Case report
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101446 on 12 August 2020. Downloaded from http://rapm.bmj.com/ on August 22, 2020 at University of Rochester Medical
1
Anesthesia, Humanitas Mater
Domini, Castellanza, Italy
2
Anesthesia, Policlinico
Universitario Campus Bio-­
Medico, Roma, Italy
3
Department of Anesthesia
and Intensive Care, Galway
University Hospitals, Galway,
Ireland
Correspondence to
Dr Romualdo Del Buono,
Anesthesia, Humanitas Mater
Domini, Castellanza, Varese,
Italy;
​romualdodelbuono@​gmail.​com
Received 6 March 2020
Revised 24 June 2020
Accepted 2 July 2020
© American Society of Regional
Anesthesia & Pain Medicine
2020. No commercial re-­use.
See rights and permissions.
Published by BMJ.
To cite: Del Buono R,
Padua E, Pascarella G, et al.
Reg Anesth Pain Med Epub
ahead of print: [please
include Day Month Year].
doi:10.1136/rapm-2020-
101446
Continuous PENG block for hip fracture: a case series
Romualdo Del Buono  ‍ ‍,1 Eleonora Padua,1 Giuseppe Pascarella  ‍ ‍,2
Corina Gabriela Soare,3 Enrico Barbara1
ABSTRACT
Introduction  The pericapsular nerve group (PENG)
block is a novel regional technique indicated for
analgesia for hip joint pain. We administered PENG
blocks and performed catheter insertion for continuous
infusions in patients with femur fractures on hospital
admission. In this case series, we describe our initial
experience of pain management in 10 patients with
continuous infusion and its associated adverse events.
Case series  The PENG block was administered with
an introducer needle. The catheter was then inserted
3 cm beyond the needle tip. In three patients, blood
aspiration through the catheter occurred. In each
patient, the catheter was repositioned 0.5–1.0 cm more
medially. No blood aspiration or visible hematoma
occurred subsequently. The presence of any vascular
structure deep to the iliopsoas muscle was excluded
postoperatively based on a Doppler color flow scan.
Discussion  Overall, eight patients had femoral neck
fractures, and two patients had intertrochanteric
fractures. All 10 patients reported good pain relief.
The median (IQR) Numerical Rating Scale (NRS) score
decreased from 7 (6–7) before the block to 2 (2–2.75)
20 min after PENG catheter placement. The median (IQR)
NRS score after 12, 24 and 48 hours were 2 (2–3), 2
(2–3), and 2 (0.25–2), respectively. Patients underwent
surgery 24–48 hours following catheter placement.
Catheters were removed by an Acute Pain Service
nurse 72 hours postinsertion. We want to highlight
the potential for intravascular catheter placement in
this anatomical region. Further studies are required
to confirm if this is a technical error or an associated
complication of continuous PENG blocks.
INTRODUCTION
Regional anesthesia techniques are frequently used
for preoperative pain management in patients
with hip fractures. Femoral nerve blocks, fascia
iliaca blocks, sciatic blocks and three-­in-­one blocks
provide good analgesia and have an opioid-­sparing
effect. However, the obturator nerve is inconsis-
tently covered by these blocks, while the accessory
obturator nerve is not covered at all.
The pericapsular nerve group (PENG) block was
recently described as an alternative technique for
analgesia in hip fractures.1
Interest toward this novel technique has increased.
There have been multiple reports of PENG blocks
being successfully performed without major
complications, although inadvertent femoral and
obturator nerve blocks have also been reported.2 3
On the placement of peripheral nerve cathe-
ters for continuous PENG blocks, the literature is
scarce. To date, there have been two papers that
Del Buono R, et al. Reg Anesth Pain Med 2020;0:1–4. doi:10.1136/rapm-2020-101446
described this technique for postoperative anal-
gesia.4 5 Accordingly, we used PENG blocks and
catheter-­delivered continuous infusions for pain
management in patients with femur fractures.
In this case series, we describe our experience and
pain management using continuous infusions for 10
patients as well as the complications encountered.
CASE REPORT
All patients included in our series or their next-­
of-­kin provided verbal consent for anonymous data
recording and sharing in relation to this procedure.
We describe the management of 10 cases (eight
femoral neck fractures and two intertrochanteric
fractures) with a catheter continuous infusion PENG
block. Table 1 summarizes patient characteristics.
On arrival to the emergency department,
following orthopedic evaluation, patients were
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examined by an anesthetic team. Suitability of block
performance was assessed, and informed consent
was obtained following a risk–benefit discussion
with the patients or their next of kin. All patients
were evaluated for block suitability with regard
to anticoagulant and antithrombotic therapies as
per the current recommendations. Except for low-­
dose aspirin and prophylactic dose low-­molecular-­
weight heparin, no other clotting altering therapies
were recorded.
Subsequently, the PENG block and catheter
placement were performed with the aseptic tech-
nique under ultrasound guidance. Before the
procedure, all patients reported a median (IQR)
pain score of 7 (6–7) in the absence of intravenous
rescue analgesia (pain score measured with the
0–10 Numerical Rating Scale (NRS)). No premed-
ication or sedation was administered before block
performance.
For all cases, a catheter-­through-­needle kit was
used (Contiplex Tuohy, B. Braun Melsungen,
Germany) with a 10 cm long/18 G Tuohy introducer
needle and a 0.45 × 0.85 × 1000 mm catheter. The
anatomical landmarks and technique used were the
same as the ones described by Girón-­Arango et al.1
Once the introducer needle was placed on the
target (figure 1) in the plane between the iliopsoas
tendon and periosteum and between the anterior
inferior iliac spine (AIIS) and iliopubic eminence
(IPE), the PENG block was performed by injecting
20  mL of the local anesthetic. The local anes-
thetic used consisted of ropivacaine 0.375% (nine
patients) or lidocaine 0.5% (one patient). The cath-
eter was then inserted 3 cm beyond the needle tip
into the hydrodissected plane, and an injection/
aspiration test with saline was performed (figure 2,
left).
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 Case report

Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101446 on 12 August 2020. Downloaded from http://rapm.bmj.com/ on August 22, 2020 at University of Rochester Medical
Table 1  Patient’s characteristics and observed outcomes
Gender Age NRS pre NRS 20 min NRS 12 hours NRS 24 hours NRS 48 hours Fracture type Blood flowback
F 76 7 4 2 2 2 Intertrochanteric Yes
F 85 8 2 2 3 0 Intertrochanteric No
M 78 5 2 3 1 1 Femur neck No
M 70 7 3 2 2 0 Femur neck No
M 75 6 1 2 0 0 Femur neck No
F 83 9 1 0 2 2 Femur neck Yes
F 81 7 2 3 4 2 Femur neck No
M 77 7 2 0 2 2 Femur neck No
F 81 6 4 4 3 4 Femur neck Yes
F 72 6 2 3 3 3 Femur neck No
Median (IQR) 77.5 (75.25–81) 7 (6–7) 2 (2–2.75) 2 (2–3) 2 (2–3) 2 (0.25–2)    
NRS, Numerical Rating Scale.

If the test was negative for blood, the catheter was fixed exter-
nally with cyanoacrylate glue, sterile strips and transparent semi-
permeable adhesive film dressing (figure 2, right). After fixation,
a 5 mL/hour infusion of ropivacaine 0.2% was started via an elas-
tomeric pump and continued for 72 hours after catheter place-
ment. No adjuvants were added.
All patients reported good pain relief postblockade with
a decrease in the median (IQR) NRS score from 7 (6–7) to 2
(2–2.75) 20 min after PENG catheter placement. The median
DISCUSSION
The PENG block targets the articular branches innervating the
anterior hip capsule. We report the analgesic effect of this block
on two intertrochanteric fractures and eight femoral neck frac-
tures. In all cases, the continuous PENG block provided effec-
tive analgesia in both preoperative and postoperative periods.
However, we encountered some technical difficulties.
First, regarding the equipment used, we observed that a

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(IQR) NRS scores after 12, 24 and 48 hours were 2 (2–3), 2
(2–3), and 2 (0.25–2), respectively.
We used the Wilcoxon signed-­ rank test to compare the
repeated pain score measurements before and 20 min after block
execution. The difference in pain scores was statistically signifi-
cant (p=0.002), despite the small sample size (figure 3).
Patients underwent surgery between 24 and 48 hours after
arrival, as per the institutional policy. The 48-­hour NRS score
was recorded postoperatively. Catheters were removed by an
Acute Pain Service nurse 72 hours postinsertion. The multi-
modal analgesia regimen at our institution includes paracetamol
3 g/day intravenously, ketorolac 30 mg intravenously on request
(maximum 90 mg/day) and tramadol 50 mg intravenously, as
required (max 150 mg/day), if NRS score ≥5 after administering
the non-­steroidal anti-­inflammatory drugs. No medication other
than paracetamol was required.
catheter-­through-­needle kit with a Tuohy introducer was more
suitable for catheter placement than a catheter-­ over-­
needle
model. The catheter-­through-­needle kit allowed easier insertion
of the catheter below the psoas tendon and above the perios-
teum in the hydrodissected plane, although a steep needle angle
was used (figure 2, left). In contrast, when using a catheter-­over-­
needle kit (E-­ Cath, Pajunk, Geisingen, Germany; Contiplex
C, B. Braun Melsungen, Germany), the relatively steep needle
angle and catheter tip facing the bone were the two main issues
impeding its insertion in the proper plane.
The second obstacle is the novelty of this block. Since this is
a recently described technique, the operator has to be familiar
with both the PENG block and peripheral nerve catheter place-
ment under ultrasound guidance. Another issue is potential
catheter displacement due to self-­ removal in uncooperative
patients, particularly the elderly, who were representative in our

Figure 1  Needle path for the PENG block. The catheter is inserted for 3 cm beyond the needle tip. AIIS, anterior inferior iliac spine; arrow, needle; FA,
femoral artery; FV, femoral vein; IPE, iliopubic eminence; IPM, iliopsoas muscle; IPT, iliopsoas tendon.
2 Del Buono R, et al. Reg Anesth Pain Med 2020;0:1–4. doi:10.1136/rapm-2020-101446

Figure 2  Left: color Doppler scan of an injection through a correctly placed catheter. Right: external catheter fixation with cyanoacrylate glue, sterile
strips and transparent semipermeable adhesive film dressing.
series. We did not encounter this problem in any of our cases
but performed preventive triple fixation with cyanoacrylate
glue, sterile strips and transparent semipermeable adhesive film
dressing.
Our patients were continuously monitored by Acute Pain
Service nurses for signs and symptoms of local anesthetic
Figure 3  Wilcoxon signed-­rank test to compare the repeated
pain scores measurements before and 20 min after block execution
(p=0.002). Dots: NRS values. vertical lines: IQR. NRS, Numerical Rating
Scale.
Del Buono R, et al. Reg Anesth Pain Med 2020;0:1–4. doi:10.1136/rapm-2020-101446
Case report
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101446 on 12 August 2020. Downloaded from http://rapm.bmj.com/ on August 22, 2020 at University of Rochester Medical
systemic toxicity (LAST), as per the hospital policy. No cases of
LAST have been identified.
Our case series also demonstrated a complication. We recorded
three cases of potential intravascular cannulation when we
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performed aspiration via the catheter. In all three cases, blood
was autofilling the catheter along with the attached syringe.
Intrafemoral artery placement is unlikely because the femoral
artery is usually more than 3 cm away from the needle tip. It is
also unlikely for intravenous placement because the catheter fills
quickly with blood without aspiration.
The psoas bursa is an avascular plane, except in the situation
of a hot inflamed bursitis (in which case the Doppler could be
positive because of hyperaemia in the peribursal soft-­tissues). In
our series, the presence of vascular structures deep to the ilio-
psoas muscle was excluded postoperatively based on a color
Doppler scan. However, blood vessels, if any, crossing this fascial
plane should not have a wide enough lumen to allow inadvertent
cannulation.
In all three cases, after blood backflow, the catheter was
removed, and the puncture was repeated with the needle tip
repositioned 0.5–1 cm more medially. The catheter was reth-
readed 3 cm beyond the needle tip, and an aspiration test was
performed with no blood backflow.
The reason for a more medial insertion point for the second
time was to allow a more medial catheter placement between
AIIS and IPE. The first puncture site was in close proximity to
AIIS, rather than IPE.
One possible explanation for blood aspiration via the catheter
in the absence of identifiable vascular structures could be the
presence of blood collection with dilution of local anesthetics
spreading cranially through the iliopsoas bursa. This bursa lies
closer to the base of the femoral triangle between the psoas
tendon and the anterior surface of the femoral neck. In adults,
the psoas bursa communicates with the hip joint in approxi-
mately 15% of the cases and can therefore be a pathway for
intra-­articular hematoma spread.6–9 To simplify, there could be
enlargement of the psoas bursa because of blood collection after
the facture. This hypothesis could explain the negative aspira-
tion test after catheter repositioning because the psoas bursa
would be located more laterally. Scanning of the area could not
reveal hematoma, as it is not hematoma but blood collection in
3
 Case report
the bursa with dilution of the local anesthetic. Therefore, it can
be compressed with ultrasound probe positioning.
Another hypothesis is that the trauma causing the fracture led
to the formation of an iliopsoas muscle hematoma.
In both scenarios, the needle tip could have just slightly pierced
the posterior fascial layer of the iliopsoas muscle or bursa to
allow plane hydrodissection as well as a negative aspiration test.
On needle withdrawal, advancement of the catheter could have
pushed the soft tip distally within the collection. Relocation to
a medial direction potentially moved the catheter outside the
bursa.
There was no clinically visible hematoma in any of the three
cases. Eventually, no femoral or obturator nerve block was
recorded.
In conclusion, we would like to raise awareness about poten-
tial intra-­vascular catheter placement in this anatomical region
giving a limited experience with PENG blocks. Further studies
are required to assess if this is a technical error or a potential
associated complication of this block.
Contributors  RDB: block execution, acquisition of data, drafting and revision of
manuscript. EP: block execution, acquisition of data, critical revision of manuscript.
GP: revision of manuscript. CGS: revision of manuscript, language editing. EB: critical
revision, supervisor.
4 Del Buono R, et al. Reg Anesth Pain Med 2020;0:1–4. doi:10.1136/rapm-2020-101446
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101446 on 12 August 2020. Downloaded from http://rapm.bmj.com/ on August 22, 2020 at University of Rochester Medical
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
ORCID iDs
Romualdo Del Buono http://​orcid.​org/​0000-​0001-​5240-​6131
Giuseppe Pascarella http://​orcid.​org/​0000-​0002-​5076-​3693
REFERENCES
1 Girón-­Arango L, Peng PWH, Chin KJ, et al. Pericapsular nerve group (PENG) block for
hip fracture. Reg Anesth Pain Med 2018;43:1–63.
2 Yu HC, Moser JJ, Chu AY, et al. Inadvertent quadriceps weakness following the
pericapsular nerve group (PENG) block. Reg Anesth Pain Med 2019;44:611–3.
3 Ahiskalioglu A, Aydin ME, Celik M, et al. Can high volume pericapsular nerve group
(PENG) block act as a lumbar plexus block? J Clin Anesth 2020;61:109650.
4 Santos O, Pereira R, Cabral T, et al. Is continuous peng block the new 3-­in-1. J Anesth
Clin Res 2019;10:2.
5 Soares J, Veiga M, Galacho J, et al. Esra19-0060 efficacy of continuous pericapsular
nerve group (peng) block for pain relief after hemiarthroplasty of the hip: A case report.
Regional Anesthesia & Pain Medicine 2019;44:A210.
6 Chandler SB. The iliopsoas bursa in man. The Anatomical Record 1934;58:235–40.
7 Gatch WD, Green W. Cysts of the ilio-­psoas bursa. Annals of surgery 1925;82:277.
8 Sartoris DJ, Danzig L, Gilula L, et al. Synovial cysts of the hip joint and iliopsoas bursitis:
a spectrum of imaging abnormalities. Skeletal radiology 1985;14:85–94.
9 Wunderbaldinger P, Bremer C, Schellenberger E, et al. Imaging features of iliopsoas
bursitis. Eur Radiol 2002;12:409–15.
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