What do we know about the PENG block for hip surgery? A narrative review / ¿Qué conocemos del bloqueo PENG para cirugía de cadera? Una revisión narrativa

Abstract Postoperative pain management in hip surgery is classified as severe and its inadequate control leads to complications that increase patient morbidity and mortality. The PENG block is advocated as a safe, opioid-sparing analgesic technique, which provides an adequate level of analgesia. The purpose of this study is to analyze about the efficacy, safety and therapeutic appropriateness of the PENG block in hip surgery. To this end, a narrative review is conducted using various databases such as PubMed and the Cochrane library. In all of the studies analyzed, an adequate postoperative pain control was achieved using the PENG block, with reduction in pain assessment scales and opioid consumption in the first postoperative hours. Improved results were also seen as compared with other regional blocks. There were few adverse effects and none of them was classified as severe. The PENG block contributes with numerous advantages and few adverse effects for hip surgery. Further studies are needed on this block, whether alone or in combination with other regional techniques, so as to include it in analgesia protocols, developing a standardized approach and study the outcomes in more controlled settings.

Resumen El manejo del dolor posoperatorio en cirugía de cadera se cataloga como severo y su inadecuado control conduce a complicaciones que aumentan la morbimortalidad de los pacientes. El bloqueo PENG se postula como una técnica analgésica segura, ahorradora de opioides, que otorga un nivel analgésico adecuado. El objetivo de este estudio es analizar acerca de la eficacia, seguridad y el lugar terapéutico del bloqueo PENG en cirugía de cadera. Para ello, se hace una revisión narrativa utilizando distintas bases de datos como PubMed y la biblioteca Cochrane. En todos los estudios analizados se observó un adecuado control del dolor posoperatorio con el uso del bloqueo PENG, con reducción en las escalas de evaluación del dolor y en el consumo de opioides en las primeras horas del posoperatorio. También se evidenciaron mejores resultados en comparación con otros bloqueos regionales. Los efectos adversos fueron escasos, y ninguno se catalogó como grave. El bloqueo PENG aporta numerosas ventajas con escasos efectos adversos para cirugía de cadera. Es necesario continuar estudiando este bloqueo, solo o en combinación con otras técnicas regionales, e incluirlo en protocolos de analgesia, estandarizarlo y estudiar sus resultados en escenarios más controlados.

The impact of IPACK combined with adductor canal block under ultrasound guidance on early motor function after total knee arthroplasty.

BACKGROUND: This study aimed to evaluate the impact of Infiltration between the Popliteal Artery and Capsule of the posterior Knee (IPACK) combined with an adductor canal block under the guidance of ultrasound on early motor function after Total Knee Arthroplasty (TKA). METHODS: A sample of 60 cases who were scheduled for elective unilateral TKA were divided into two groups using random number table method: a group with IPACK combined with an adductor canal block (I group, n = 30), and a group with femoral nerve block combined with superior popliteal sciatic nerve block (FS group, n = 30). Before anesthesia induction was completed, the patients in I group received an ultrasound-guided adductor canal block with 15 mL of 0.375% ropivacaine and an IPACK block with 25 mL of ropivacaine, and the patients in FS group received a femoral nerve block and a superior popliteal sciatic nerve block with 20 mL of 0.375% ropivacaine under ultrasound guidance. Post-operation, all the patients received patient-controlled intravenous analgesia combined with an oral celecoxib capsule to relieve pain and maintain a visual analogue scale score of ≤ 3. RESULTS: The quadriceps femoris muscle strength score was significantly higher in Ⅰ group than in FS group (p = 0.001), while the modified Bromage score were significantly lower and walking distance results were significantly higher in Ⅰ group than in FS group (both p = 0.000). CONCLUSION: Compared with femoral nerve block combined with superior popliteal sciatic nerve block, IPACK combined with adductor canal block had a mild impact on early motor functions after TKA.

Which types of peripheral nerve blocks should be included in residency training programs?

BACKGROUND: Despite the increasing use of regional anesthesia, specific recommendations regarding the type of procedures to be included in residency training programs are not currently available. We aimed to determine the nerve block techniques that practicing Chilean anesthesiologists perceived as essential to master during residency training. METHODS: After institutional ethics committee approval, an online survey was sent to 154 anesthesiologists that graduated between 2005-2012, from the two largest university residency programs in Chile. Multiple-choice questions elicited responses concerning the use of regional anesthesia. RESULTS: A total of 109 questionnaires were completed, which corresponded to a response rate of 70.8%. Almost all (98.2%) of the respondents used regional anesthesia in their clinical practice, 86.7% regularly performed peripheral nerve blocks (PNBs) and 51% used continuous PNB techniques. Residency programs represented their primary source of training. The most common PNB techniques performed were interscalene (100%), femoral (98%), popliteal sciatic (93%), and Bier block (90%). Respondents indicated that they were most confident performing femoral (98%), Bier block (90%), interscalene (90%), and popliteal sciatic (85%) blocks. The PNBs perceived as essential for their actual clinical practice were femoral (81%), interscalene (80%), popliteal sciatic (76%), and Bier blocks (62%). CONCLUSIONS: Requesting information from former anesthesiology residents may be a source of information, guiding the specific types of PNBs that should be included in residency training. Other groups can easily replicate this methodology to create their own evidence and clinical practice based guidelines for residency training programs.

Tratamento da dor neuropática crônica pós-trauma com o uso do bloqueio periférico: relato de caso / Treatment of post-traumatic chronic neuropathic pain with peripheral block: case report

JUSTIFICATIVA E OBJETIVOS: As dores neuropáticas podem apresentar sinais inequívocos, mas, podem ser de difícil diagnóstico e o tratamento é difícil. O objetivo deste estudo foi relatar o caso de um paciente com dor crônica pós-traumática, com baixa adesão ao tratamento farmacológico e que foi tratado com bloqueios periféricos e adjuvantes. RELATO DO CASO: Paciente do gênero masculino, 42 anos, sofreu acidente automobilístico com trauma no quadril e na região lombar direita. Foi submetido à laparotomia exploradora com nefrectomia direita, osteossíntese de fêmur direito e de semilunar direito. Evoluiu com dor na região lombar direita que não melhorava com as medicações prescritas e com baixa adesão ao esquema terapêutico proposto, devido a sua difícil situação socioeconômica. Optou-se pelos bloqueios de nervos periféricos, em cinco sessões, realizados em regime ambulatorial. CONCLUSÃO: O tratamento com os bloqueios de nervos periféricos na região lombar foi eficaz e reduziu as sintomatologias da dor neuropática em até 60%, permanecendo com intensidade entre 3 e 4 pela escala analógica visual e ausência de dor ao toque da cicatriz.

BACKGROUND AND OBJECTIVES: Neuropathic pain may have earmarks, but may be difficult to diagnose and treat. This study aimed at reporting a case of post-traumatic chronic pain, with poor adherence to pharmacological treatment, which was treated with peripheral blocks and adjuvants. CASE REPORT: Male patient, 42 years old, who suffered a car accident with hip and right lumbar region trauma. Patient was submitted to laparotomy with right nephrectomy, right femur and right lunate osteosynthesis. Patient evolved with right lumbar region pain not improving with prescribed drugs and with poor adherence to proposed therapeutic approach due to his difficult socio-economic status. We decided for peripheral nerve blocks in five sessions, in outpatient regimen. CONCLUSION: Treatment with peripheral nerve blocks in the lumbar region was effective and has decreased neuropathic pain symptoms in up to 60%, remaining with intensity between 3 and 4 by the visual analog scale and with no pain when the scar was touched.