Comparison of Ultrasound-Guided Pericapsular Nerve Group Block Versus Intravenous Ketamine for Positional Pain Management Before Spinal Anesthesia in Patients Who Underwent Hip Fracture Surgery: A Randomized Controlled Trial

BACKGROUND Hip fractures are a common problem among the elderly, leading to significant morbidity, mortality, and complications related to pain management. Effective analgesia is crucial to optimize positioning during spinal anesthesia and reduce postoperative pain. This study aimed to compare the efficacy of ultrasound-guided pericapsular nerve group (PENG) block versus intravenous ketamine in managing positional pain before spinal anesthesia in patients undergoing hip fracture surgery. MATERIAL AND METHODS This randomized controlled trial was conducted between 10/1/2024 and 5/25/2025 at Istanbul Training and Research Hospital. ASA II-III patients aged 35 to 90 years who were scheduled for hip fracture surgery under spinal anesthesia were enrolled. Exclusion criteria included contraindications for spinal anesthesia or PENG block, cognitive dysfunction, and previous analgesic use within 12 hours. Participants were randomly assigned to receive either a PENG block or intravenous ketamine. Pain intensity was assessed using the Numeric Rating Scale (NRS) preoperatively, during positioning, post-positioning, and at postoperative intervals (0, 3, 6, 12, and 24 hours). Secondary outcomes included total tramadol consumption, patient satisfaction as measured by the Quality of Recovery-15 (QoR-15) scale, and incidence of complications. RESULTS A total of 62 patients were included in the final analysis (30 in the PENG group and 32 in the control group). PENG block significantly reduced pre-positioning (2 vs 4, P<0.001), positioning (2 vs 5, P<0.001), and post-positioning NRS scores (2 vs 3, P<0.001) compared to ketamine. Patient positioning quality was rated higher in the PENG group (2.8 vs 2, P<0.001). Total tramadol consumption in the first 24 hours was significantly lower in the PENG group (50 mg vs 100 mg, P<0.001) and there was a delayed time to first request for analgesia (10.5 vs 5.6 hours, P<0.001). Postoperative NRS scores were also lower at 0, 3, 6, and 12 hours in the PENG block group (P<0.001). In addition, the PENG block group reported fewer adverse effects, including nausea (0% vs 12.5%, P=0.045). CONCLUSIONS Ultrasound-guided PENG block is an effective analgesic technique for managing positional pain during spinal anesthesia in hip fracture patients, significantly improving patient comfort and reducing postoperative opioid requirements. This study highlights the advantages of PENG block over intravenous ketamine, suggesting its potential as a preferred method for pain management in this population. Further multicenter studies are required to confirm these findings and explore the long-term benefits of PENG block in hip fracture surgery.