Comparison of efficacy of ultrasound guided pericapsular nerve group (PENG) vs iliopsoas plane block (IPB) for facilitating positioning for central neuraxial block in patients for proximal hip surgeries: a prospective observational study

this prospective observational study will be conducted at orthopaedic operation theatre and emergency trauma operation theatres of LTMMC Sion in patients posted for hip surgery between the period of 2024-2025. A thorough preanaesthetic evaluation will be done. After obtaining written and informed consent from each subject, data such as sex, age, as well as type of fracture will be collected. The subjects fulfilling the inclusion criteria will be included in the study. Routine protocol is as follows: Standard ASA monitors (non-invasive blood pressure, pulse, oxygen saturation, and electrocardiogram) are applied and supplemental oxygen (nasal cannula at 2 L/ min) is given. Intravenous (I.V) access is secured and I.V Fluid is started. Ultrasound-guided PENG (Pericapsular nerve group)block, IPB(Illiopsoas block), FNB (femoral nerve block) or fascia iliac block or I.V fentanyl are routinely administered for pain relief for facilitating positioning for spinal anaesthesia in patients with hip fractures. Baseline parameters like VAS, Heart rate (HR), Systolic Blood pressure (SBP), Diastolic Blood Pressure (DBP), Saturation (SPO2) will be noted. Patients given PENG block or IPB will be included in the study. Patients receiving PENG block will be included in Group A, and those receiving IPB will be included in Group B. The USG blocks will be administered by a senior anaesthesiologist experienced in regional anaesthesia. After standard skin disinfection the block will be performed with a portable ultrasound machine with curvilinear probe, 2-5 MHz and 100- mm short-bevelled stimulating needle after a short introduction and explanation of the procedure. Technique for PENG block: With patient in supine position, under all aseptic precautions, the low frequency curvilinear ultrasound probe is placed over the line joining anterior superior iliac spine (ASIS) and pubic tubercle (PT) keeping lateral margin at ASIS. The probe is thereafter tilted cranially to visualize the AIIS (Anterior inferior iliac spine), iliopsoas muscle and tendon, Iliopubic eminence, the femoral artery, and the pectineus muscle.  After local infiltration (2% lignocaine 2 cc), the needle tip is placed next to the iliopsoas tendon. Drug administered routinely is 20cc 0.375% ropivacaine. Technique for IPB: With patient in supine position, under all aseptic precautions, the low frequency curvilinear ultrasound probe is placed distal to the anterior superior iliac spine in the transverse plane. The probe is then gyrated in an anticlockwise direction on right and clockwise on the left, about 30° and slid along the inguinal ligament until the head of the femur is seen enter the acetabular rim. After a local infiltration (2% lidocaine 2cc), a needle tip reaches the plane between the iliopsoas muscle and the iliofemoral ligament . Drug administered routinely is, 10 ml of 0.375% ropivacaine. Thereafter the following parameters would be monitored and compared between USG guided PENG block and IPB.Thereafter patient will be made to sit after 30 min of the block and the above parameters will be assessed. Central neuraxial block will be administered as per protocol.

PARAMETERS TO BE STUDIED: After administration of blocks, the following parameters for the study purpose will be monitored in both the groups Heart rate, blood pressure, saturation, VAS (Visual analogue scale), onset of analgesia, additional analgesic requirement for positioning will be noted. Haemodynamic parameters  and VAS will be observed every minute in first 5 minutes and every 5 minutes for next 30 minutes. Side effects or complications if any will be noted.

1. VAS (Visual Analogue scale) during sitting position

2. VAS during supine position

I. Static

ii. Dynamic (Passive leg raising 15°) at 5,10,15,30 min

iii. VAS (Visual Analogue scale) during sitting position iv. Quadriceps strength using MMT scale [0-5], where 0 is no muscle contraction and 5 can bear full resistance.

3. Quality of patient positioning will be assessed by the anaesthetist giving spinal anaesthesia (0 = not satisfactory, 1 = satisfactory, 2 = good, 3 = optimal).

4. patient satisfaction score in sitting position using a three point likert scale In the event of VAS score more than 5 in sitting position after 30 min, rescue analgesia will be given. The rescue analgesia /technique will be decided by senior anaesthetist in-charge. The same will be noted.

5.block administration time from ultrasound scanning to completion of drug injection

6.number of needle passes required [number of needle redirection]

7.ease of performance of block [ easy, moderate, difficult]

8.Requirement of supplemental IV analgesic agents for positioning Additional analgesia in the form of injection paracetamol 1gm IV, injection fentanyl (1-2 mcg/ kg) IV, injection tramadol (2 mg/kg) IV will be noted. The time, dose and drug details will be noted for giving position for central neuraxial block

9.Sensory anaesthesia over anterior aspect of thigh using ether swab

10.Complications if any (bleeding / haematoma formation, neuropathy and systemic toxicity). Thereafter Spinal /CSE will be administered as per routine protocol.