Ultrasound-guided local infiltration analgesia for hip surgery: myth or reality?

Efficacy of pericapsular nerve group block vs. fascia iliaca compartment block for Hip surgeries: A systematic review and meta-analysis

Objective

The review aimed to compare outcomes of pericapsular nerve group block (PENG) vs. fascia iliaca compartment block (FICB) for patients undergoing hip surgeries.

Methods

Randomized controlled trials (RCTs) published in the databases of PubMed, CENTRAL, Embase, and Web of Science comparing PENG vs. FICB for pain control after hip surgeries were included in the review.

Results

Six RCTs were included. 133 patients received PENG block and were compared with 125 patients receiving FICB. Our analysis showed no difference in 6 h (MD: -0.19 95% CI: -1.18, 0.79 I ²= 97% p = 0.70), 12 h (MD: 0.04 95% CI: -0.44, 0.52 I ²= 72% p = 0.88) and 24 h (MD: 0.09 95% CI: -1.03, 1.21 I ²= 97% p = 0.87) pain scores between PENG and FICB groups. Pooled analysis showed that mean opioid consumption in morphine equivalents was significantly less with PENG as compared to FICB (MD: -8.63 95% CI: -14.45, -2.82 I ²= 84% p = 0.004). Meta-analysis of three RCTs showed no variation in the risk of postoperative nausea and vomiting in the two groups. The quality of evidence on GRADE was mostly moderate.

Conclusion

Moderate quality of evidence suggests that PENG may result in better analgesia than FICB in patients undergoing hip surgeries. Data on motor-sparing ability and complications are scarce to draw conclusions. Further large-scale and high-quality RCTs should be conducted to supplement current findings.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022350342.

Does pericapsular nerve group block have limited analgesia at the initial post-operative period? Systematic review and meta-analysis

Perioperative pain management related to hip surgical procedures is challenging. Pericapsular nerve group (PENG) block is a novel technique that is assumed to provide better analgesia in addition to its post-operative motor-sparing effect. In this review, we aim to assess the safety and efficacy of PENG block on pain management in patients undergoing hip surgeries. Fifteen clinical trials with a total of 837 patients were included. Pain scores favored PENG group when compared to FICB group (fascia iliaca compartment block) or analgesics-only group, but the difference could only be detected in the early post-operative period. Afterward, it seems to lose its superiority, and no difference could be detected. In addition, cumulative opioid consumption favored PENG group at 24 h but not at 48 h. Regarding patients' satisfaction, our analysis showed results favoring PENG group, but there was no difference in time to first opioid or length of hospital stay. The incidence of vomiting was lower in PENG, but there was no difference in the incidence of nausea, pruritis, and dizziness. PENG provides better analgesia and lower opioid consumption in the initial post-operative period. Current evidence is not enough, and further high-quality randomized controlled trials with larger sample sizes are required.

Regional anaesthesia: what surgical procedures, what blocks and availability of a “block room”?

PURPOSE OF REVIEW

With an expected rise in day care procedures with enhanced recovery programs, the use of specific regional anaesthesia can be useful. In this review, we will provide insight in the used regional block and medication so far known and its applicability in a day care setting.

RECENT FINDINGS

Regional anaesthesia has been improved with the aid of ultrasound-guided placement. However, it is not commonly used in the outpatient setting. Old, short acting local anaesthetics have found a second life and may be especially beneficial in the ambulatory setting replacing more long-acting local anaesthetics such as bupivacaine.To improve efficiency, a dedicated block room may facilitate the performance of regional anaesthesia. However, cost-efficacy for improved operating time, patient care and hospital efficiency has to be established.

SUMMARY

Regional anaesthesia has proven to be beneficial in ambulatory setting. Several short acting local anaesthetics are favourable over bupivacaine in the day care surgery. And if available, there are reports of the benefit of an additional block room used in a parallel (monitored) care of patients.

The role for high volume local infiltration analgesia with liposomal bupivacaine in total hip arthroplasty: A scoping review

Introduction

Liposomal bupivacaine has been integrated into clinical practice within many surgical disciplines to reduce post-operative pain and opioid consumption. This novel agent has been utilized in this regard in many subdisciplines of orthopedic surgery. Total hip arthroplasty has significant opioid use post-operatively as compared to many other orthopedic disciplines.

Objectives

The purpose of the present investigation is to summarize the current use of liposomal bupivacaine after total hip arthroplasty and to shed light on the prospect of liposomal bupivacaine to reduce opioid use after total hip arthroplasty. A tertiary purpose is to identify future areas of adjunctive pain measures that can assist in the reduction of opioid use after total hip arthroplasty.

Methods

This IRB-exempt scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist strictly. The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. The full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by three authors until an agreement was reached.

Results

A total of 21 articles were included for qualitative description of the opioid epidemic, opioid overuse in total hip arthroplasty, and risk factors for opioid overuse in total hip arthroplasty. A total of 9 articles were included regarding the use of liposomal bupivacaine in total hip arthroplasty. Several risk factors have been identified for opioid overuse after total hip arthroplasty. These include younger age, an opioid risk tool score of > 7, a higher body mass index, chronic obstructive pulmonary disease, immunodeficiency syndromes, preexisting pain syndromes, peripheral vascular disease, anxiety and mood disorders, and substance abuse disorders. Liposomal bupivacaine reduces postoperative opioid use, patient-reported outcomes, length of stay, and time to ambulation, yet is more expensive than traditional bupivacaine.

Conclusions

Liposomal bupivacaine represents a useful adjunct for multimodal pain strategies in total hip arthroplasty with sufficient evidence to suggest that it may be useful in decreasing postoperative opioid use. The high costs of LB represent a barrier to institutional acceptance of LB into standardized multimodal pain strategies. Further efforts should be aimed toward better understanding the current state of integration of LB into academic and private practice settings, industry movements to decrease the cost, and the role other adjunctive measures may have in reducing post-operative opioid use.

Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0-10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0-3.7 [0-7]) vs. 5.5 (5.0-7.0 [2-8]) at 12 h; 3 (2.0-4.0 [0-7]) vs. 6 (5.0-6.0 [2-8]) at 24 h; and 2.0 (2.0-4.0 [0-5]) vs. 3.0 (2.0-4.7 [0-6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.

Pericapsular nerve group block: an overview

INTRODUCTION

The PENG block is a recently described ultrasound-guided technique for the blockade of the sensory nerve branches to the anterior hip joint capsule. It was described as an analgesic block for the acute pain management after hip fracture, while subsequent studies expanded the original indication. The aim of this narrative review was to summarize the existing knowledge about the PENG block from the anatomical bases and to provide an up-to-date description of the technique, applications and effects.

EVIDENCE ACQUISITION

We reviewed the following medical literature databases for publications on PENG block: PubMed, Google Scholar, EMBASE, and Web of science until August 31st, 2020. Data regarding anatomy, indications, drugs and technique were also collected, reported and discussed.

EVIDENCE SYNTHESIS

From our search result we selected 57 relevant publications. Among them, 36 were case reports or case series and 12 publication were letters or correspondence; no RCT was identified. The main indication is the hip-related analgesia. The most commonly injected drug is a 20ml long-acting local anesthetic. There are some cases of femoral and obturator nerve block, but no major complication such as hematoma/bleeding or needle-related organ injury has been reported yet.

CONCLUSIONS

The PENG block is a promising technique. Randomized controlled trials of high methodological quality are required to further elaborate the role of this block.