PENG block for THA
Started by ethilo
D
deleted59964
Any decent sources on this block?
Advertisement - Members don't see this ad
Found a good video here - will try it out and report back if I run into a hip fracture patient on call.
No RCTs (as is becoming the standard for these new blocks).
Works for hip fracture (ie. need to mobilize the patient for the spinal), not good for surgery.
The "beauty" of this block is that there is NO way of showing that it work (or didn't). Since you are only blocking the articular branches you can't produce any sensory/motor block.
Works for hip fracture (ie. need to mobilize the patient for the spinal), not good for surgery.
The "beauty" of this block is that there is NO way of showing that it work (or didn't). Since you are only blocking the articular branches you can't produce any sensory/motor block.
I've done it on 3 different patients thusfar. Again, it's hard/impossible to evaluate the block other than RCTs and looking at post-op opioid requirements.
I've performed a lot of suprainguinal fascia iliaca blocks for hip arthroplasty and I really don't think that block adds much to THA. The studies out there that i've seen seem to agree with that assessment.
Therefore I'm more willing to entertain a PENG block despite it being so new and understudied. I've been doing ~15 mL marcaine 0.5% + 1:200k epi + 4 mg dexamethasone. The needling / ultrasound is actually pretty easy once you get the hang of it, very easy with a curvilinear probe even on large patients. There's also no major structures to look out for which is great. I just don't know if it's doing anything. I figure "what the hell, if it helps then great! If it does nothing, then it's so low risk to try that it has virtually no risk of causing harm." I also perform it in PACU while their spinal is still lingering so it doesn't really expose patient to the albeit minor trauma of a procedure.
I've performed a lot of suprainguinal fascia iliaca blocks for hip arthroplasty and I really don't think that block adds much to THA. The studies out there that i've seen seem to agree with that assessment.
Therefore I'm more willing to entertain a PENG block despite it being so new and understudied. I've been doing ~15 mL marcaine 0.5% + 1:200k epi + 4 mg dexamethasone. The needling / ultrasound is actually pretty easy once you get the hang of it, very easy with a curvilinear probe even on large patients. There's also no major structures to look out for which is great. I just don't know if it's doing anything. I figure "what the hell, if it helps then great! If it does nothing, then it's so low risk to try that it has virtually no risk of causing harm." I also perform it in PACU while their spinal is still lingering so it doesn't really expose patient to the albeit minor trauma of a procedure.
If that's the pitch, I would never suggest it to a surgeon.
Doesn't the surgeon cut off the head of the femur for a THA?
At least with fascia iliaca block you get all the relevant cutaneous innervation blocked.
D
deleted59964
Hmm - from this discussion, think I’ll pass on this one
I've done a few PENG + FICB for total hips. Rather than use the PENG in isolation I'm adding it to the FICB.
Advertisement - Members don't see this ad
Watch out for the Femoral nerve and Femoral artery. In addition, I have read that the ureter may run along the pelvic floor so be careful about needle placement and force.
No.
IMO, as the saying goes, you should never be the last to adopt practice changes, but you also shouldn’t be the first. Let the ivory tower academicians with a university paying their malpractice insurance determine if the block is safe and/or does anything useful, THEN start incorporating it into your practice.
D
deleted162650
Our ortho trauma docs like us to block hip fx patients on admission (who then typically go to the OR the following day) in an effort to minimize opioid consumption and facilitate transfers etc, in the often frail population. Historically we’ve done FI blocks for these, but I’ve always been less than impressed by the results. The other night I got called for 4 hip fxs in the ED needing blocks (apparently it’s going around).
Decided what the hell, I’ll try PENGs since it can’t work any worse than an FI. I found imaging to be pretty simple with both the large curvilinear and linear high freq probes, but given the choice I’d use the large curvilinear. Injected 30mL 0.25% Bupi with epi and decadron (figured more volume is better since its essentially a field block).
All 4 reported significant pain relief bordering on pain free. One had the block wear off at the 12H mark but reported minimal pain for those 12H.
I was pleased with these results (esp compared to FIBs) and will continue to use PENGs for this indication.
Decided what the hell, I’ll try PENGs since it can’t work any worse than an FI. I found imaging to be pretty simple with both the large curvilinear and linear high freq probes, but given the choice I’d use the large curvilinear. Injected 30mL 0.25% Bupi with epi and decadron (figured more volume is better since its essentially a field block).
All 4 reported significant pain relief bordering on pain free. One had the block wear off at the 12H mark but reported minimal pain for those 12H.
I was pleased with these results (esp compared to FIBs) and will continue to use PENGs for this indication.
Ive done a few of these for THA. They seem to have substantially decreased opioid requirements compared to no block. The surgeons still perform PAI either way. Lack of motor block is a key selling point for this block.
I've read that pushing larger volumes with this block can start to catch the femoral nerve and result in quad weakness. I've heard though it's a field block, using 10-15 mL is adequate and reduces motor block risk.
D
deleted162650
Do you any sources you could share?
For my purposes though, I don’t care if I catch the femoral. These patients aren’t ambulatory until the following day anyways - and if I wasn’t doing a PENG id be doing an FI which for sure gets the femoral.
I’m thinking this might also be a good option for hip scopes. In that case I would want to avoid motor weakness so being more conservative with volume may be a good idea.
D
deleted697535
The dude called the block after himself. That's a bit wierd
I've done a few PENG + FICB for total hips. Rather than use the PENG in isolation I'm adding it to the FICB.
sounds like a recipe for a double billing scam
When I started practicing there were some older anesthesiologists doing a femoral nerve block and an adductor canal block for TKAs and billing for both of them (of course in addition to spinal morphine etc etc etc) 🤣
Advertisement - Members don't see this ad
so many scammer docs out there its scary. Insane how much insurance pays out for these things and how clueless they really are.
I’m an employee of an AMC. I don’t collect a dime extra. I still do both blocks to help the patient.
In addition, if the patient needs a rescue Femoral block which happens 10 percent of the time then I do it. Again, I don’t collect one dime extra personally.
The vast majority of us are ethical practitioners trying to provide excellent care.
Salaried employees like yourself yes. However, i have seen a LOT of shady people in fee for service practices so I wouldn't say a VAST majority are completely ethical.
Don't forget to do a bilateral TAP block for your umbilical hernia repairs, which I've seen 😉
It's one of the things that's tough when you're billing yourself, if myself or family had surgery I would want blocks for pain control, I'd want a FI and femoral for a hip fracture, but realistically I may not want to pay a lot more for it.
@BLADEMDA weren't you asking about billing company questions to do your own billing? But you're an AMC employee?
It's one of the things that's tough when you're billing yourself, if myself or family had surgery I would want blocks for pain control, I'd want a FI and femoral for a hip fracture, but realistically I may not want to pay a lot more for it.
@BLADEMDA weren't you asking about billing company questions to do your own billing? But you're an AMC employee?
Are PENG block good for hip dislocation also?
I understand the rescue block rationale. But why do you need adductor canal block if you are also doing a femoral nerve block?
D
deleted162650
I think it should provide pain relief, but it’s not gonna provide any relaxation to aid with the reduction.
A better alternative is a slug of propofol and an Orthopod that’s strong like bull.
I work in multiple settings. I actually do more blocks for the AMC than when billing on my own. I only do what is necessary for the patient period. I prefer to do as few blocks as possible as I have been at this a long time and know everything has risks.
Some patients have low pain tolerance so even with an Adductor canal, IPack and LIA by the surgeon they complain of pain in the PACU. For those patients I do a rescue Femoral block.
Adductor canal blocks are very effective but, IMHO, they are not as good as a Femoral nerve block (despite all the literature on the subject).
At this point in my career I really don't care that much about whether I get paid for 1 or 2 blocks; I just do what I think is best for the patient. It makes the day so much easier and you can sleep well at night.
Advertisement - Members don't see this ad
These days I can easily “Bill” for 2 blocks when a patient comes for a shoulder surgery. I draw up 25 ml local plus decadron. 20 ml for ISB and 5 ml for the superficial cervical plexus block. Both blocks combined take about 6 min to do and I typically do both with the same needle puncture. I just redirect the needle as needed.
I have not been billing the patient for 2 blocks just the ISB. What do you all think about that ?
I have not been billing the patient for 2 blocks just the ISB. What do you all think about that ?
Last edited:
FYI, how about 3 blocks for shoulder surgery. I’ve only done 3 blocks one time but it worked quite well:
www.google.com
: The novel combination of a superficial cervical plexus block, a suprascapular nerve block, and an infraclavicular nerve block provides an alternative anesthetic modality for arthroscopic shoulder surgery.
A novel combination of peripheral nerve blocks for arthroscopic shoulder surgery | Request PDF
Request PDF | A novel combination of peripheral nerve blocks for arthroscopic shoulder surgery | Background: Interscalene brachial plexus block is currently the gold standard for intra- and post-operative pain management for patients... | Find, read and cite all the research you need on ResearchGate
www.google.com
: The novel combination of a superficial cervical plexus block, a suprascapular nerve block, and an infraclavicular nerve block provides an alternative anesthetic modality for arthroscopic shoulder surgery.
Ultrasound-Guided Inter-scalene Brachial Plexus Block with Superficial Cervical Plexus Block Compared with General Anesthesia in Patients Undergoing Clavicular Surgery: A Comparative Analysis - PMC
General anesthesia is preferred for clavicular surgeries. With the advent of ultrasound-guided technology, interscalene brachial plexus block with superficial cervical nerve block has become a new option for providing intraoperative anesthesia and ...
www.ncbi.nlm.nih.gov
Combined interscalene-superficial cervical plexus block for clavicle surgery: an easy technique to avoid general anesthesia
Clavicle surgeries are mostly performed under general anesthesia. Regional anesthesia (RA) is usually not sufficient to cover the entire clavicle bone and
academic.oup.com
I used it as an analgesia plan for a pt who was a pulmonary cripple ILD pt with severe pulm HTN who had a full meal so I figured it can help her get some analgesia until slug of propofol time came 8hrs later without having to suffer until then in the ED. Seems like a lot of the pain she had was muscular\spasms, as the block seemed to work when spasms resolved and she was able to get some sleep in the downtime.
I've started messing around with this block. One thing its great for is for position patients with hip fracture for spinal. 5 minutes after the block they can move their broken leg like nothing happened, and this is usually the only way I have to prove that the block WORKED. There seems to be some opioid sparing effect, but when compared to nothing putting 20 mL of LA anywhere will provide analgesia, so thats not a good enough reason for me to do it. For THA I go with suprainguinal fascia iliaca, since we do have good evidence to show its benefit (Desmet, RAPM 2017). Hope this help.
So you don't think PENG has a post op analgesia effect as FI?
For him the fact that a patient w/ a hip fx is in substantially less pain is proof enough for him to do a PENG, but he needs an RCT as proof to do the same block for a THA. It would appear that there are logical inconsistencies in his practice choices.
D
deleted162650
I think it does, but THA’s aren’t really that painful anyways.
The problem with FI’s for THA’s is that the surgeons have such a hard on for early ambulation, and want them walking the afternoon on the DOS. FI’s are gonna prevent that. PENG’s won’t.
If you feel you must do a block for a THA, I think PENG’s are where it’s at.
IMHO, a PENG block is probably worth about 1,000 mg of Tylenol in terms of efficacy. Better than nothing not really that impressive either.
FYI, when doing this block some experts recommend a lateral to medial approach to avoid the ureter on the pelvic floor. They claim one may be more likely to injure the ureter if inserting the needle in a medial to later direction.
Advertisement - Members don't see this ad
As for difficulty of doing this block I would rate it an extremely easy to perform block.
I think you misunderstood. I haven't changed my practice or chosen PENG block as my go–to technique for hip fractures (or THAs). I've only started to do it to see for myself how easy it is to do and how well it works (and sharing my view of it), since there is not enough evidence to answer those questions. As @SaltyDog said, postop recovery is a huge factor and I wouldn't do SIFI if patients were mobilized on POD #0, but in my hospital patients start physio on POD #1 so its not a problem. Just recently ortho started to brew a day–surgery THA program. In that case I'll have to change my practice. PENG seems a good candidate, but I still consider it inferior to SIFI simply because we have no studies to provide objective analgesic measures (compared with placebo or with other blocks).
