50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Pericapsular Nerve Group (PENG) Block Catheter: A Novel Technique for Analgesia and Palliative Care
in Geriatric Hip Fractures

Tanzib Razzaki, MD, Thomas Hurysz, MD, J. Tasker Gundy, MD , Zahraa Majeed MBChB

Department of Anesthesiology & Perioperative Medicine, University of Rochester Medical Center, Rochester, NY

Case:

•An 85-year-old female (49kg) sustained a left hip fracture from a mechanical fall at her nursing home. Past medical history was pertinent for dementia, thoracic and abdominal aortic aneurysms s/p prior endovascular repair, COPD and diabetes.

•During evaluation, an incidental endoleak of her thoracic aneurysm repair was found. Patient was ultimately transferred to the surgical ICU until a decision could be made for next steps either with vascular or orthopedic surgery.

•After interdisciplinary assessment and family discussion, the decision was made to forego hip surgery for the patient given her vascular condition and frailty.

•Although this was no longer a perioperative case, the APS (acute pain service) was consulted as patient was in severe pain radiating into her groin and thigh, with increasing opioid requirements that were causing side effects.

•As patient’s family moved towards comfort measures with Palliative Care, the APS team was able to place a continuous PENG catheter with the goal of reducing opioid needs and limiting further invasive interventions, in keeping with the comfort goals.

Introduction:

•The PENG block represents an emerging and promising regional anesthetic technique for hip fracture management1.

•Peripheral nerve blocks like femoral or fascia iliaca blocks have been traditional mainstays for perioperative analgesia, although they may provide incomplete coverage of the hip joint.

•The PENG block targets the sensory articular branches of the femoral, obturator and accessory obturator nerves2.

•Geriatric patients with hip fracture often have multiple co-morbidities, and in select cases a decision to forego surgery to pursue comfort measures may constitute the goals of care3.

Discussion & Conclusion:

•This case demonstrated the challenge geriatric hip fractures present in terms of pain control and the value of regional anesthesia when surgery is not a viable option.

•In this palliative scenario, the APS team aligned treatment with the family’s goals: non-sedating pain control with minimal invasive procedures.

•The PENG catheter, which delivered 0.125% bupivacaine at 6ml/hr with 5ml 0.25% boluses as needed, provided comfort for our patient and significantly reduced opioid requirements.

• The PENG block can be an effective continuous nerve block via catheter to uniquely facilitate both analgesia and palliative care in select geriatric patients.

•Further research is needed to explore optimal pharmacologic strategies for continuous PENG catheters, and to standardize technique for placement, tunneling, and securement4,5.

References:

1.Girón‑Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular nerve group (PENG) block for hip fracture. Reg Anesth Pain Med 2018;43:859‑63.

2.Kolli S, Nimma SR, Kukreja P, et al. How I do it: pericapsular nerve group (PENG) block. ASRA Pain Medicine News 2023;48.

3.Hung WW, Egol KA, Zuckerman JD, Siu AL. Hip Fracture Management: Tailoring Care for the Older Patient. JAMA. 2012;307(20):2185–2194. doi:10.1001/jama.2012.4842

4.Del Buono R, Padua E, Pascarella G, Soare CG, Barbara E. Continuous PENG block for hip fracture: a case series. Reg Anesth Pain Med. 2020;45(10):835-838. doi:10.1136/rapm-2020-101446

5.Rengaraj P, Vishnampettai Vaidyanathan S. Effectiveness of a PENG catheter and the implications and a complication of tunnelling. BMJ Case Rep. 2022;15(12):e252901. Published 2022 Dec 30. doi:10.1136/bcr-2022-252901

50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

PERICAPSULAR NERVE GROUP (PENG) BLOCK CATHETER: A NOVEL TECHNIQUE FOR ANALGESIA AND PALLIATIVE CARE IN GERIATRIC HIP FRACTURES

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