Continuous Pericapsular Nerve Group Block in Hip Fracture Patients
Condition: Hip Fractures
MeSH terms: Fractures, Bone; Hip Fractures
Study type: Interventional

Summary: 
      Background- Despite clinical guidelines favoring surgical repair of hip fracture (HF) within
      48 hours of injury, patients may wait considerable periods of time for their turn in the
      operating room. In this context, continuous nerve blocks are an attractive alternative for
      pain management. However, the ideal block technique is not yet defined. Recently a new
      ultrasound-guided approach for selective blockade of the articular branches to the hip, the
      PENG (Pericapsular Nerve Group) block, has been proposed with potentials advantages for
      perioperative hip fracture analgesia.

      Objective- To describe the analgesic efficacy and feasibility of continuous Pericapsular
      Nerve Group block (CPENGB) in patients with HF.

      Design-Interventional study. Setting-Academic Level 3 center. Methods- Two experienced
      anesthesiologist completed 15 sonographically guided Pericapsular Nerve Group (PENG)
      injections and catheter insertion in patients with severe pain awaiting HF surgery. Each
      injection consisted of 20 mL of local anesthetics followed by a 0.1% bupivacaine continuous
      infusion at a constant rate of 8 ml per hour. Pain at rest and on 15° leg lift of the
      fractured leg were assessed before procedure, 10 and 30 minutes after block performance, and
      each 24 hours until surgery. A reduction of severe or moderate dynamic pain to mild pain or
      no pain, and a pain relief of 2 (moderate) were clinically significant findings. To determine
      feasibility time and number of attempts to perform the procedure were measured.
    

Detailed description: 
      Methods: 15 sonography-guided PENG injections and catheter placement were performed in
      consecutive HF patients who were admitted to a single level 3 center and who report severe
      pain despite a standardized analgesia protocol. Patients were assessed by the Pain Service as
      part of a multidisciplinary care pathway and CPENGB was offered as a component of a
      multimodal analgesic regimen. All patients, or their legal representatives, provided written
      informed consent for procedure. Demographic and clinical characteristics were reviewed. To
      determine feasibility, time to perform the procedure was recorded, number of attempts and
      complications. To assess pain control, patient reported pain scores were used and the amount
      of morphine intravenous equivalent consumption (MIVEC) before and after block. Patients were
      asked to rate the severity of their pain on a 4-point numeric rating scale (Verbal Rating
      Scale with four response categories, VRS-4): 1) no pain, 2) mild pain, 3) moderate pain, and
      4) severe pain or ''worst pain imaginable''. Pain at rest and on movement (pain on 15° leg
      lift of the fractured leg) were evaluated at baseline and at different times after procedure
      (10 minutes, 30 minutes, 24 hours and 48 hours after procedure) while the catheter was in
      situ. Pain relief [PR, 0 (none), 1 (slight), 2 (moderate), 3 (lots), 4 (complete)] was
      recorded at 30 minutes after procedure. A reduction of severe dynamic pain to mild pain or no
      pain, according to verbal report of patients, and a pain relief of 2 (moderate) were
      clinically significant findings. Type of fracture (extra or intracapsular), periprocedural
      complications, the presence of analgesic-related adverse effects and bromage score (30
      minutes after catheter placement and each 24 hours during routine medical round) were also
      recorded. Complications were assessed until first orthopedic review (at 3-6 week
      postoperative). Procedure: All procedures were performed by two anesthesiology
      co-investigators who had more that 5 years of experience performing regional techniques in
      clinical practice and who underwent one prior training PENG blocks to standardize the
      approach. Injections were performed using a curvilinear low-frequency ultrasound probe (3.5-
      to 5-MHz). The lateral border of iliopsoas tendon in an oblique axial plane at level of
      iliopectineal eminence provides target for needle placement. Toggling the transducer was
      necessary to optimize visualization of the iliopsoas tendon secondary to anisotropy.
      Injections were performed using an 18-gauge Tuohy needle under sterile conditions. Following
      negative aspiration, a test injection was performed using 10 ml 1% lidocaine in 3-mL
      increments while observing in real time for ensure adequate peritendinous fluid spread of
      local anesthesia. Then, 10 mL 0.25% bupivacaine was administered and a 20-G polyamide
      catheter (connect to a filter) was advanced into the space. The end point of the catheter
      placement was the direct visualization of microbubbles in a peritendinous distribution using
      a bolus of agitated saline applied through threaded catheter connected to not purged filter.
      After catheter placement patients received a 0.1% bupivacaine continuous infusion at a
      constant rate of 8 ml per hour. If needed per anesthesiologist discretion, rescue bolus was
      administrated and continuous infusion rate was increased until adequate analgesia was noted.
      In addition, patients received a standardized analgesia protocol (preoperatively and later in
      the ward) consisting of 1 g paracetamol orally 2-3 times a day and opioid rescue analgesia as
      needed if pain moderate or severe was reported (0.05-0.1 mg/kg of intravenous morphine, or
      hydromorphone or tramadol equivalent, 4-6 times a day). Patients in who there were other
      possible causes of pain (per example: multiples traumatic lesions) received an opioid regimen
      by schedule plus rescue doses or intravenous patient-controlled analgesia under standardized
      protocols.
    

Intervention name(s): Continuous Pericapsular Nerve Group block
Intervention type(s): Other
Intervention description(s): Continuous Pericapsular Nerve Group block to standardize the approach. Injections were performed using a curvilinear low-frequency ultrasound probe (3.5- to 5-MHz). The lateral border of iliopsoas tendon in an oblique axial plane at level of iliopectineal eminence provides target for needle placement. Toggling the transducer was necessary to optimize visualization of the iliopsoas tendon secondary to anisotropy. Injections were performed using an 18-gauge Tuohy needle under sterile conditions. Then, 10 mL 0.25% bupivacaine was administered and a 20-G polyamide catheter (connect to a filter) was advanced into the space. The end point of the catheter placement was the direct visualization of microbubbles in a peritendinous distribution using a bolus of agitated saline applied through threaded catheter connected to not purged filter. After catheter placement patients received a 0.1% bupivacaine continuous infusion at a constant rate.
Intervention model: Single Group Assignment
Intervention model description: interventional study.
Masking: None (Open Label)
Primary purpose: Treatment