Hemodynamic-Protective and Neuromonitoring-Preserving Pericapsular Nerve Group Regional Analgesia for Cemented Hip Hemiarthroplasty in an Elderly Patient with Coexisting Traumatic Intracerebral Hemorrhage and Bundle Branch Block: An Observational Analytic Case Study

Abstract

Background. Pain control after hip fracture surgery is difficult when intracranial injury and cardiac conduction disease limit systemic opioids. Opioids can raise intracranial pressure through hypoventilation. They can also obscure serial neurological examination.

Objective. To describe an opioid-sparing multimodal analgesic course centered on an ultrasound-guided pericapsular nerve group (PENG) block in cemented hip hemiarthroplasty.

Methods. A 64-year-old man (ASA III) fell from two meters. He had a displaced right intertrochanteric fracture, a minimal traumatic right frontal intracerebral hemorrhage (ICH score 0) and right bundle branch block. Cemented hemiarthroplasty was done under general anesthesia. After induction, a PENG block was placed with 20 mL of 0.25% bupivacaine, and scheduled intravenous paracetamol followed. Pain, quadriceps strength, Glasgow Coma Scale, hemodynamics and delirium were recorded at six time points.

Results. On arrival in the High-Care Unit, resting pain was 1/10 (7/10 before surgery) and movement pain 2/10 (9/10 before). No rescue opioid was needed over 72 hours; fentanyl 100 mcg was given at induction. The Glasgow Coma Scale stayed 15. Mean arterial pressure fell 19.4% to 82.0 mmHg at cementation and recovered within four minutes without a vasopressor or arrhythmia. Quadriceps strength was MRC 4/5 on arrival and 5/5 on day 1. No delirium occurred, and he went home on day 3.

Conclusion. A PENG block within a multimodal regimen was followed by low pain scores, no postoperative opioid use and a clear sensorium. One case cannot show causation. Fracture fixation, paracetamol and anesthesia acted at the same time.