then rotated counterclockwise to bring iliopubic eminence (IPE) and femoral vessels into picture [Figure 1]a and [Figure 1]b. We then scanned little below to visualize the hip joint and then returned back to confirm for the final position of IPE. A 10-cm echogenic needle was introduced by in-plane technique from the lateral to the medial direction, and equal volume of 0.5% ropivacaine with 2% lignocaine with adrenaline (1:200,000) making the final volume of 10 ml was deposited in the eminence [Figure 2]a, [Figure 2]b, [Figure 2]c. Fifteen minutes after the block, all the patients were assessed for the NRS and were found to be significantly better (median 3/10) after which they were positioned for the neuraxial block. However, during initial part of positioning, although median NRS rose to 4, they were comfortable after final sitting position [Figure 2]d. Postoperatively, the median time to first request of analgesic was 4 h; however, the pain got relieved with intravenous paracetamol (650 mg), which was then repeated sixth hourly. None of the patients required any opioid rescue.
|Figure 1: (a) Low-frequency curvilinear probe placed obliquely on anterolateral side over anteriorinferior iliac spine and pubic ramus. (b) US image showing sonoanatomy. FV: Femoral vein, FA: Femoral artery, IPE: Iliopubic eminence, AIIS: Anterior inferior iliac spine|
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|Figure 2: (a) Echogenic needle entering from lateral to medial side (b) Dotted arrow showing the needle direction hitting the iliopubic eminence. (c) Deposition of local anesthetic, * denotes local anesthetic (d) The patient sitting comfortably after the block for the placement of neuraxial block|
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| Discussion|| |
Analgesic options in hip fracture are crucial and challenging owing to the dense neural contributions from multiple nerves listing femoral, obturator, accessory obturator, sciatic, superior gluteal, and also nerve to quadratus femoris. However, the concentration of sensory nerve endings and mechanoreceptors are much more dense in anterior hip capsule and specifically superiorly from 10.00 O' Clock to 2.00 O' clock position. The above microneural anatomy is self-explanatory for the effective analgesia provided by the PENG block. In our cases also, we noticed excellent analgesia that drastically improved the NRS scoring and the patients comfortably allowed for the performance of neuraxial block. The effective bathing of distal articular branches with local anesthetic was further established by the methylene blue dye staining of the anterior hip joint capsule in soft embalmed cadavers even with 10 ml. The effective analgesia guided us for the planning of further comparative study between a fascia iliaca block and the current block, which might tell us the advantages.
Financial support and sponsorship
All drugs and equipment used in the case series are our hospital resources (All India Institute of Medical Sciences, New Delhi).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Association of Anaesthetists of Great Britain and Ireland, Griffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, et al
. Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2012;67:85-98.
Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular nerve group (PENG) block for hip fracture. Reg Anesth Pain Med 2018;43:859-63.
Simons MJ, Amin NH, Cushner FD, Scuderi GR. Characterization of the neural anatomy in the hip joint to optimize periarticular regional anesthesia in total hip arthroplasty. J Surg Orthop Adv 2015;24:221-4.
Tran J, Agur A, Peng P. Is pericapsular nerve group (PENG) block a true pericapsular block? Reg Anesth Pain Med 2019;44:257.
[Figure 1], [Figure 2]