Evaluation of the effectivenes of two different bupivacaine concentrations of postoperative pericapsular nerve group block (PENG block) applied with ultrasound-guided in hip operations performed with spinal anesthesia

The hip joint is the joint that is exposed to the most weight in the human body. Total hip replacement and hip fracture operations are among the most common and succesful orthopedic procedures. Despite the latest advances in hip joint surgery, postoperative side effects such as nausea, vomiting and postoperative pain are common. Lumbar plexus block, femoral block and fasia iliaca compartment block, which are regional anesthesia techniques that are increasingly used today, are the most commonly used peripheral nerve blocks that have been shown to be effective and have been found to provide perioperative analgesia in hip surgeries and thus reduce the risk of postoperative nausea and vomiting by reducing opioid consumption. The complex innervation of the hip makes it difficult to provide analgesia after hip surgery, and patients still experience pain after hip surgery. As a result of their anatomy study, Short et al found that the femoral, obturator and accessory obturator nerves supply the innervation of the anterior hip joint. Considering this information, Giron-Arango et al. defined Pericapsular Nerve Group Block (PENG Block) for hip analgesia by infiltrating local anesthesia into the space where the psoas tendon is located in the front and the pubic ramus in the back. Our aim in this study is to evaluate the effectiveness of two different bupivacaine concentrations of PENG block applied postoperatively on postoperative analgesia and opioid analgesic use in patients undergoing unilateral hip surgery. Following the permission of the Local Ethics Committee dated 17/01/2023 and numbered 2023/11 and the written consent of the patients, 60 patients with ASA I-III risk, aged between 18-85, who were planned for hip surgery, were included in the study. All patients were divided into 3 groups: Group 0.25, Group 0.16 and Group K (Control) by prospective, randomized and sealed envelope method before the operation. Group 0.25 and Group 0.16 patients were placed in a supine position after the opertions, and the probe was placed on the spina iliaca anterior inferior with vii ultrasound and then. Rotated approximately 45 degrees counterclockwise to visualize the anterior inferior iliac crest and iliopubic eminence, the tendon of the iliopsoas muscle and the femoral artery from the pubic ramus level. Unilateral PENG block was performed respectively by applying 20 ml bupivacaine 0.25% and 20 ml bupivacaine 0.16% to the area under the tendon of the iliopubic eminence and iliopsoas muscle with a peripheral block needle. No postoperative invasive block procedure was performed on patients in Group K. Postoperatively, in both groups, Tramadol HCL (Tramosel 100mg/2ml Haver Pharma Drugs Inc. Istanbul) was given upto the maximum döşe of 400 mg within 24 hours, with a continuous infusion of 2 cc/hour at a concentration of 4mg/ml via IV Patient Controlled Analgesia (PCA). Doses that could be administered as an iv bolus of 20 mg tramadol HCL each time the patient pushes the button, with a lock-in interval of 20 minutes were adjusted. Visual Analogue Scale (VAS) values at the 1st, 2nd, 4th,8th, 12th, 18th, 24th hours after the operation, as well as analgesic consumption at 0-1,1-12,12-24 hours, nausea, vomiting and itching were recorded. Total analgesic consumption and patient satisfaction were evaluated and recorded. There was no significant difference between the groups in demographic data. In the VAS evaluation of the patients, it was determined that the PENG block groups were statistically significantly lower than the control groups at postoperative at all hours compared to Group K (p<0,05). Also 1st, 2nd, 4th and 18th between Group 0.16 and Group 0.25 no significant difference was detected in VAS score between hours. Tramadol consumption 0-1., 1-12. and 12-24. hours were found to be statistically significantly lower in Group 0.25 and Group 0.16 compared to Group K (p<0,05). Additionaly, the first 12 hours were significantly lower in Group 0.25 than in Group 0.16 (p<0,05). However, no significant difference was detected between Group 0.25 and Group 0.16 between 12-24 hours. It was also observed that total tramadol consumption amounts were statistically significantly lower in Group 0.25 compared to Group 0.16 (p<0,05). Heart rate (HR) and systolic blood pressure (SBP) measumerents were found to be significantly lower in all determined time periods (p<0,05). Diastolic blood pressure (DBP) was found to be significantly lower in Group 0.25 and Group 0.16 compered to Group K at the 1st, 2nd and 4th hours (p<0,05). In addition, it was found to be significantly lower in Group 0.16 compared to Group 0.25 (p<0,05). It showed that there was no significant difference viii in mean blood pressure (OCB) between the groups at the 12th hour measurements, but there were significant differences between the groups in mean blood pressure in allother measurements (p<0,05). When examined in terms of side effects, nausea and vomiting at 1-12. hours were found to be significantly lower in Group 0.25. In conclusion; we believe that the PENG block applied with 20 ml 0.25% bupivacaine in hip surgery provides lower pain scores as a part of multimodal analgesia, reduces analgesic consumption and side effects due to tramadol consumption, and provides effective postoperative analgesia compared to the one applied with 20 ml 0.16% bupivacaine. However pain scores in Group 0.16, similar to Group 0.25 in the first 4 hours, suggest that Group 0.16 also provides effective analgesia, albeit for a shorter period. Keywords: Hip Surgery, Postoperative Pain, Pericapsular Nerve Group Block, Regional Anesthesia