Utilization of a Continuous Pericapsular Nerve Group (PENG) Block with an Opioid-Sparing Repair of a Femoral Neck Fracture in a Pediatric Patient

Abstract

In the pediatric population, femoral neck fractures are usually associated with high-impact trauma and often present with pain in the groin area. Regional anesthesia can offer adjunctive therapy for acute pain management. Various techniques have been employed to circumvent pain related to hip fractures and resultant hip surgery. Neuraxial, lumbar plexus, caudal, epidural, fascia iliaca, and femoral continuous nerve block techniques are advantageous in mitigating hip pain. However, these approaches require patient repositioning during placement and carry the potential for motor blockade with resultant weakness. A newly described method, the Pericapsular Nerve Group (PENG) block, allows for analgesia of the anterior hip capsule via the obturator, accessory obturator, and femoral nerves while sparing motor blockade. PENG blockade has demonstrated efficacy in both adult and pediatric patients. Herein, we describe the perioperative course of a 9-year-old girl with a transcervical femoral neck fracture who underwent an opioid-sparing open repair with the utilization of a continuous PENG block. PENG blockade via a continuous nerve block resulted in optimal analgesia and markedly reduced perioperative opioid consumption with preserved motor function. Our experience facilitated early discharge and rehabilitation mobility while reducing potential rebound hyperalgesia and enabling parental/patient satisfaction.

Pericapsular nervegroup (PENG) block—a scoping review

“…The combination of PENG and FN block was successful in providing acceptable analgesia in a paediatric patient with pain of the hip and thigh related to vaso-occlusive crisis (sickle cell disease) (Wyatt et al, 2020a , b ). This combination was chosen based on the possible site of pain generators in that patient.…”

“…Local anaesthetics like bupivacaine, lidocaine, levobupivacaine, ropivacaine, and mepivacaine have all been used successfully in different concentrations, alone as well as in combination (Girón-Arango et al, 2018 ; Jadon et al, 2020a , b ; Pagano et al, 2019 ; Aydin et al, 2020 ). Some researchers have also added dexamethasone and epinephrine to local anaesthetic (Luftig et al, 2020 ; Girón-Arango et al, 2018 ; Yu et al, 2019 ; Fusco et al, 2019 ; Orozco et al, 2019 ; Acharya & Lamsal, 2020 ; Wyatt et al, 2020a , b ; Sandri et al, 2020 ; Fusco et al, 2020a , b ; Mysore et al, 2020 ; Talawar et al, 2020 ; Ayub et al, 2020 ). Index description used 20 ml volume in the block and the use of a similar volume is reported in most of the subsequent publications (Girón-Arango et al, 2018 ).…”

“…Literature suggests the theoretical possibility of subpectineal obturator nerve block with the administration of a higher volume and proposed it as an alternative to lumbar plexus block (Ahiskalioglu et al, 2020a ). Continuous PENG block, infusing local anaesthetic at the rate of 5ml/h and 7ml/h (believed to have added advantage of the distal femoralblock), has also been demonstrated to be an efficient technique (Singh, 2021 ; Santos et al, 2019 ; Wyatt et al, 2020a , b ; Del Buono et al, 2020 ; Singh et al, 2020 ; Jacob Wolf, 2019 ; Prado-Kittel et al, 2020 ; Singh, 2020 ).…”

“…Later on, it has been used in elderly and paediatric patients and even in fragile co-morbid patients (Luftig et al, 2020 ; Yu et al, 2019 ; Ince et al, 2020 ; Santos et al, 2019 ; Shankar et al, 2020 ; Aksu et al, 2020a ; Orozco et al, 2019 ; Wyatt et al, 2020a , b ; Ince & Kilicaslan, 2020 ; Fusco et al, 2020a , b ; Romero et al, 2019 ; Ahiskalioglu et al, 2020a , b ; Wyatt et al, 2020a , b ; Wolf, 2019 ; Singh, 2020 ; Thallaj, 2019 ; Fusco et al, 2020a , b ; Jaramillo et al, 2020 ). Perioperatively, it has been used alone or in combination with general and other regional techniques as an analgesic or anaesthetic technique in open and arthroscopic hip surgery, hip positioning, acetabular fracture, pelvic fractures, surgery of medial thigh, vein ligation and stripping surgery, in the prevention of adductor muscle spasm during TURBT, and during the management of the acute phase of opioid- resistant hip vaso-occlusive crisis (Luftig et al, 2020 ; Shankar et al, 2020 ; Bilal et al, 2020 ; Orozco et al, 2019 ; Acharya & Lamsal, 2020 ; Aydin et al, 2020 ; Wyatt et al, 2020a , b ; Sandri et al, 2020 ; Ayub et al, 2020 ; Ahiskalioglu et al, 2020a ; Ahiskalioglu et al, 2020b ; Prado-Kittel et al, 2020 ; Orozco et al, 2020 ; Alrefaey & Abouelela, 2020 ; Sahoo et al, 2020 ). Its successful use for postoperative analgesia, both with a single injection and continuous infusion, has also been reported (Fusco et al, 2019 ; Aksu et al, 2020a ; Roy et al, 2019 ; Casas Reza et al, 2020 ; Mysore et al, 2020 ; Thallaj, 2019 ).…”

“…Its successful use for postoperative analgesia, both with a single injection and continuous infusion, has also been reported (Fusco et al, 2019 ; Aksu et al, 2020a ; Roy et al, 2019 ; Casas Reza et al, 2020 ; Mysore et al, 2020 ; Thallaj, 2019 ). The use of catheters has been suggested to further extend the duration of analgesia, while simultaneously minimizing the needed volume of drug and preventing rebound hyperalgesia (Singh, 2021 ; Wyatt et al, 2020a , b ). In fact, its potential as the first step in embarking outpatient total hip arthroplasty in light of the reduction of pain, post-op medical and surgical complications, and thus duration of hospital stay has been mentioned (Remily et al, 2020 ).…”