PENG Block forTranscatheter Aortic Valve Implantation
Condition: Aortic Valve Stenosis; Aortic Diseases
MeSH terms: Aortic Valve Stenosis; Aortic Diseases
Study type: Interventional

Summary: 
      Pericapsular nerve group (PENG block) is a new fascial block defined by Arango et al. This
      block aims to block the femoral nerve and the accessory obturator nerve by injecting local
      anesthetic between the pubic ramus and psoas tendon. By blocking these nerves, anterior hip
      analgesia is created. It is a safe and effective method as it is applied superficially and
      under ultrasound guidance. In radiological and cadaver studies, it has been reported that
      when high volume is applied, total hip analgesia can be achieved by blocking the lateral
      femoral cutaneous, genitofemoral, obturator, and femoral nerves.
    

Detailed description: 
      Aortic valve stenosis (AS) is the most common valve pathology, affecting 2% to 4% of patients
      over the age of 75. Surgical aortic valve replacement (SAVR) has been accepted as a class I
      recommendation for the treatment of AS for decades. However, given that advanced age,
      frailty, and significant comorbidities are increasingly common in affected patients; More
      than one-third of high-risk and severely symptomatic AS patients are physiologically
      unsuitable for major surgery. This is the development and implementation of TAVI, an
      appropriate intervention for high-risk patients and those deemed unsuitable for surgery. With
      a shift in the clinical paradigm towards minimally invasive procedures, the development of
      TAVI has revolutionized clinical outcomes in AS, particularly in those once considered
      inoperable.

      Selective candidate criteria and advances in operative techniques within TAVI are major
      contributors to successful outcomes. Basically, there are both retrograde and anterograde
      operative approaches that can be adopted within a TAVI procedure. While the transfemoral
      approach remains the most widely used, others include the transapical, transaxillary,
      transported, and transaortic pathways. The choice of technique adopted is greatly influenced
      by patient-related factors such as anatomical considerations and comorbidities present.

      Because of the increasing use of ultrasound (US) in anesthesia practice, nerve blocks with US
      guidance are widely used. Pericapsular nerve group (PENG block) is a new fascial block
      defined by Arango et al. This block aims to block the femoral nerve and the accessory
      obturator nerve by injecting local anesthetic between the pubic ramus and psoas tendon. By
      blocking these nerves, anterior hip analgesia is created. It is a safe and effective method
      as it is applied superficially and under ultrasound guidance. In radiological and cadaver
      studies, it has been reported that when high volume is applied, total hip analgesia can be
      achieved by blocking the lateral femoral cutaneous, genitofemoral, obturator, and femoral
      nerves.

      This prospective, randomized study, it was aimed to evaluate the efficacy of the PENG block
      for the management of analgesia during and after the procedure in patients undergoing TAVI.
      Our primary aim is to evaluate pain scores (Numerical Rating Scale-NRS), our secondary aim is
      to evaluate the amount of additional sedation intraoperatively, the degree of quadriceps
      motor block (paresis or paralysis in knee extension), and opioid-related side effects
      (allergic reaction, nausea, vomiting, etc.).
    

Intervention name(s): Postoperative analgesia management; PENG-Bupivacaine; Local infiltration-Bupivacaine
Intervention type(s): Drug; Drug; Drug
Intervention description(s): Intravenous 0.5 mg/kg tramodol and 1 gr paracetamol will be administered to all patients 30 minutes before the end of the surgical procedure. In the postoperative period, patients will be administered iparacetamol iv 1 gr 3x1. Postoperative patient evaluation will be performed by another pain nurse who is unaware of the procedure. If the NRS score is ≥ 4, 0.5 mg kg-1 iv meperidine will be administered as a rescue analgesic.; The probe will be placed on the anterior inferior iliac crest in the transverse plane. Then, the pubic ramus will be visualized by rotating 45 degrees. The femoral artery, iliopubic process, and psoas muscle will be visualized. The needle will be punctured with the in-plane method to reach between the pubic ramus and the psoas tendon. After the block area is confirmed with 5 ml of saline, 30 ml of local anesthetic solution containing 0.25% bupivacaine will be injected.; Local infiltration will be applied with 30 ml of a local anesthetic solution containing 0.25% bupivacaine by the surgical team
Intervention MeSH terms: Bupivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Sixty patients aged 20-95 years old with American Society of Anesthesiologists (ASA) classification I-IV and scheduled for TAVI will be included in the study. Patients will be randomly divided into two groups (Group PENG = PENG block group, Group Control = local infiltration group) including 30 patients each, before entering the operating room.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Aortic valve stenosis; Transcatheter aortic valv implantation (TAVI); PENG block; Postoperative analgesia management