Combined Lumbar Erector Spinae Plane Block and Pericapsular Nerve Group Block in Patients Undergoing Hip Surgeries

Study Overview
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Brief Summary
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The investigators are going to evaluate the postoperative analgesic efficacy of combined LESPB and PENG block after hip surgeries.

Detailed Description
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Hip surgeries are very common surgeries and has high postoperative pain potential. There are different ways to execute postoperative analgesia and each of them has advantages and disadvantages. As the patients submitted to this procedure are usually older and with multiple comorbidities, analgesia options with better profile of adverse effects should be preferred. Peripheral nerve block with long-acting local anesthetics is very suitable in this situation, in comparison with systemic or neuraxial opioids. Pain control after total hip arthroplasty (THA) can be challenging because of complex innervation of the hip joint from both the lumbar and sacral nerve plexus. pain was the cause of 12% of unplanned hospital patient admissions, 60% of these patients were admitted for orthopedic concerns. The consequences of severe postoperative pain are prolonged hospital stay, increase hospital readmission, precipitation in the use of opioids with subsequent increase in postoperative nausea and vomiting, and overall low patient satisfaction. Furthermore, postoperative pain can seriously impact the physical and mental health of the patient and lead to secondary complications such as nausea, vomiting, slowed bowel movements, muscle spasms, thrombosis, cardiopulmonary complications and delayed recovery of organ functions. The hip joint is innervated by the articular branches of multiple nerves that emerge from the lumbosacral plexus (L2-S1). The nerve supply to a specific region of the joint typically corresponds to the innervation of the muscle that crosses it :- The femoral nerve innervates the anterior aspect The obturator nerve supplies the inferior aspect The superior gluteal nerve supplies the superior aspect The nerve to the quadratus femoris innervates the posterior aspect. Hip joint capsular innervation was found to consistently involve the femoral and obturator nerves, which supply the anterior capsule, and the nerve to the quadratus femoris, which supplies the posterior capsule. Lumbar erector spinae plane block (LESPB) local anesthetics spread to lumbar paravertebral space and lumbar nerve roots, reaching the nerves responsible for the innervation of the hip joint lumbar plexus nerves - femoral, obturator and lateral femoral cutaneous nerves - providing analgesia for hip surgery. LESPB can be a block easier to perform than other options for hip surgery analgesia, such as posterior lumbar plexus. (L-ESPB) is an effective analgesic technique after hip surgeries. However, an insufficient sensorial blockade of the medial part of the thigh which is innervated by the obturator nerve. The pericapsular nerve group (PENG) block is an ultrasound-guided approach, first described by Giron-Arango et al. for the blockade of the articular branches of the femoral, obturator and accessory obturator nerves that provide sensory innervation to the anterior hip capsule. It has been successfully used as an alternative regional anaesthesia technique for the management of acute pain after hip fracture, but its applications are expanding, suggesting a potential role for analgesia after elective hip surgery. After all the investigators hypothesize that combination of LESPB and PENG block can be more effective in pain control after hip surgeries.

Official Title
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Analgesic Efficacy of Combined Lumbar Erector Spinae Plane Block and Pericapsular Nerve Group Block in Patients Undergoing Hip Surgeries

Conditions
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Lumbar Erector Spinae Plane Block, Pericapsular Nerve Group Block (PENG Block)

Intervention / Treatment
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* Procedure: Ultrasound guided L-ESPB and PENG block using Bupivacaine
* Drug: Postoperative conventional analgesia in form of Acetaminophen


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients aged 18-70 years old American Society of Anesthesiologists (ASA) class I to III Both sex Scheduled for hip surgery. Exclusion Criteria: Refusal to participate Allergy to any of the study drugs Bleeding disorder Localized infection Neurological disease Renal impairment Psychological disorders Opioid dependent Intellectual disability (patients unable to express pain with visual analogue) Morbid obesity.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 70 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Group A: L-ESPB and PENG<br>receiving after end of hip surgery (PENG) block first and (LESPB) at lumber 4 vertebrae level | Procedure: Ultrasound guided L-ESPB and PENG block using Bupivacaine<br>* Combined Lumbar Erector Spinae Plane Block and Pericapsular Nerve Group Block in Patients Undergoing Hip Surgeries<br>* Other names: Lumbar Erector Spinae Plane Block and Pericapsular Nerve Group Block;|
| Active Comparator: Group B: conventional analgesia<br>receiving postoperative conventional analgesia in form of acetaminophen 15 mg/kg/6hrs | Drug: Postoperative conventional analgesia in form of Acetaminophen<br>* Postoperative conventional analgesia in form of acetaminophen 15 mg/kg/6hrs<br>* Other names: Conventional analgesia;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postoperative pain intensity | Postoperative pain intensity using Visual Analogue Scale (VAS) (which is over 10 centimeter scale) (where 0 indicates no pain at all , 10 indicates severe pain) | at 1 hour after the block | 
| Postoperative pain intensity | Postoperative pain intensity using Visual Analogue Scale (VAS) (which is over 10 centimeter scale) (where 0 indicates no pain at all , 10 indicates severe pain) | at 3 hour after the block | 
| Postoperative pain intensity | Postoperative pain intensity using Visual Analogue Scale (VAS) (which is over 10 centimeter scale) (where 0 indicates no pain at all , 10 indicates severe pain) | at 6 hour after the block | 
| Postoperative pain intensity | Postoperative pain intensity using Visual Analogue Scale (VAS) (which is over 10 centimeter scale) (where 0 indicates no pain at all , 10 indicates severe pain) | at 12 hour after the block | 
| Postoperative pain intensity | Postoperative pain intensity using Visual Analogue Scale (VAS) (which is over 10 centimeter scale) (where 0 indicates no pain at all , 10 indicates severe pain) | at 24 hour after the block | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Vital signs | Heart Rate | assessed at preoperative, postoperative (0,3,6,12,24 hours), Value is averaged of total measurements | 
| Vital signs | Arterial Blood Pressure | assessed at preoperative, postoperative (0,3,6,12,24 hours), Value is averaged of total measurements | 
| Vital signs | Arterial Oxygen Saturation | assessed at preoperative, postoperative (0,3,6,12,24 hours), Value is averaged of total measurements | 
| Time to first analgesic administration | Time to first analgesic administration | 24 hours postoperative | 
| Total Analgesic Requirements | Total analgesic requirements in 24 hours postoperative | 24 hours postoperative | 
| Patient satisfaction | patients will be asked to assess their satisfaction :- I Very satisfied. II sometimes satisfied. III Neither satisfied nor dissatisfied. IV Somewhat dissatisfied. V Very dissatisfied. | 24 hours after the block | 
| Adverse events | Either hematoma, infection, postoperative nausea, vomiting orlocal anesthetic systemic toxicity | 24 hours after the block | 
| Block failure (patients still feeling pain immediately after 1 hour from block) | Block failure (patients still feeling pain immediately after 1 hour from block) | 1 hour after the block | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Lumbar Erector Spinae Plane Block, Pericapsular Nerve Group Block, Hip Surgeries, L-ESPB, PENG block