Written by Chris Thom
Spoon Feed
We recently covered the PENG (pericapsular nerve group) block, which improved pain and reduced opioid use. In this new single-center retrospective study, the PENG block was also associated with a reduction in opioid utilization among patients with hip fractures.
Remove the Pain with PENG
This single-center retrospective study evaluated the efficacy of the PENG block for hip fractures. Patients with isolated acute hip fractures who underwent operative repair between July 2021 and June 2023 were included. Propensity-score matching was utilized to compare similarly matched patients who received PENG blocks versus those who received opioid-analgesia only. Total opioid consumption up until time of operative intervention was analyzed.
287 patients were included in the analysis, with 36 (13%) having received a PENG block in the ED. At the 6-hour time point, PENG patients had a reduction in morphine milligram equivalents (MMEs) of -0.14 MME/kg (95%CI -0.2 to -0.08) compared to the opioid-only cohort. At 18 hours, this reduction was -0.14 MME/kg (95%CI -0.23 to -0.04).
How will this change my practice?
We’ve covered regional anesthesia for hip fractures several times here on JournalFeed, but this tends to involve discussion of the more common and established fascia iliaca block. PENG is an interesting alternative, as it may be easier to perform and does not involve any motor blockade. Some patients have more difficult fascia iliaca sonoanatomy; PENG can provide another route to safe and effective hip fracture analgesia. The jury is still out on which one is better. For now, I’ll often look at both areas on a given patient and select the sonoanatomy where I suspect it will be easier to deliver the anesthetic to the target area.
POCUS pro tips and clips
A significant advantage of the PENG block is the reliance on consistent bony anatomy for block delivery. You’ll find the femoral head, which is easy and reliable from patient to patient. Then scan slightly cephalad until you see anterior inferior iliac spine (AIIS), the psoas tendon, and the iliopubic eminence (IPE). You’ll want to deliver the anesthetic just lateral to the psoas tendon. An advantage of the pelvic bone being directly underneath the target area is that you really can’t end up too deep, as you’ll feel the tactile feedback of the bone and then deliver the anesthetic just superficial to this.
Source
Pericapsular Nerve Group Block-Augmented Analgesia vs. Conventional Opioid Analgesia for Hip Fracture Patients in the Emergency Department: A Comparative Effectiveness Study. J Emerg Med. 2025 Dec;79:232-245. doi: 10.1016/j.jemermed.2025.08.019. Epub 2025 Aug 18. PMID: 41138560.
View JournalFeed Critical Appraisal
Critical Appraisal
Study Identification
Background
Study Question
Study Design & Conduct
Prospective / Retrospective: Retrospective
Multicenter: No
Unit of Allocation: Not applicable
Unit of Analysis: Patients
Randomization Method: Not applicable
Allocation Concealment: Not applicable
Blinding: Not applicable
Follow-up Duration: Up to 24 hours post-index event
Population
- Isolated hip fracture
- ED visit at a level 1 trauma center
- Admitted to hospital and underwent repair in OR
- Incarceration
- Pregnancy
- Age under 18
- Significant mechanism of injury
- Polytrauma
- Current methadone therapy
- Intubation in ED
- Sedative or anxiolytic administration
- Allergy to sodium channel blockers or opioids
Number Enrolled: 287
Number Analyzed: 287
Key Baseline Characteristics
Sex: 69.3% female
Disease Severity: Not reported
Care Setting Distribution: ED of a level 1 trauma center
Additional Baseline Characteristics
- Weight
- BMI
- Type of hip injury
- Medical history
- Substance use history
- Renal function
- Initial mean arterial pressure
Exposures / Interventions
Description: Pericapsular nerve group (PENG) block
Definition / Dose: 0.25% Bupivacaine
Timing: Between ED arrival and OR arrival
Classification Method: Performed by trained emergency physicians under ultrasound guidance
Protocolized / Discretionary: Protocolized
Description: Conventional opioid analgesia
Definition: Opioid administration between ED arrival and OR arrival
Outcomes & Results
Primary Outcomes
Definition: Reduction in morphine milligram equivalents (MME) administered
Time Point: 6 and 18 hours post-index event
Measurement Method: Converted into oral MME per kilogram of body weight
Results: -0.14 MME/kg (95% CI: -0.20, -0.08 at 6 hours; -0.23, -0.04 at 18 hours)
Secondary Outcomes
Definition: Duration of hospital stay
Time Point: Not specified
Measurement Method: Hospital records
Results: Comparable between groups
Definition: Duration of ICU stay
Time Point: Not specified
Measurement Method: Hospital records
Results: Comparable between groups
Definition: Patient discharge status
Time Point: Not specified
Measurement Method: Hospital records
Results: Comparable between groups
Risk of Bias
Risk of Bias - ROBINS-I
- Confounding (Some concerns): Propensity score matching used, but residual confounding possible.
- Selection of participants (Low): Clear inclusion and exclusion criteria applied.
- Classification of interventions (Low): Interventions clearly defined and classified.
- Deviations from intended interventions (Low): Interventions were applied as intended.
- Missing data (Low): No significant missing data reported.
- Measurement of outcomes (Low): Outcomes measured consistently across groups.
- Selection of the reported result (Low): All relevant outcomes reported.
Transparency
COI Statement Present: TRUE
