Ultrasound-guided pericapsular nerve group block versus intravenous morphine for pain management in older adults with hip fractures: a randomised controlled trial in the emergency department.

Abstract

Background: Hip fracture pain is severe and is commonly managed with intravenous opioids that cause adverse effects in older adults. Although the use of regional anaesthesia is increasing, high-quality evidence remains limited, with insufficient randomised controlled trial (RCT) evaluating the effectiveness of the pericapsular nerve group (PENG) block in the emergency department (ED). This study aimed to compare the analgesic efficacy of ultrasound-guided PENG block with intravenous morphine for acute hip fracture pain in older adults presenting to the ED.

Methods: This open label, 1:1 parallel RCT using software-generated randomisation compared PENG block versus intravenous morphine (0.1 mg/kg) in patients aged ≥65 years who presented to the ED with femoral head, intertrochanteric, subtrochanteric and neck fractures with acute moderate-to-severe pain, defined as ≥5 on an 11-point Verbal Numeric Rating Scale (VNRS). The primary outcome was improvement in the VNRS score at 30 min. The secondary outcomes included the need for rescue therapy (intravenous fentanyl 0.5 µg/kg) and the incidence of adverse events. RESULTS: A total of 34 patients were included in the final analysis, with 17 patients in each group. At 30 min, the median reduction in pain score was greater in the PENG block group than in the intravenous morphine group (-6 (IQR-6 to -5) vs -3 (IQR -5 to -2); p=0.001). Generalised estimating equation analysis accounting for repeated measures demonstrated that the PENG block was associated with a significantly more pronounced reduction in pain over time than intravenous morphine (adjusted β = -1.55; 95% CI -2.63 to -0.47; p=0.005). Rescue analgesia was required in 5.9% of patients receiving intravenous morphine, whereas no patients in the PENG block group required rescue therapy.

Conclusion: PENG block is a highly effective and safe alternative to intravenous morphine for managing acute hip fracture pain, particularly in older adults.