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 linkcopy

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

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 2021²⁶	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 2022²⁸	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 2022¹²	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 2021¹³	RCT	33/33	I, II, III	29.5/ 30/ 15	42.4/39.4	67.87/ 70.39	NA/NA		NA
Mosaffa 2021¹⁸	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 2021¹⁹	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 2021²⁹	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 2020²⁰	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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Sociedade Brasileira de Anestesiologia (SBA) Rua Professor Alfredo Gomes, 36, Botafogo , CEP: 22251-080 , tel: +55 (21) 97977-0024 - Rio de Janeiro - RJ - Brazil
E-mail: editor.bjan@sbahq.org

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[TFN1] BMI, Body Mass Index (kg.m^-2); FI, Fascia Iliaca compartment block; IV, Intravenous; PENG, Pericapsular Nerve Group block; PCA, Patient Controlled Analgesia; RCT, Randomized Control Trial; Surgical time, minutes; NA, Not Available; Age and BMI, mean.