PENG Block

Leu, Luftig, Mantuani, Sobrero, Nagdev – ACEP Now 2022

PENG (Pericapsular Nerve Group) Block

INDICATIONS: Fractures of Hip or Pubic Ramus. This is a motor sparing block that provides better anesthesia for hip fractures. It is used in OR for patients who are expected to be ambulatory after their surgery, but it is a great option for opioid sparing regional anesthesia for ED hip fracture patients as complications are limited and anesthesia excellent.

ANATOMY: PENG blocks target terminal sensory branches of femoral obturator and accessory obturator nerves. These are proximal to and not affected by femoral nerve block or fascia iliaca blocks.

SUPPLIES:

  • 20-40 mL Ropivacaine 0.5% (max 3 mg/kg of 5mg/mL) i.e. for 50kg use 30 mL, for 70kg use 42 mL.
  • 1% lidocaine for skin wheal
  • 25 gauge needle for local skin wheal
  • 5 cc syringe for skin wheal
  • Chlorhexidine skin prep
  • Large Curvilinear Transducer (greater insonation field than the other option – a linear transducer)
  • US gel packet
  • Saline flushes
  • 90 mm 22g Pajunk SonoMSK blunt-tip block needle
  • 91cm (or 36 inch) tubing

SAFETY:

  • Place on Monitor
  • Place on Pulse Oximetry
  • Ensure Intralipid is available to treat possible LAST (local anesthesia systemic toxicity)

PREPARATION:

  • Patient should be supine with bed flat
  • Machine on contralateral side to procedure
  • Survey Anatomy

FINDING BLOCK PLANE (INFERIOR to SUPERIOR):

  • Place transducer in inguinal crease
  • Identify femoral vessels medially and femoral head laterally (See figure above)
  • Slide transducer cephalad until you see bony Ilium.
  • Identify Psoas Tendon (hyperechoic, round) between Anterior Superior Iliac Spine and Iliopubic Eminence. (See figure above)

FINDING THE BLOCK PLANE (SUPERIOR to INFERIOR):

  • Place probe transversely over ASIS
  • Slide caudally to find AIIS (next bony contour)
  • Rotate 45 degrees
  • Tilt caudally

PLACING THE BLOCK:

  • Prep with chlorhexidine
  • Place Skin wheal lateral to transducer
  • Advance block needle lateral to medial at 30-45 degree angle aiming below psoas tendon.
  • Advance until needle hits bony ilium.
  • Aspirate then hydrodissect
  • anechoic anesthetic placed under psoas tendon will lift it upward and spread medially.

ISSUES / TROUBLESHOOTING:

  • If you can’t see needle, the angle may be off. Try “toeing in” so the needle is more perpendicular to probe.
  • If you can’t inject anesthetic while on ilium, try rotating needle.