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Reply to Aydin et al.: A Novel Indication of Pericapsular Nerve Group Block: Surgical Anesthesia for Vein Ligation and Stripping

2019; Elsevier BV; Volume: 34; Issue: 3 Linguagem: Inglês

10.1053/j.jvca.2019.10.027

1532-8422

Laura Girón-Arango, John Tran, Philip Peng,

Shoulder Injury and Treatment

We read with interest the Letter to the Editor by Aydin et al. on the use of pericapsular nerve group (PENG) block for surgical anesthesia for vein ligation and stripping.1Aydin M.E. Borulu F. Ates I. Kara S. Ahiskalioglu A. A Novel Indication of PericapsularNerve Group (PENG) Block: Surgical Anesthesia for Vein Ligation and Stripping.J Cardiothorac Vasc Anesth. 2019 Aug 12; (doi:10.1053/j.jvca.2019.08.006)PubMed Google Scholar Recently, there have been several letters to the editor describing the use of PENG block for anesthetic purposes.2Ahiskalioglu A. Aydin M.E. Ahiskalioglu E.O. Tuncer K. Celik M. Pericapsular nerve group (PENG) block for surgical anesthesia of medial thigh.J Clin Anesth. 2019; 59: 42-43Crossref PubMed Scopus (17) Google Scholar,3Ueshima H. Otake H. Below-knee amputation performed with pericapsular nerve group and sciatic nerve blocks.J Clin Anesth. 2019; 54: 45Crossref PubMed Scopus (6) Google Scholar We would like to highlight some points regarding the PENG block technique and indications. The PENG block was originally described to provide analgesia in hip-fracture patients. The main advantage of this technique is its motor-sparing effect by targeting only the sensory articular branches of the femoral nerve (FN) and accessory obturator nerve.4Girón-Arango L. Peng P.W.H. Chin K.J. et al.Pericapsular nerve group (PENG) block for hip fracture.Reg Anesth Pain Med. 2018; 43: 859-863PubMed Google Scholar A previous dye injection study suggested that 10 to 20 mL of injectate also covers the articular branches of the obturator nerve.5Tran J. Agur A. Peng P. Is pericapsular nerve group (PENG) block a true pericapsular block?.Reg Anesth Pain Med. 2019; 44 (257-257)Crossref Scopus (39) Google Scholar This suggests the PENG block targets the 3 nerves that provide sensory innervation to the anterior hip joint capsule, confirming the true "pericapsular" nature of this block. Any motor or sensory block beyond the hip joint capsule would be considered an undesired effect. A recent letter to the editor reported quadriceps weakness in 2 patients after the performance of PENG block for hip surgery.6Yu H.C. Moser J.J. Chu A.Y. et al.Inadvertent quadriceps weakness following the pericapsular nerve group (PENG) block.Reg Anesth Pain Med. 2019; 44: 611-613Crossref PubMed Scopus (40) Google Scholar There are 2 plausible explanations for this undesired and unexpected motor and sensory blockade. First, instead of injecting local anesthetic deep to the fascia of the psoas muscle, there may have been intramuscular injection into the psoas muscle, which subsequently spread to the FN (Fig 1). Alternatively, a medial placement of the needle closer to the pectineus or use of injectate volumes greater than 20 mL (the volume described in the original technique) could result in anesthetic spread through the intermuscular plane between the pectineus and psoas, to capture the FN, resulting in the undesired motor and sensory block. Furthermore, as shown in our dye injection study, high-volume injectate may spread to the main trunk of the obturator nerve as the nerve courses along the lateral wall within the true pelvis.5Tran J. Agur A. Peng P. Is pericapsular nerve group (PENG) block a true pericapsular block?.Reg Anesth Pain Med. 2019; 44 (257-257)Crossref Scopus (39) Google Scholar The key to this unexpected spread was the use of a high volume of injectate. Because the PENG block is a recently described block, more anatomic and clinical studies need to be conducted to expand the understanding of the mechanism of action, ideal volume of local anesthetic, and indications. Dr. Laura Girón-Arango and Mr. John Tran have no conflicts of interest to declare. Dr. Philip Peng received equipment support from Sonosite Fujifilm Canada. A Novel Indication of Pericapsular Nerve Group (PENG) Block: Surgical Anesthesia for Vein Ligation and StrippingJournal of Cardiothoracic and Vascular AnesthesiaVol. 34Issue 3PreviewVARICOSE VEINS are dilated and twisted veins that often are located in the lower extremities. Conservative or interventional methods are used in the treatment of varicose veins. The main interventional methods are laser or thermal ablation, sclerotherapy, and surgery.1 Although new treatment modalities are alternative to surgery, ligation and stripping surgery remain the standard treatment, especially for complicated varicose veins. Some of these procedures can be performed with the patient under general or regional anesthesia. Full-Text PDF