Newer Horizons for the Pericapsular Nerve Group Block

Sir, Pericapsular nerve group (PENG) block is a novel regional anesthetic technique described for the management of pain in hip fracture patients. PENG block was described by Giron-Arango et al., where he performed the block with 20 mL of the drug.[1] This is an interfascial plane block which acts on the articular branches of femoral, obturator and accessory obturator nerves. In this case report, we describe our experience with using high volume of local anaesthetic in PENG block for the perioperative management of a patient with right posterior column acetabular fracture. A 50-year-old male, weighing approximately 75 kg was posted for elective fixation of fracture acetabulum. It was decided to do the acetabular surgery under general anaesthesia with PENG block. Under standard monitors, he was induced with injection fentanyl 150 μg and injection propofol 150 mg and injection atracurium 40 mg. Following intubation with an endotracheal tube, the PENG block was administered under sterile precautions. A mixture of 20 mL 0.5% ropivacaine, 10 mL 2% lignocaine with adrenaline and 4 mg dexamethasone was prepared. A curvilinear, low-frequency probe was placed over the anterior superior iliac spine and then rotated 45° anticlockwise and aligned toward the inferior pubic ramus. A 22 G, 10 cm nerve stimulator needle was inserted in a lateral to medial direction with in-plane technique aiming for the plane between the psoas tendon and pubic ramus. After negative aspiration, 30 ml of the prepared mixture was administered slowly while watching for the spread. The patient was then positioned for the surgery in lateral decubitus. There was no tachycardia or hypertension on the incision and intraoperative analgesia was supplemented with injection paracetamol 1 g. No long-acting opioids were given. The surgery took 3 h and the patient remained hemodynamically stable. Postoperatively, the patient was very comfortable and his visual analog scores remained below 3 in the first 24 h. He did not require any rescue analgesics and was maintained on injection paracetamol 1 g eighth hourly. Several reports have demonstrated the utility of PENG block in the perioperative management of hip surgeries.[23] Most of the reports have shown the PENG block to be very useful in allowing the patients to be positioned comfortably for subarachnoid block.[4] Recently a study described the landmark technique for this block.[5] Tran et al. showed that the spread of the dye injected for the PENG block was more extensive as the volume of injectate increased.[6] High volume local anesthetic administration in PENG block being used for analgesia in acetabular fracture was shown in a report.[7] Similarly, injecting a large volume of the drug for PENG block is believed to act as a lumbar plexus block, but these findings were not confirmed by cadaveric studies or by injecting dyes.[8] These studies prompted us to make use of PENG block for analgesia for our case and it was found to be effective. More research with clinical and cadaveric studies is required to further explore the indications and volume of drugs needed for the PENG block. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.