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49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting
March 21-23, 2024 | The Hilton Bayfront San Diego | San Diego, California
5559
COMBINATION PENG AND FASCIA ILIACA BLOCKS FOR HIP FRACTURE
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Medically Challenging Cases
Combination PENG and Fascia Iliaca Blocks for Hip Fracture
Introduction
•Hip fractures in elderly adults are associated with multiple comorbidities.
•Optimal analgesic regimen with minimal side effects like sedation or muscle weakness has yet to be described.
•Peripheral nerve blocks targeting the anterior and superolateral capsule include the femoral, obturator, and accessory obturator nerves.
•Options for regional analgesia include:
- Femoral nerve block (FNB)
- Fascia iliaca block (FI)
- PENG block
•Quadriceps weakness can compromise recovery and increase fall risk where rapid postoperative mobilization is prioritized.
•PENG blocks target articular branches of the hip with minimal muscle weakness but spare the lateral femoral cutaneous nerve which carries incisional pain.
Case Report
64-year-old 100kg male with BMI 31 kg/m2 and no significant PMHpresented with a left hip intertrochanteric fracture after a fall from a bicycle.
Discussion
•We demonstrated an approach to hip analgesia using both FI and PENG.
•Different local anesthetic combinations can be used in different anatomic locations to best achieve the desired results.
•FNB and FI have proven effective in providing analgesia, but motor block is an issue for rapid mobilization. Evidence for PENG is mixed but is reliably motor-sparing if avoiding intramuscular injection.
•We chose FI block with 0.25% bupivacaine to minimize risk of weakness from femoral nerve blockade during PT the next day while still providing analgesic benefit overnight since he would not be mobilized until 18 hours post-block.
•PENG was added to block afferent nerves not covered by the FI with 20mL 0.5% bupivacaine, a higher concentration, since risk of weakness is less than FI.
•PENG and FI do not need to be mutually exclusive. Both have been shown to be effective in spread to desired targets with 20mL or less.
•Hip analgesia remains an issue. He required some opioid likely contributing to urinary retention.
•Longer acting local anesthetics or continuous catheters can be beneficial in his population if placed in motor-sparing locations. We often utilize continuous FI catheters in patients less likely to participate in physical therapy.