Pericapsular Nerve Group (PENG) block versus fascia iliaca compartment (FI) block for hip surgery: a systematic review and meta-analysis of randomized controlled trials

Andrade, Priscila P.; Lombardi, Rafael A.; Marques, Isabela R.; Braga, Anna Carla Di Napoli Andrade e; Isaias, Beatrice R.S.; Heiser, Nicholas E.

doi:10.1016/j.bjane.2023.07.007

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REVIEW ARTICLE • para Braz. J. Anesthesiol. 73 (6) • Nov-Dec 2023 • https://doi.org/10.1016/j.bjane.2023.07.007 copy

Pericapsular Nerve Group (PENG) block versus fascia iliaca compartment (FI) block for hip surgery: a systematic review and meta-analysis of randomized controlled trials

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

This study compares Fascia Iliaca compartment (FI) block and Pericapsular Nerve Group (PENG) block for hip surgery.

Methods:

Pubmed, Embase and Cochrane were systematically searched in April 2022. Inclusion criteria were: Randomized Controlled Trials (RCTs); comparing PENG block versus FI block for hip surgery; patients over 18 years of age; and reporting outcomes immediately postoperative. We excluded studies with overlapped populations and without a head-to-head comparison of the PENG block vs. FI block. Mean-Difference (MD) with 95% Confidence Intervals (CI) were pooled. Trial Sequential Analyses (TSA) were performed to assess inconsistency. Quality assessment and risk of bias were performed according to Cochrane recommendations.

Results:

Eight RCTs comprising 384 patients were included, of whom 196 (51%) underwent PENG block. After hip surgery, PENG block reduced static pain score at 12h post-surgery (MD = 0.61 mm; 95% CI 1.12 to -0.09; p = 0.02) and cumulative postoperative oral morphine consumption in the first 24h (MD = -6.93 mg; 95% CI -13.60 to -0.25; p = 0.04) compared with the FI group. However, no differences were found between the two techniques regarding dynamic and static pain scores at 6 h or 24 h post-surgery, or in the time to the first analgesic rescue after surgery.

Conclusion:

The findings suggest that PENG block reduced opioid consumption in the first 24 h after surgery and reduced pain scores at rest at 12 h post-surgery. Further research is needed to fully understand the effects of the PENG block and its potential benefits compared to FI block.

PROSPERO registration: CRD42022339628

PROSPERO registration: https://www.crd.york.ac.uk/prospero/display_record.php?

RecordID=339628

KEYWORDS
PENG block; Pericapsular nerve group block; Fascia iliaca block; Hip surgery; Hip replacement; Meta-analysis

Study	Design	Patients FI/ PENG	ASA	BMI FI/ PENG	Male (%) FI/ PENG	Age, y FI/ PENG	Surgical time FI/ PENG	IV PCA	FI Anesthetics	PENG Anesthetics
Aliste 2021²⁶26 Pascarella G, Costa F, Del Buono R, Pulitanò R, Strumia A, Piliego C, et al. Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial. Anaesthesia. 2021 ;76: 1492-8.	RCT	20/20	I, II, III	28.4/ 27.6	35/35	59.6/ 56.8	73.5/ 74.9	Morphine (mg) IV PCA	40 ml adrenalized levobupivacaine 0.25%	20 ml adrenalized levobupivacaine 0.50% 20 ml of adrenalized ropivacaine 0.2% 20 ml ropivacaine 0.4% NA
Choi 2022²⁸28 Natrajan P, Bhat RR, Remadevi R, Joseph IR, Vijayalakshmi S, Paulose TD. Comparative Study to Evaluate the Effect of Ultrasound-Guided Pericapsular Nerve Group Block Versus Fascia Iliaca Compartment Block on the Postoperative Analgesic Effect in Patients Undergoing Surgeries for Hip Fracture under Spinal Anesthesia. Anesth Essays Res. 2021;15:285-9.	RCT	27/27	I, II, III	25/ 25.8	59.3/51.9	61.51/ 60.27	69.90/ 67.43	Fentanyl (mcg) IV PCA	30 ml of adrenalized ropivacaine 0.2%
Hua 2022¹²12 Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.	RCT	24/24	II, III	23/24	54.2/58.3	74/74	129/133	Sufentanil (mcg) IV PCA Number of doses of Tramadol 50 mg	30 ml ropivacaine hydrochloride 0.4%
Jadon 2021¹³13 Schünemann H, Brozek J, Guyatt G, Oxman A. GRADE handbook for grading quality of evidence and strength of recommendations. The GRADE Working Group; 2013 Updated October 2013Available from guidelinedevelopment.org/handbook.	RCT	33/33	I, II, III	29.5/ 30/ 15	42.4/39.4	67.87/ 70.39	NA/NA		NA
Mosaffa 2021¹⁸18 Hua H, Xu Y, Jiang M, Dai X. Evaluation of Pericapsular Nerve Group (PENG) Block for Analgesic Effect in Elderly Patients with Femoral Neck Fracture Undergoing Hip Arthroplasty. J Healthc Eng. 2022;2022:7452716.	RCT	22/30	I, II	NA/NA	72.7/73.3	50/53	NA/NA	Morphine (mg) IV PCA	3 ml.kg^-1 (a maximum of 40 ml) of ropivacaine 0.5%	3 ml.kg^-1 (a maximum of 40 ml) of ropivacaine 0.5%
Natrajan 2021¹⁹19 Jadon A, Mohsin K, Sahoo RK, Chakraborty S, Sinha N, Bakshi A. Comparison of supra-inguinal fascia iliaca versus pericapsular nerve block for ease of positioning during spinal anaesthesia: A randomised double-blinded trial. Indian J Anaesth. 2021;65:572-8.	RCT	12-Dec	I, II	NA/NA	NA/NA	NA/NA	NA/NA	N/A	20 ml of 0.5% ropivacaine	20 ml of 0.5% ropivacaine
Senthil 2021²⁹29 Shankar K, Ashwin AB, Rangalakshmi S. Comparative evaluation of peng block [pericapsular nerve group block] v/s fascia iliaca block[fib] for positioning and post operative analgesia prior to spinal anaesthesia for hip surgeries: Prospective randomized controlled trial. Indian J Anaesth. 2020;64:S37-8.	RCT	20/20	I, II	NA/NA	50/60	52.5/ 53.9	NA/NA	Fentanyl (mcg) IV PCA	30 ml levobupivacaine 0.25% & 4 mg dexamethasone	30 ml levobupivacaine 0.25% & 4 mg dexamethasone
Shankar 2020²⁰20 Egger M, Davey Smith G, Schneider M, Minder C. Bias in metaanalysis detected by a simple, graphical test. BMJ. 1997;315:629 -34.	RCT	30/30	I, II, III	NA/NA	30/66.6	49.54/ 53.58	NA/NA	N/A	25 ml ropivacaine 0.25%	25 ml ropivacaine 0.25%

Outcomes	Risk of bias	Inconsistency	Indirectness	Imprecision	Publication bias	Mean difference (95% CI)	Number of participants (studies)	Quality or certainty of the evidence (GRADE)
Cumulative postoperative oral morphine consumption	Serious^a	Not serious	Not serious	Not serious	Not detected	MD -6.93 (-13.60 to -0.25)	300 (6 RCTs)	⨁⨁⨁⨁ High^b
Dynamic pain score at 6 hours post-surgery	Not serious	Not serious	Not serious	Serious^c	Not detected	MD -0.22 (-0.81 to 0.37)	200 (4 RCTs)	⨁⨁⨁⭕ Moderate
Static pain score at 6 hours post-surgery	Not serious	Not serious	Not serious	Serious^c	Not detected	MD -0.32 (-0.96 to 0.32)	212 (4 RCTs)	⨁⨁⨁⭕ Moderate
Static pain score at 12 hours post-surgery	Not serious	Not serious	Not serious	Not serious	Not detected	MD -0.61 (-1.12 to -0.09)	218 (4 RCTs)	⨁⨁⨁⨁ High
Dynamic pain score at 24 hours post-surgery	Not serious	Not serious	Not serious	Serious^c	Not detected	MD 0.57 (-0.01 to 1.14)	200 (4 RCTs)	⨁⨁⨁⭕ Moderate
Static pain score at 24 hours post-surgery	Not serious	Not serious	Not serious	Serious^c	Not detected	MD -0.14 (-0.49 to 0.22)	220 (4 RCTs)	⨁⨁⨁⭕ Moderate
Time to first analgesic rescue after surgery	Not serious	Serious^d	Not serious	Serious^c	Not detected	MD -1.07 (-2.21 to 0.02)	202 (4 RCTs)	⨁⨁⭕⭕ Low
Subgroup for hip fracture opioid consumption	Serious^a	Serious^d	Not serious	Serious^c	Not detected	MD -6.29 (-13.85 to 1.27)	206 (4 RCTs)	⨁⭕⭕⭕ Very low
Postoperative nausea and vomiting (PONV)	Not serious	Not serious	Not serious	Not serious	Not detected	MD -2.00 (0.82 to 4.90)	59 (3 RCTs)	⨁⨁⨁⨁⨁ High

Outcomes	Anticipated absolute effects^a (95% CI)		Relative effect (95% CI)	N° of participants (studies)	Certainty of the evidence (GRADE)
Outcomes	Risk with FIC	Risk with PENG	Relative effect (95% CI)	N° of participants (studies)	Certainty of the evidence (GRADE)
Cumulative postoperative oral morphine conumption Follow-up: mean 1 day	The mean cumulative postoperative oral morphine conumption was 0	MD 6.93 lower (13.6 lower to 0.25 lower)	-	300 (6 RCTs)	⨁⨁⨁⨁ High^a
Dynamic pain score at 6 hours post-surgery Follow-up: mean 1 day	The mean dynamic pain score at 6 hours post-surgery was 0	MD 0.22 lower (0.81 lower to 0.37 higher)	-	200 (4 RCTs)	⨁⨁⨁⭕ Moderate 4✢
Static pain score at 6 hours post-surgery Follow-up: mean 1 day	The mean static pain score at 6 hours post-surgery was 0	MD 0.32 lower (0.96 lower to 0.32 higher)	-	212 (4 RCTs)	⨁⨁⨁⭕ Moderate 4✢
Static pain score at 12 hours post-surgery Follow-up: mean 1 day	The mean static pain score at 12 hours post-surgery was 0	MD 0.61 lower (1.12 lower to 0.09 lower)	-	218 (4 RCTs)	⨁⨁⨁⨁ High
Dynamic pain score at 24 hours post-surgery Follow-up: mean 1 day	The mean dynamic pain score at 24 hours post-surgery was 0	MD 0.57 higher (0.01 lower to 1.14 higher)	-	200 (4 RCTs)	⨁⨁⨁⭕ Moderate 4✢
Static pain score at 24 hours post-surgery Follow-up: mean 1 day	The mean static pain score at 24 hours post-surgery was 0	MD 0.14 lower (0.49 lower to 0.22 higher)	-	220 (4 RCTs)	⨁⨁⨁⭕ Moderate 4 ✢
Time to first analgesic rescue after surgery Follow-up: mean 1 day	The mean time to first analgesic rescue after surgery was 0	MD 1.07 lower (2.21 lower to 0.07 higher)	-	202 (4 RCTs)	⨁⨁⭕⭕ Low 4 ✢**
Subgroup for hip fracture opioid consumption Follow-up: mean 1 day	The mean subgroup for hip fracture opioid consumption was 0	MD 6.29 lower (13.85 lower to 1.27 higher)	-	206 (4 RCTs)	⨁⭕⭕⭕ Very low ✢*
Postoperative nausea and vomiting (PONV)	85 per 1.000	169 per 1.000 (69 to 415)	RR 2.00 (0.82 to 4.90)	118 (3 RCTs)	⨁⨁⨁⨁ High

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[1] * Corresponding author. E-mail: rarskylombardi@unmc.edu (R.A. Lombardi).