Is Continuous PENG Block the New 3-in-1? Olga Santos 1 , Rui Pereira 1 , Tiago Cabral 2 , Neusa Lages 1 and Humberto Machado 1,3,4* 1 Hospital and University Center of Porto, Porto, Portugal 2 Hospital of the Divino Espírito Santo, Ponta Delgada, Portugal 3 Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal 4 Central Research Center in Anesthesiology, Hospital and University Center of Porto, Porto, Portugal * Corresponding author: Dr Humberto S. Machado, Central Research Center in Anesthesiology, Hospital and University Center of Porto, Porto, Portugal, Tel: +351935848475; E-mail: hjs.machado@gmail.com Received date: April 22, 2019; Accepted date: June 21, 2019; Published date: June 28, 2019 Copyright: © 2019 Santos O, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Fascia iliaca or femoral nerve blocks are used frequently for hip fracture patients due to the opioid-sparing effects. However, these techniques prove to be insufficient in many cases. A recent anatomical study on hip innervation, led to the identification of relevant landmarks to target the hip articular branches, namely the Pericapsular Nerve Group (PENG), which allowed a novel ultrasound-guided approach. The aim of this case report is to show an anesthetic technique not described previously, that included an ultra-sound guided PENG block with perineural catheter. Keywords: Peripheral nerve blocks; Hip surgery; Accessory obturator nerve Introduction Peripheral nerve blocks are becoming increasingly popular for hip arthroplasty anesthesia. Modern regional anesthesia for major hip surgery includes the use of a single shot and continuous epidural or spinal injections, continuous lumbar plexus blockade and continuous peripheral blockade of the femoral nerve (FN), fascia iliaca (FI) block, 3-in-1 FN block and sciatic nerve [1,2]. Te use of either single shot or continuous peripheral nerve blocks are becoming increasingly popular. Tese techniques have shown efective and safe postoperative pain control, resulting in lower opioid consumption, improved earlier rehabilitation and high patient satisfaction [2]. Taking into account previous anatomical studies, the anterior hip capsule is innervated by the obturator nerve (ON), accessory obturator nerve (AON) and FN1. A recent anatomical study by Short et al confrmed the innervation of the anterior hip and also identifed the relevant landmarks for those articular branches [3]. Ultrasound-guided techniques for blockade of these articular branches to the hip include the PENG block, which has been described in a recent paper with promising results [1]. We will be reporting on the anesthetic management of a patient proposed for a second lef hip prosthesis revision. An ultra-sound guided PENG block with a perineural catheter was performed. Written informed consent for publication was obtained from the patient. Case Report A 63-year old male, with obstructive sleep apnea and a hereditary polyneuropathy diagnosed at the age of 36 was proposed for hip arthroplasty. Due to long standing corticoid therapy, a bilateral aseptic femur necrosis has developed, requiring multiple hip replacement surgeries. Moreover, a lumbar spine surgery has also taken place some years ago. At the time of surgery, the patient presented with signs of skin infection in the lumbar surgical site. A combined general anesthesia with an ultra-sound guided PENG block with a perineural catheter was proposed to the patient and fully accepted. Te patient was monitored with American Society of Anesthesiologists (ASA) standards and invasive blood pressure. Te regional block was performed in the supine position. A curvilinear low-frequency (2-5 MHz) ultrasound probe was initially placed in a transverse plane over the lef anterior inferior iliac spine and then aligned with the pubic ramus by rotating the probe counterclockwise approximately 45 degrees. In this view, with a 7.8 cm depth, the iliopubic eminence, the iliopsoas muscle and tendon, the femoral artery and pectineus muscle were observed (Figure 1). Local skin anesthesia with 4 ml of 2% lidocaine was administered and an 18- gauge 150 mm needle was inserted from lateral to medial in an in- plane approach. During the block, the tip was placed between the psoas tendon anteriorly and the pubic rami posteriorly, and following negative aspiration 20 ml of 0.5% ropivacaine and 4 mg of dexamethasone were injected (Figure 2). Figure 1: Sonogram. 1-femoral artery; 2-pectineus muscle; 3- femoral Nerve; 4-psoas muscle; 5-Psoas tendon. J o u r n a l o f A n e s t h e s i a & C l i n i c a l R e s e a r c h ISSN: 2155-6148 Journal of Anesthesia & Clinical Research Santos et al., J Anesth Clin Res 2019, 10:6 Case Report Open Access J Anesth Clin Res, an open access journal ISSN: 2155-6148 Volume 10 • Issue 6 • 1000898