Continuous Pericapsular Nerve

Group Block for Hip Surgery:

A Case Series

Speaker- Dr. vivek vishal

Moderator- Dr. Swati
Addl. professor
 Introduction
 Girón-Arango et al described pericapsular nerve group (PENG) block to target
articular branches of the obturator, accessory obturator, and femoral nerves, which
can be spared in fascia iliaca and femoral nerve block approaches resulting in
incomplete analgesia.
 Most case reports describe using this block to decrease pain due to hip fracture and
facilitate positioning to perform a subarachnoid block (SAB) but in this study it was
hypothesized that if a catheter is placed in the potential space between the iliopubic
eminence and iliopsoas muscle, analgesia can be further prolonged.
 In this study this block was performed before performing the SAB, which reduced
the fracture pain and helped in proper positioning and the catheter was used for
postoperative analgesia
 In this study a series of 10 cases of hip fracture repair is described where we
continuous PENG blocks for perioperative analgesia was used.
 Cases
 Ten patients with hip fractures (intertrochanteric, neck of femur,
and subtrochanteric fractures) were assessed and consented for
the block procedure
 All the patients received spinal anesthesia with a preoperative
PENG block. A catheter was placed between the iliopsoas muscle
and iliopubic eminence for postoperative analgesia.
 Patients were given 1mg midazolam and 50 μg fentanyl before
performing the block.
 The Ultrasound-Guided Technique for
PENG Block
 After sterile preparation, 2 mL of 2% lidocaine at the insertion site using a 25–27 gauge
needle is injected.
 The low-frequency curvilinear transducer was placed in the transverse plane over the
anterior inferior iliac spine (AIIS) and moved inferiorly to visualize the pubic ramus
 The femoral artery and iliopubic eminence were visualized and using an in-plane
technique, an 18-gauge Tuohy needle was advanced from lateral to medial through the skin
wheal at a 30°–45° angle toward the ultrasound beam, and 20 mL of 0.25% bupivacaine
was deposited between the psoas tendon anteriorly and pubic ramus posteriorly
 Before removing the needle, a 20-gauge catheter was secured with a 4-cm catheter in the
space. The catheter was properly fixed to the skin. The patients were transferred to the
operating room after 30 minutes.
The Ultrasound-Guided Technique for
PENG Block Cntd..
 All the patients were given a SAB with 2.5 mL of 0.5% hyperbaric bupivacaine
(bupivacaine hydrochloride in 8.25% dextrose) at the L3–4 interspace
 After completion of the surgery, a continuous infusion of 0.25% bupivacaine was
started at 5 mL/h via the catheter.
 In the postoperative period, pain score was assessed every 6 hours, and rescue
analgesia (intravenous morphine 0.05mg/kg) was given for visual analog scale
(VAS) pain score >4.
 The catheters were removed on the second postoperative day
 Methods

 The demographic data of all the patients was noted. Pain scores were assessed before the
PENG block, 30 minutes after the PENG block, and at the time of positioning for the SAB.
 The success of the block was defined by a decrease of 4 points in the VAS pain score, 30
minutes after the block. Additional doses of intraoperative analgesics were noted.
 In the postoperative period, pain VAS scores on movement were measured at 0, 6, 12, 18,
24, 30, 36, 42, and 48 hours by an anesthesiology resident with no knowledge of the
peripheral nerve block being performed. Postoperative morphine requirements were noted.
 If VAS pain score on movement was >4, rescue analgesia (intravenous morphine
0.05mg/kg) was administered every 6 hours as needed for the first 48 hours,
postoperatively. The maximum dose limit of morphine was 0.2mg/kg over 4 hours.
Figure showing execution of continuous pericapsular nerve group (PENG) block by
placement of a catheter in the space between iliopsoas muscle and iliopubic eminence.
A, Relevant sonoanatomy for PENG block. B, Deposition of drug in the space between
iliopsoas muscle and iliopubic eminence
C) advancing catheter via Tuohy needle, (D) catheter fixed to the skin. AIIS indicates
anterior inferior iliac spine; FA, femoral artery; FV, femoral vein; LA, local anesthetic.
 Results

 All patients had significant pain before the PENG blocks. The VAS scores were 8–9 pre-
PENG blocks.
 All patients were comfortable during active movement 30 minutes after the PENG blocks.
VAS scores were 1 (9 patients) to 3 (1 patient) 30 minutes after the PENG blocks
 All patients were comfortable during positioning for the SAB. The patients had a score of
1 or 2 during SAB.
 No patient required additional doses of analgesics in the intraoperative or postoperative
periods. No complications were observed during or after the removal of the catheters.
 Discussion

 The hip capsule is divided into 2 parts: anterior and posterior, with nociceptive fibers
mostly present on the anterior part while the posterior part has mechanoreceptors.
 An anatomic study by Short et al demonstrated that proximal branches of both the femoral
and obturator nerves provide innervations to the anterior hip capsule. The accessory
obturator nerve was found to innervate the medial capsule, which has sensory fibers.
 a cadaveric study of the PENG block, injected dye stained the entire anterior hip capsule
area innervated by the articular branches of femoral, obturator, and accessory obturator
nerves area. Therefore, a PENG block, theoretically, may optimize analgesia compared to
other regional analgesia techniques by most effectively targeting the nociceptive fibers
while minimizing motor involvement.
Figure showing diagrammatic approach of pericapsular nerve
group block. AIIS indicates anterior inferior iliac spine; FA,femoral
artery; FN, femoral nerve; IPE, iliopubic eminence;L, lateral; M,
medial; PT, psoas tendon.
 Discussion contd….

 This block has been described in a few studies to eliminate fracture pain. No reports have
been published on the use of PENG blocks for postoperative analgesia. Future studies need
to compare the PENG block with an already established femoral nerve block and fascia
iliaca block for postoperative analgesia in hip surgery.
 Patients were assessed for complications including paresthesia, quadriceps weakness,
catheter migration, and symptoms of local anesthetic systemic toxicity daily while the
catheter was in place. No complications were observed during or after the removal of the
catheter.
 The PENG block has the advantage of being a sensory block primarily, but 2 cases of
inadvertent motor block in the form of quadriceps weakness has been reported been
reported. According to the authors, the superficial injection of local anesthetics may have
resulted in the aforementioned complication
 Discussion contd…

 The authour postulate that since a large volume of drug was injected for a single-injection
PENG block, the drug may ascend cranially. None of the patients in this study reported
motor weakness. Since a small volume of local anesthetic was administered continuously,
the cranial spread was avoided. Studies with bigger sample sizes are needed to substantiate
our findings.
 The potential advantage of this block is to decrease opioid consumption, facilitate early
mobility in the postoperative period, and allow early discharge.
 Limitations

 This case series is limited in scope since there is no comparator group and larger
randomized clinical trials are warranted