Review of Current Practices of Peripheral Nerve Blocks for Hip Fracture and Surgery

Comparing the Efficacy of Landmark-Based Fascia Iliaca Compartment Block and Pericapsular Nerve Group Block for Preoperative Positioning and Postoperative Analgesia in Patients Undergoing Surgery for Hip Fractures: A Randomized Controlled Trial

BACKGROUND

Subarachnoid block is the most common anesthetic technique for patients having corrective hip surgeries. However, adequate positioning for a successful subarachnoid block is a major challenge in this particular population of patients, owing to the site of fracture. Regional anesthesia, in the form of nerve blocks, is an effective means of alleviating such constraints and gives an added benefit of prolonged postoperative analgesia. The pericapsular nerve group (PENG) block and the fascia iliaca compartment block (FICB), under ultrasonography guidance, are a few examples of the commonly performed peripheral nerve blocks in such settings. However, the landmark-based techniques of nerve blockade still hold good in many resource poor settings, given the lack of ultrasonography facilities.

AIM

To compare the ease of spinal positioning using the patient sitting satisfaction score between the landmark-guided FICB and PENG block.

MATERIALS AND METHODS

This study was done on 80 patients of the American Society of Anesthesiology (ASA) grade I or II with intertrochanteric fractures of the hip joint scheduled for proximal femoral nailing. Patients were allocated into two groups of 40 each through computer generated random numbers, to receive 30 ml of 0.5% ropivacaine via the landmark-guided technique of FICB in Group F and peripheral nerve stimulator assisted landmark-guided PENG block in Group P, 30 minutes prior to spinal positioning. Time to passive leg raise (PLR) to 15 degrees and time to PLR to 30 degrees with a standard goniometer guidance at visual analogue scale (VAS) score < 4 and ease of spinal positioning through the sitting satisfaction score at the 30th minute were assessed. Any adverse effects and events of failure were noted. The duration of postoperative analgesia was measured through the time to the first dose of paracetamol on arrival at the post-anesthesia care unit.

RESULTS

Statistical analysis was done using JASP version (0.18.3.0) using the independent samples t-test and significance was taken when p value was < 0.001. The time to PLR to 15 degrees and 30 degrees were achieved faster in the patients who received the PENG block in comparison to the patients who received the FICB, and the average patient sitting satisfaction score was significantly higher in Group P as compared to Group F (p < 0.001). While the overall amount of analgesics used in both groups was similar, the overall period of postoperative analgesia was prolonged in Group F compared to Group P (p < 0.001).

CONCLUSION

The landmark guided PENG block is feasible and superior to the landmark-guided FICB for preoperative positioning and analgesia. The FICB provides a longer duration of postoperative analgesia for patients with intertrochanteric fractures.

Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis

STUDY OBJECTIVE

We conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block types for preoperative pain management of hip fractures.

METHODS

We searched Cochrane, Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar for randomized clinical trials. We included participants aged more than 16 years with hip fractures who received peripheral nerve blocks or analgesics for preoperative pain management. The primary outcomes were defined as absolute pain score 2 hours after block placement, preoperative consumption of morphine equivalents, and length of hospital stay. We used a random-effects network meta-analysis conceptualized in the Bayesian framework. Confidence of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA).

RESULTS

We included 63 randomized controlled studies (4,778 participants), of which only a few had a low risk of bias. The femoral nerve block, 3-in-1 block, fascia iliaca compartment block, and pericapsular nerve group block yielded significantly lowered pain scores at 2 hours after block placement compared with those with no block (standardized mean differences [SMD]: -1.1; 95% credible interval [CrI]: -1.7 to -0.48, [confidence of evidence: low]; SMD: -1.8; 95% CrI: -3.0 to -0.55, [low]; SMD: -1.4; 95% CrI: -2.0 to -0.72, [low]; SMD: -2.3; 95% CrI: -3.2 to -1.4, [moderate], respectively). The pericapsular nerve group block, 3-in-1 block, fascia iliaca compartment block, and femoral nerve block resulted in lower pain scores than the no-block group. Additionally, the pericapsular nerve group block yielded a lower pain score than femoral nerve block or fascia iliaca compartment block (SMD: -1.21; 95% CrI: -2.18 to -0.23, [very low]: SMD: -0.92; 95% CrI: -1.70 to -0.16, [low]). However, both the fascia iliaca compartment block and femoral nerve block did not show a reduction in morphine consumption compared with no block. To our knowledge, no studies have compared the pericapsular nerve group block with other methods regarding morphine consumption. Furthermore, no significant difference was observed between peripheral nerve blocks and no block in terms of the length of hospital stay.

CONCLUSIONS

Compared with no block, preoperative peripheral nerve blocks for hip fractures appear to reduce pain 2 hours after block placement. Comparing different blocks, pericapsular nerve group block might be superior to fascia iliaca compartment block and femoral nerve block for pain relief, though the confidence evidence was low in most comparisons because of the moderate to high risk of bias in many of the included studies and the high heterogeneity of treatment strategies across studies. Therefore, further high-quality research is needed.

Lumbar Erector Spinae Plane Block for Dega Pelvic Osteotomy in a Pediatric Patient With Complex Neurological Issues: A Case Report

The erector spinae plane (ESP) block, initially designed for thoracic analgesia, has evolved into a versatile regional anesthesia technique with literature support for success in numerous contexts. In this case report, we highlight the successful application of ESP to provide postoperative analgesia for pediatric Dega osteotomy involving both the femoral head and acetabulum, in a patient with numerous neurological comorbidities that would have weighed against some more traditional regional anesthesia techniques. This case further highlights the versatility of ESP, demonstrating its use in blocking lumbar nerve roots in a pediatric patient with complex neurological challenges.

Comparative Evaluation of Analgesic Efficacy of Ultrasound-Guided Pericapsular Nerve Group Block and Femoral Nerve Block During Positioning of Patients With Hip Fractures for Spinal Anesthesia: A Prospective, Double-Blind, Randomized Controlled Study

INTRODUCTION

Hip fractures cause severe pain during positioning for spinal anesthesia (SA). Intravenous systemic analgesics can lead to various complications in elderly patients, hence peripheral nerve blocks are emerging as a standard of care in pain management for hip fractures, among which femoral nerve block (FNB) is widely known and practiced. Pericapsular nerve group (PENG) block is a recently described technique that blocks the articular nerves of the hip with motor-sparing effects and is used to manage positional pain in hip fractures. This study aims to evaluate the analgesic efficacy of PENG block over FNB in managing pain during positioning before SA in hip fractures.

MATERIALS AND METHODS

This was a prospective, randomized, double-blinded study. After ethical clearance, 70 patients undergoing hip fracture surgery under SA in a tertiary-care hospital were recruited and randomized to receive either ultrasound-guided PENG block or FNB with 20 ml of 0.25% bupivacaine before performing SA. We compared pain severity using the visual analog scale (VAS) 15 and 30 minutes after the block and during positioning. The sitting angle, requirement of rescue analgesia for positioning, and anesthesiologist and patient satisfaction scores were also analyzed. Continuous data were analyzed with an unpaired t-test while the chi-square test was used for categorical data.

RESULTS

There was a significant reduction in VAS scores after PENG block (PENG: 0.66 ± 1.05 and FNB: 1.94 ± 1.90; p = 0.001) with lesser requirement of rescue analgesia for positioning compared to FNB. The anesthesiologist and patient satisfaction scores were also significantly better in the PENG group.

CONCLUSION

PENG block offers better analgesia for positioning before SA than FNB without any significant side effects, and improves patient and anesthesiologist satisfaction, thus proving to be an effective analgesic alternative for painful hip fractures.

Comparison of the Analgesic Efficacy between Levobupivacaine 0.25% and Ropivacaine 0.375% for PENG (Pericapsular Nerve Group) Block in the Context of Hip Fracture Surgery of Elderly Patients: A Single-Center, Randomized, and Controlled Clinical Trial

Previous studies have compared levobupivacaine versus ropivacaine in various peripheral nerve blocks in terms of block duration, quality of analgesia, and onset time, but this has not occurred in the PENG block. Here, a single-center, randomized, and controlled clinical trial is presented. One hundred and twenty patients older than 65 years suffering from hip fractures and surgically treated at our institution under spinal anesthesia were eligible for participation; of them, one hundred and eight were analyzed. Patients were randomized to receive ultrasound-guided PENG blocks using 20 mL of either 0.25% levobupivacaine or 0.375% ropivacaine (both of which are equipotent concentrations). The primary endpoint was to compare the analgesic duration (time to first rescue) and analgesic quality (pain scores using the VAS, PAINAD, and AlgoPlus scales) between the groups. Secondary endpoints included comparing the onset time, describing the need for and type of rescue analgesics, and possible associated adverse effects. There were no statistically significant differences in analgesic duration between levobupivacaine (median 861.0, IQR 960) and ropivacaine (median 1205.0, IQR 1379; p = 0.069). Likewise, the quality of analgesia and onset time were comparable among the groups. A small number of patients required opioids as rescue analgesics (4.6%). The possible associated adverse effects included postoperative infection (11.1%) and delirium (2.8%).

Effects of posterior lumbar plexus block on anesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric comminuted fractures

To study the effect of posterior lumbar plexus nerve block on anaesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures. The research subjects selected 48 patients with postmenopausal osteoporotic subtrochanteric comminuted fractures who were hospitalized between January 2020 and January 2022, and were allocated to clusters according to the random number TBL approach. The controlling cluster (24 situations) underwent dura mater Under external anesthesia, the test cluster (24 situations) underwent posterior lumbar plexus block, and the block effect, anesthesia effect, sedation effect, hemodynamics, vital signs and reactions of adverse nature were contrasted involving the two clusters. In comparison to the control group, the test group had a longer duration of anesthesia and motor block, higher oxygenation indices but lower ITBVI, GEDVI, and ScrO2 values, lower MAP levels, and lower BIS contraction values at 5, 15, and 30 minutes following anesthesia (P < 0.05). The test group had shorter induction time and block onset time compared to the control group (P < 0.05), and a lower incidence of adverse reactions (16.67% vs. 29.17% in the control group), but the variation was not noTBL (P < 0.05). Posterior lumbar plexus nerve block in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures has a better sedative effect, shortens the induction time of anaesthesia and the onset of block, promotes sTBL haemodynamic indexes and has fewer adverse effects to ensure safety.

Lumbar Plexus Nerve Blocks for Perioperative Pain Management in Cerebral Palsy Patients Undergoing Hip Reconstruction: More Effective Than General Anesthesia and Epidurals

BACKGROUND

Hip reconstruction in patients with cerebral palsy (CP) is associated with. significant postoperative pain. However, adequate analgesia can be difficult to achieve. in this population due to spasticity, communication barriers, and postoperative. spasticity. Recently, multimodal pain management techniques such as epidurals and. regional nerve blocks have been described for postoperative pain control, but it is unclear if 1 technique is more beneficial. The purpose of this study was to compare the outcomes of different perioperative pain management techniques.

METHODS

This study is a retrospective review of a consecutive series of children with CP over a 5-year period at a single pediatric tertiary-care hospital who underwent hip reconstruction (proximal femoral osteotomy with or without a pelvic osteotomy). Patients were subdivided based on their anesthetic protocol into the following groups: general anesthesia alone (G), general anesthesia with an epidural (E), and general anesthesia with lumbar plexus block (LPB). Our primary outcome was cumulative postoperative narcotic consumption (converted to morphine equivalents). Secondary outcomes included length of stay (LOS), average postoperative heart rate, and pain scores. analysis of variance testing was utilized to compare differences between the groups.

RESULTS

Fifty-four patients who underwent hip reconstruction were included: 19 in the G group, 18 in the E group, and 17 in the LPB group. LOS was significantly higher in the E group compared with the G and LPB groups: F(2,51)=3.58, P=0.04. The average pain score was significantly lower in the LPB group compared with the others: F(2,51)=4.26, P=0.02. The average postoperative heart rate was significantly lower in the LPB group: F(2,51)=7.08, P<0.01. Postoperative narcotic consumption was significantly lower in the LPB group: F(2,51)=11.57, P<0.01.

CONCLUSION

The LPB patients required the least amount of narcotics compared with the other groups. This, combined with a lower perioperative heart rate and shorter LOS would suggest these patients experienced less pain over the time of their in-patient stay. In comparison to general anesthesia alone and epidural anesthesia, lumbar plexus nerve blocks are an effective pathway for postoperative pain control after hip reconstruction in a CP population.

LEVEL OF EVIDENCE

Level III-Case control or retrospective comparative study.

Unilateral sacral erector spinae plane block for lower limb surgery in children

The erector spinae plane block is a versatile regional anaesthesia technique used for a variety of truncal surgeries. A novel variation is the sacral erector spinae plane block which is gaining popularity for perineal and anorectal procedures. Local anaesthetic injected at this level blocks the sacral dermatomes and has the potential for more proximal spread to involve lumbar nerve fibres via spread to the lumbar plexus or the epidural space. The advantage of a sacral erector spinae plane block over a neuraxial block is that it is less invasive and may have a better safety profile: there is a reduced risk of epidural haematoma, epidural abscess, haemodynamic instability and motor weakness of the lower extremities. Until now, this approach has been used for midline surgical procedures when the local anaesthetic was injected bilaterally. Its application for lower limb procedures with a single unilateral injection has not been described. We report the use of a unilateral sacral erector spinae plane block at the level of the S2 median crest in two children undergoing lower limb procedures of the hip and thigh. The block was found to provide effective peri-operative analgesia with minimal need for any opioid analgesics and without any significant adverse effects.

Pericapsular nervegroup (PENG) block—a scoping review

The obturator nerve and its accessory branch supplying the hip region, unlike the femoral nerve, are not adequately anaesthetized by conventional regional anaesthetic techniques targeting the hip region. With advancements in ultrasound-guided regional anaesthetic techniques, interests are revived in the field and efforts are being made to block them together. One such successful attempt is the novel peri-capsular nerve group (PENG) block. Consequently, further research on the PENG block began to explore its versatilities. The present study undertakes a scoping review of research on the PENG block in humans for any indication to determine the extent of the research done, the methodologies used, and other practical issues addressed in the research. This will help to identify potential research gaps that should be addressed in the future. PubMed, Google Scholar, Cochrane Library, KoreaMed, Latin American and Caribbean Health Science Literature, and the directory of open access journals were searched with the keyword “PENG block” and “pericapsular nerve group”. Manual search of electronically retrieved papers was also carried out. Among the 67 articles selected in our review, eighteen are case series; twenty-nine are case reports; two are randomized studies; one each of prospective cohort study, review, and cadaveric study; and 15 are editorials. However, only 64 articles were included later due to the retraction of three case reports. Data is insufficient to provide firm recommendations for or against different aspects of the block. The review encourages future work addressing different aspects of the PENG block.

Transmuscular Quadratus Lumborum Block versus Infrainguinal Fascia Iliaca Nerve Block for Patients Undergoing Elective Hip Replacement: A Double-blinded, Pilot, Randomized Controlled Trial

Purpose

Transmuscular quadratus lumborum (TQL) block has been described as an effective option for postoperative analgesia in patients undergoing hip replacement with single injection described as providing analgesia for up to 24 h. We hypothesize that a TQL block, when compared to fascia iliaca block (FIB), will provide better analgesia and less motor block in the initial 24-h postoperative period.

Patients and Methods

Fifty patients undergoing elective hip replacement surgery, ASA I–III, were included in the study. Patients were randomized into two groups. Patients in group A received spinal anesthesia followed by FIB. Patients in group B received spinal anesthesia followed by TQLB. Postoperative pain scores and motor block were assessed at 6 and 24 hours. The primary outcome measure was 24 h total morphine consumption. Secondary outcome measures included pain score (VNS) and motor block (modified Bromage scale) at 6 and 24 h postoperatively.

Results

There was no statistical difference in morphine consumption between the two groups (p-value 0.699). There was no difference in pain scores at 6 h (p-value 0.540) or 24 h (p-value 0.383). There was no difference in motor block at 6 h (p-value 0.497) or at 24 h (p-value 0.773).

Conclusion

Transmuscular quadratus lumborum block along with spinal anesthesia for patients undergoing elective hip replacement surgery does not reduce opioid consumption or motor weakness when compared to fascia iliaca block. The results and conclusion apply to a dose of 20 mL of 0.25% bupivacaine used in each group.

Applications of Ultrasound in the Postoperative Period: A Review

Background Recent advances in ultrasound technology have further increased its potential for routine use by plastic and reconstructive surgeons.

Methods An extensive literature review was performed to determine the most common applications of ultrasound in the postoperative care of plastic and reconstructive surgery patients.

Results In contrast with other available imaging modalities, ultrasound is cost-effective, rapid to obtain, eliminates the need for ionizing radiation or intravenous contrast, and has virtually no contraindications. In addition to its diagnostic capabilities, ultrasound can also be used to facilitate treatment of common postoperative concerns conveniently at the bedside or in an office setting.

Conclusion This article presents a review of the current applications of ultrasound imaging in the postoperative care of plastic and reconstructive surgery patients, including free flap monitoring following microsurgery, diagnosis and treatment of hematoma and seroma, including those associated with BIA-ALCL, and breast implant surveillance.

Role of regional anesthesia in Enhanced Recovery After Surgery (ERAS) protocols

PURPOSE OF REVIEW

Enhanced Recovery After Surgery (ERAS) protocols and interventional locoregional anesthesia (LRA) techniques continuously evolve. This review outlines the latest recommendations for the use of regional anesthesia in ERAS protocols and emerging interventional analgesia techniques.

RECENT FINDINGS

Research in ultrasound-guided regional anesthesia has led to a refinement of the traditional techniques and the introduction of a number of new approaches to complement ERAS strategies. The efficacy and versatility of LRA enable its use in an increasing number of ERAS indications.

SUMMARY

The implementation of ERAS protocols in different surgical procedures reduces overall complications and recovery time. Multimodal analgesia strategies with regional anesthesia techniques are some of the key interventions contributing to the improvement in postoperative outcomes.