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Zhao F, Jin M, Xue FS. Comparing analgesic efficacy of continuous serratus anterior plane and thoracic epidural blocks for multiple rib fractures. Acta Anaesthesiol Scand 2024; 68:714-715. [PMID: 38366370 DOI: 10.1111/aas.14390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/07/2023] [Indexed: 02/18/2024]
Affiliation(s)
- Fang Zhao
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Mu Jin
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Fu-Shan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, People's Republic of China
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2
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van Zyl T, Ho AMH, Klar G, Haley C, Ho AK, Vasily S, Mizubuti GB. Analgesia for rib fractures: a narrative review. Can J Anaesth 2024; 71:535-547. [PMID: 38459368 DOI: 10.1007/s12630-024-02725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/11/2023] [Accepted: 12/27/2023] [Indexed: 03/10/2024] Open
Abstract
PURPOSE Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach. SOURCE Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts. PRINCIPAL FINDINGS Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities. CONCLUSION Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).
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Affiliation(s)
- Theunis van Zyl
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Christopher Haley
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Adrienne K Ho
- Department of Public Health Sciences (Epidemiology), School of Medicine, Queen's University, Kingston, ON, Canada
| | - Susan Vasily
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology & Perioperative Medicine, Queen's University, Kingston General Hospital, Victory 2 Wing, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
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3
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Tong L, Solla C, Staack JB, May K, Tran B. Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach. Semin Cardiothorac Vasc Anesth 2024:10892532241235750. [PMID: 38506340 DOI: 10.1177/10892532241235750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.
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Affiliation(s)
- Larry Tong
- Virginia Commonwealth University, Richmond, VA, USA
| | - Che Solla
- University of Tennessee, Knoxville, TN, USA
| | | | - Keith May
- University of Tennessee, Knoxville, TN, USA
| | - Bryant Tran
- Virginia Commonwealth University, Richmond, VA, USA
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Bethlahmy JM, Hanst BA, Giafaglione SM, Elia JM. Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review. J Clin Anesth 2023; 91:111275. [PMID: 37797395 DOI: 10.1016/j.jclinane.2023.111275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/12/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Abstract
Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF.
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Affiliation(s)
- Jessica M Bethlahmy
- UC Irvine School of Medicine, 1001 Health Sciences Road Irvine, CA 92617, USA
| | - Brian A Hanst
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Sarah M Giafaglione
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Jennifer M Elia
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA.
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Proaño-Zamudio JA, Argandykov D, Renne A, Gebran A, Ouwerkerk JJJ, Dorken-Gallastegi A, de Roulet A, Velmahos GC, Kaafarani HMA, Hwabejire JO. Timing of regional analgesia in elderly patients with blunt chest-wall injury. Surgery 2023; 174:901-906. [PMID: 37582669 DOI: 10.1016/j.surg.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/22/2023] [Accepted: 07/08/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Rib fractures represent a typical injury pattern in older people and are associated with respiratory morbidity and mortality. Regional analgesia modalities are adjuncts for pain management, but the optimal timing for their initiation remains understudied. We hypothesized that early regional analgesia would have similar outcomes to late regional analgesia. METHODS We retrospectively reviewed the American College of Surgeons Trauma Quality Improvement Program database from 2017 to 2019. We included patients ≥65 years old admitted with blunt chest wall trauma who received regional analgesia. We divided patients into 2 groups: (1) early regional analgesia (within 24 hours of admission) and (2) late regional analgesia (>24 hours). The outcomes evaluated were ventilator-associated pneumonia, mortality, unplanned intensive care unit admission, unplanned intubation, discharge to home, and duration of stay. Univariable analysis and multivariable logistic regression adjusting for patient and injury characteristics, trauma center level, and respiratory interventions were performed. RESULTS In the study, 2,248 patients were included. The mean (standard deviation) age was 75.3 (6.9), and 52.7% were male. The median injury severity score (interquartile range) was 13 (9-17). The early regional analgesia group had a decreased incidence of unplanned intubation (2.7% vs 5.3%, P = .002), unplanned intensive care unit admission (4.9% vs 8.4%, P < .001), and shorter mean duration of stay (5.5 vs 6.5 days, P = .002). In multivariable analysis, early regional analgesia was associated with decreased odds of unplanned intubation (odds ratio, 0.58; 95% confidence interval, 0.36-0.94; P = .026), unplanned intensive care unit admission (odds ratio, 0.60; 95% confidence interval, 0.041-0.86; P = .006), and increased odds of discharge to home (odds ratio, 1.27; 95% confidence interval, 1.04-1.55; P = .019). After multivariable adjustment, no significant difference was found for ventilator-associated pneumonia or mortality (odds ratio, 0.60; 95% confidence interval, 0.34-1.04; P = .070). CONCLUSION Early regional analgesia initiation is associated with improved outcomes in older people with blunt chest wall injuries. Geriatric trauma care bundles targeting early initiation of regional analgesia can potentially decrease complications and resource use.
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Affiliation(s)
- Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Angela Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Joep J J Ouwerkerk
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Ander Dorken-Gallastegi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Amory de Roulet
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
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6
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Elkins MR. Physiotherapy management of rib fractures. J Physiother 2023; 69:211-219. [PMID: 37714770 DOI: 10.1016/j.jphys.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/17/2023] Open
Affiliation(s)
- Mark R Elkins
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
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Alanwer KM, Refat AM, Negm EM. Impact of flail chest injury on morbidity and outcome: ten years' experience at a tertiary care hospital in a developing country. BMC Anesthesiol 2023; 23:229. [PMID: 37403012 DOI: 10.1186/s12871-023-02185-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/18/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND One of the worst types of severe chest injuries seen by clinicians is flail chest. This study aims to measure the overall mortality rate among flail chest patients and then to correlate mortality with several demographic, pathologic, and management factors. METHODOLOGY A retrospective observational study tracked a total of 376 flail chest patients admitted to the emergency intensive care unit (EICU) and surgical intensive care unit (SICU) at Zagazig University over 120 months. The main outcome measurement was overall mortality. The secondary outcomes were the association of age and sex, concomitant head injury, lung and cardiac contusions, the onset of mechanical ventilation (MV) and chest tubes insertion, the length of mechanical ventilation and ICU stay in days, injury severity score (ISS), associated surgeries, pneumonia, sepsis, the implication of standard fluid therapy and steroid therapy, and the systemic and regional analgesia, with the overall mortality rates. RESULTS The mortality rate was 19.9% overall. The shorter onset of MV and chest tube insertion, and the longer ICU, and hospital length of stay were noted in the mortality group compared with the survived group (P-value less than 0.05). Concomitant head injuries, associated surgeries, pneumonia, pneumothorax, sepsis, lung and myocardial contusion, standard fluid therapy, and steroid therapy were significantly correlated with mortality (P-value less than 0.05). MV had no statistically significant effect on mortality. Regional analgesia (58.8%) had a significantly higher survival rate than intravenous fentanyl infusion (41.2%). In multivariate analysis, sepsis, concomitant head injury, and high ISS were independent predictors for mortality [OR (95% CI) = 568.98 (19.49-16613.52), 6.86 (2.86-16.49), and 1.19 (1.09-1.30), respectively]. CONCLUSION The current report recorded mortality of 19.9% between flail chest injury patients. Sepsis, concomitant head injury, and higher ISS are the independent risk factors for mortality when associated with flail chest injury. Considering restricted fluid management strategy and regional analgesia may help better outcome for flail chest injury patients.
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Affiliation(s)
- Khaled M Alanwer
- Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ali Mohammed Refat
- Cardiothoracic Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Essamedin M Negm
- Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
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8
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Jiang M, Peri V, Ou Yang B, Chang J, Hacking D. Erector Spinae Plane Block as an Analgesic Intervention in Acute Rib Fractures: A Scoping Review. Local Reg Anesth 2023; 16:81-90. [PMID: 37334278 PMCID: PMC10275321 DOI: 10.2147/lra.s414056] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/01/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction Rib fractures are a common sequelae of chest trauma and are associated with significant morbidity. The erector spinae nerve block (ESB) has been proposed as an alternative first-line regional technique for rib fractures due to ease of administration and minimal complication profile. We aimed to investigate the current literature surrounding this topic with a focus on pain and respiratory outcomes. Methods A comprehensive literature search was performed on the Medline, Embase, Web of Science, Scopus, and Cochrane databases. Keywords of "erector spinae block" and "rib fractures" were used to form the search strategy. Papers published in English investigating ESB as an analgesic intervention for acute rib fracture were included. Exclusion criteria were operative rib fixation, or where the indication for ESB was not rib fracture. Results There were 37 studies which met the inclusion criteria for this scoping review. Of these, 31 studies reported on pain outcomes and demonstrated a 40% decrease in pain scores post administration within the first 24 hours. Respiratory parameters were reported in 8 studies where an increase in incentive spirometry was demonstrated. Respiratory complication was not consistently reported. ESB was associated with minimal complications; only 5 cases of haematoma and infection were (incidence 0.6%) reported, none of which required further intervention. Discussion Current literature surrounding ESB in rib fracture management provides a positive qualitative evaluation of efficacy and safety. Improvements in pain and respiratory parameters were almost universal. The notable outcome from this review was the improved safety profile of ESB. The ESB was not associated with complications requiring intervention even in the setting of anticoagulation and coagulopathy. There still remains a paucity of large cohort, prospective data. Moreover, no current studies reflect an improvement in respiratory complication rates compared to current techniques. Taken together, these areas should be the focus of any future research.
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Affiliation(s)
- Michael Jiang
- Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
| | - Varun Peri
- Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
| | - Bobby Ou Yang
- Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
| | - Jaewon Chang
- Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
| | - Douglas Hacking
- Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
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9
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Lin CJ, Yeh YS, Lin YK, Chen CW. K-Rod: An Innovative Method of Personalized Rib Splinting for Expeditious Management of Flail Chest in Acute Care Settings. Medicina (B Aires) 2022; 59:medicina59010076. [PMID: 36676700 PMCID: PMC9865151 DOI: 10.3390/medicina59010076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023] Open
Abstract
Flail chest is a severe type of multiple rib fracture that can cause ventilation problems and respiratory complications. Historically, flail chest has been mainly managed through pain control and ventilatory support as needed. Operative fixation has recently become popular for the condition, and some studies have revealed its potentially positive effects on the outcomes of patients with flail chest. However, for those for whom surgery is unsuitable, few treatment options, other than simply providing analgesia, are available. Herein, we introduce our innovative method of applying personalized rib splinting for quick management of flail chest, which is easy, tailor-made, and has significant effects on pain reduction.
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Affiliation(s)
- Chia-Jung Lin
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yung-Sung Yeh
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yen-Ko Lin
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Department of Emergency Medicine, Faculty of Medicine, College of Medicine, Kaohsiung 80708, Taiwan
| | - Chao-Wen Chen
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Department of Emergency Medicine, Faculty of Medicine, College of Medicine, Kaohsiung 80708, Taiwan
- Correspondence:
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Marasco SF, Nguyen Khuong J, Fitzgerald M, Summerhayes R, Sekandarzad MW, Varley V, Campbell RJ, Bailey M. Flail chest injury-changing management and outcomes. Eur J Trauma Emerg Surg 2022; 49:1047-1055. [PMID: 36318281 PMCID: PMC9628626 DOI: 10.1007/s00068-022-02152-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 10/21/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to assess trends in management of flail chest injuries over time and to determine impact on patient outcomes. METHODS A retrospective review of data from a prospectively collated database of all trauma patients admitted to a level 1 trauma service in Victoria was conducted. All trauma patients admitted to the hospital between July 2008 and June 2020 with an Abbreviated Injury Scale (AIS) code for flail chest injury were included. RESULTS Our study included 720 patients, mean age was 59.5 ± 17.3 years old, and 76.5% of patients were male. Length of ICU stay decreased on average by 9 h each year. Regional anaesthesia use increased by 15% per year (0% in 2009 to 36% in 2020) (p < 0.001). Surgical stabilisation of rib fractures increased by 16% per year (2.9% in 2009 to 22.3% in 2020) (p = 0.006). The use of invasive ventilation decreased by 14% per year (70% in 2008 to 27% in 2020) (p < 0.001), and invasive ventilation time decreased by 8 h per year (p = 0.007). CONCLUSION Over the past decade, we have seen increasing rates of regional anaesthesia and surgical rib fixation in the management of flail chest. This has resulted in lower requirements for and duration of invasive mechanical ventilation and intensive care unit stay but has not impacted mortality in this patient cohort.
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Affiliation(s)
- Silvana F. Marasco
- Cardiothoracic Surgery Unit, The Alfred Hospital, Melbourne, VIC 3004 Australia ,Department of Surgery, Monash University, Melbourne, VIC Australia
| | | | - Mark Fitzgerald
- Department of Surgery, Monash University, Melbourne, VIC Australia ,National Trauma Research Institute, Melbourne, VIC Australia ,Trauma Service, The Alfred Hospital, Melbourne, VIC Australia
| | - Robyn Summerhayes
- Cardiothoracic Surgery Unit, The Alfred Hospital, Melbourne, VIC 3004 Australia
| | - Mir Wais Sekandarzad
- Department of Anesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, VIC Australia
| | - Vincent Varley
- Department of Surgery, Monash University, Melbourne, VIC Australia
| | - Ryan J. Campbell
- Department of Surgery, Monash University, Melbourne, VIC Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC Australia
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11
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Sborov KD, Dennis BM, de Oliveira Filho GR, Bellister SA, Statzer N, Stonko DP, Guyer RA, Wanderer JP, Beyene RT, McEvoy MD, Allen BFS. Acute pain consult and management is associated with improved mortality in rib fracture patients. Reg Anesth Pain Med 2022; 47:rapm-2022-103527. [PMID: 35882429 DOI: 10.1136/rapm-2022-103527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/09/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Traumatic rib fractures result in significant patient morbidity and mortality, which increases with patient age and number of rib fractures. A dedicated acute pain service (APS) providing expertize in multimodal pain management may reduce these risks and improve outcomes. We aimed to test the hypothesis that protocolized APS consultation decreases mortality and morbidity in traumatic rib fracture patients. METHODS This is a retrospective observational, propensity-matched cohort study of adult patients with trauma with rib fractures from 2012 to 2015, at a single, large level 1 trauma center corresponding to introduction and incorporation of APS consultation into the institutional rib fracture pathway. Using electronic medical records and trauma registry data, we identified adult patients presenting with traumatic rib fractures. Patients with hospital length of stay (LOS) ≥2 days were split into two cohorts based on presence of APS consult using 1:1 propensity matching of age, gender, comorbidities and injury severity. The primary outcome was difference in hospital mortality. Secondary outcomes included LOS and pulmonary morbidity. RESULTS 2486 patients were identified, with a final matched cohort of 621 patients receiving APS consult and 621 control patients. The mortality rate was 1.8% among consult patients and 6.6% among control patients (adjusted OR 0.25, 95% CI 0.13 to 0.50; p=0.001). The average treatment effect of consult on mortality was 4.8% (95% CI 1.2% to 8.5%;. p<0.001). APS consultation was associated with increased intensive care unit (ICU) LOS (1.19 day; 95% CI 0.48 to 1.90; p=0.001) and hospital LOS (1.61 days; 95% CI 0.81 to 2.41 days; p<0.001). No difference in pulmonary complications was observed. DISCUSSION An APS consult in rib fracture patients is associated with decreased mortality and no difference in pulmonary complications yet increased ICU and hospital LOS.
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Affiliation(s)
| | - Bradley M Dennis
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Seth A Bellister
- Department of Acute Care Surgery, CHRISTUS Trinity Mother Frances Health System, Tyler, Texas, USA
| | - Nicholas Statzer
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Richard A Guyer
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan P Wanderer
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robel T Beyene
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D McEvoy
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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12
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Piennette PD, Morris SE, Northern T. Current Review of Analgesia and Regional Anesthesia Practices for Rib Fracture and Chest Wall Trauma. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00530-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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13
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O'Connell KM, Patel KV, Powelson E, Robinson BRH, Boyle K, Peschman J, Blocher-Smith EC, Jacobson L, Leavitt J, McCrum ML, Ballou J, Brasel KJ, Judge J, Greenberg S, Mukherjee K, Qiu Q, Vavilala MS, Rivara F, Arbabi S. Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 2021; 91:265-271. [PMID: 33938510 PMCID: PMC9704032 DOI: 10.1097/ta.0000000000003258] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers. METHODS Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence. RESULTS Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16). CONCLUSION In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury. LEVEL OF EVIDENCE Therapeutic, level IV; Epidemiologic, level III.
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Affiliation(s)
- Kathleen M O'Connell
- From the Department of Surgery (K.M.O'C., B.R.H.R., S.A.), Department of Anesthesiology and Pain Medicine (K.V.P., E.P., M.S.V.), and Department of Pediatrics (F.R.), Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Department of Surgery (K.B.), Medical College of Wisconsin, Milwaukee; Department of Surgery (J.P.), Gundersen Health System, La Crosse, Wisconsin; Department of Family Medicine (E.C.B-S.), Mercy Health, Muskegon, Michigan; Department of Surgery (L.J.), St. Vincent Indianapolis Hospital, Indianapolis, Indiana; School of Medicine (J.L.), Department of Surgery (M.L.M.), University of Utah, Salt Lake City, Utah; Department of Surgery (J.B., K.J.B.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (J.J.), Mission Trauma Services, Asheville, North Carolina; Department of Surgery (S.G., K.M.), Loma Linda University, Loma Linda, California; Harborview Injury Prevention and Research Center (Q.Q.), Seattle, Washington
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14
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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15
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Mizubuti GB, Camiré D, Ho AMH, Breton S, Klar G. Erector Spinae Plane Block When Neuraxial Analgesia Is Contraindicated by Clotting Abnormalities. Ann Thorac Surg 2021; 112:e245-e247. [PMID: 33549523 DOI: 10.1016/j.athoracsur.2021.01.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 01/21/2023]
Abstract
We describe 4 cases in which patients with coagulopathies, an absolute contraindication to epidural/paravertebral blocks, received an erector spinae plane block to manage severe thoracic pain with respiratory impairment. Intubation was avoided in 2 cases, and weaning from the ventilator was facilitated in 2 cases. Ultrasound-guided erector spinae plane block is simple to perform, has a low risk profile, and provides an excellent analgesic alternative.
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Affiliation(s)
- Glenio B Mizubuti
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Daenis Camiré
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Sophie Breton
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Gregory Klar
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada.
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