Surgery Book

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PENG Regional Anesthesia

Aka: PENG Regional Anesthesia, PENG Block, Pericapsular Nerve Group Block
  1. See Also
    1. Fascia Iliaca Block
    2. Femoral Nerve Block
    3. Hip Fracture
    4. Regional Anesthesia (Nerve Block)
    5. Local Skin Anesthesia
    6. Point of Care Ultrasound (POCUS)
  2. Background
    1. First described in 2018 for hip arthroplasty patients
  3. Mechanism
    1. Interfascial plane block with Anesthesia to femoral nerve, obturator nerve, and accessory obturator nerve
    2. Hip Joint articular branches (esp. accessory obturator) branches above the level of other common hip Nerve Blocks
      1. PENG Block includes these nerves
    3. PENG Block does not completely anesthetize the Hip Joint
      1. Posteromedial hip capsule is innervated by sciatic nerve which is not included in this block
  4. Indications
    1. Regional Anesthesia covering proximal femur (hip and anterior medial thigh) to knee
    2. Also provides Regional Anesthesia to medial lower leg and ankle
    3. Acetabular Fracture
    4. Femoral Neck Fracture (also covered by Fascia Iliaca Block)
    5. Mid-shaft Femur Fracture (also covered by Femoral Nerve Block)
  5. Contraindications
    1. Coagulopathy (e.g. Warfarin, Rivaroxaban, Clopidogrel)
    2. Multi-system Trauma
    3. Compartment Syndrome
  6. Complications
    1. See Regional Anesthesia
    2. Local Anesthetic Systemic Toxicity (LAST Reaction)
  7. Technique
    1. Images
      1. hipPENGnerveBlock.jpg
    2. Preparation
      1. Chlorhexidine or Povidone-Iodine Skin Preparation
      2. Patient in supine position
    3. Ultrasound Probe
      1. Low frequency curvilinear transducer
    4. In-Plane Technique
      1. Transverse plane with Ultrasound probe parallel to the inguinal ligament
      2. Start in transverse plane over the femoral head and slide superiorly up to anterior inferior iliac spine (AIIS)
        1. May also slide medially along the inguinal crease from the ASIS to the AIIS
      3. Slide probe back inferiorly to visualize the psoas tendon (hyperechoic) overlying the public ramus
        1. Iliopubic emminence will sit inferior to the psoas tendon
      4. Identify femoral artery prior to injection
    5. Needle insertion
      1. Raise a small skin wheel of local Anesthetic laterally over needle insertion site
        1. Avoid obscuring underlying structures (i.e. bubbles in local Anesthetic) on Ultrasound
      2. Advance Nerve Block needle (e.g. 20 to 22 gauge, 100 mm) at 30-45 degrees transverse (in plane)
        1. Target inferior to the psoas tendon and superior to the public ramus
    6. Anesthetic
      1. Inject 20 ml Anesthetic (e.g. Ropivacaine 0.5%) into target region
      2. Hydrodissection should lift the the psoas tendon
  8. References
    1. (2022) HQMedED Regional Anesthesia for Acute Care Providers, Minneapolis, MN, attended 6/3/2022
    2. Ben Aziz and Muhdomi (2022) Pericapsular Nerve Group Block, Stat Pearls, Treasure Island, accessed 6/4/2022
    3. Berlioz and Bojaxhi (2022) Pericapsular Nerve Group Block, Stat Pearls, Treasure Island, accessed 6/4/2022

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