STUDY OBJECTIVES: The study aimed to compare the analgesic effect of USG-guided PENG (Peri capsular nerve group) block with Intravenous Nalbuphine hydrochloride (IVN) in patients with hip fracture coming to the emergency department (ED). The purpose was also to monitor the adverse effects and rescue analgesic requirements in both treatment modalities.
METHODS: The study was an open-label randomised controlled trial (RCT) comparing PENG block versus IVN in treating patients with femoral head and neck fractures, as well as pubic rami fracture of the hip (HF). The participants in the PENG group received a USG-guided PENG block by injection of 25 ml of 0.25% bupivacaine, whereas the IVN group received 0.15 mg/kg of nalbuphine. An emergency physician with expertise in ultrasound-guided nerve blocks performed the PENG blocks. The primary outcome was to measure the improvement of the NRS (Numerical rating scale) score at 30 min in both static position (Patient-chosen position for the best comfort) and dynamic position (15-degree passive affected lower limb elevation). Secondary outcomes were to measure static and dynamic NRS pain scores at 2 h, 4 h, and 6 h after intervention in both groups. The requirement for rescue analgesia, adverse events and any block-related complications were also recorded.
RESULTS: A total of 60 patients with HF were included in the final analysis. The static and dynamic NRS score was significantly lower in the PENG group compared to the IVN group at 30 min, 2 h, 4 h, and 6 h post-intervention. In the PENG group, the static NRS score was improved by 5.73 ± 1.17, while In the IVN group, the static NRS score was just improved by 2.13 ± 0.97 at 30 min. In the same duration, the Dynamic NRS score in the PENG group was improved by 6.13 ± 1.38, while In the IVN group, it improved just by 2.43 ± 1.28. Rescue analgesia was required in 50.0% of patients in the IVN group but none in the PENG group. Further, no block-related complications or adverse events were observed in the patients of the PENG group.
CONCLUSION: The study provides evidence that the ultrasound-guided PENG block has a better analgesic effect and has fewer adverse events than IV opioids in patients with HF.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
This study is presented as a non-inferiority study in the text but structurally carried out as a superiority trial (non-inferiority margin, delta and confidence interval, ITT and PP not described in the methods, need for one-sided hypothesis for non-inferiority, etc.) Ideally, the threshold should be less than the minimum difference in effectiveness of a reference treatment compared with placebo, initially demonstrated in a superiority trial or meta-analysis RCT carried out without blinding (single or double).
Physician rater
In this single-center (tertiary care hospital) open-label study, ultrasound-guided pericapsular nerve block (PENG) performed by an emergency physician with expertise in peripheral nerve block provided superior analgesia and fewer adverse events compared to IV opioids in hip fracture patients. Nevertheless, the study's limitations, including lack of blinding and cost-effectiveness analysis, a small sample size, and brief pain score monitoring, restrict the broader applicability of PENG as a standard alternative to existing systemic and regional analgesia techniques for hip fractures.
Physician rater
This study compared pain relief in patients with hip fractures treated with opioids (nalbuphine) to peri-capsular nerve block with 25 ml 0.25% bupivacaine. Results: 1. Pain decreased by ~6 points in the nerve block group vs ~2 points in the narcotic group measured at 30 minutes and persisted for 6 hours; 2. 50% in the narcotic group required rescue analgesia while no rescue analgesia was needed in the nerve block group; 3. No complications were observed in the nerve block group. Summary: ultrasound-guided nerve blocks help with pain control in patients with hip fracture.
, McMaster University