Prospective, Randomized Comparison of Continuous Thoracic Epidural and Thoracic Paravertebral Infusion in Patients With Unilateral Multiple Fractured Ribs—A Pilot Study

Analgesia for rib fractures: a narrative review

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).

Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice

BACKGROUND/IMPORTANCE

Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity.

OBJECTIVE

We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults.

EVIDENCE REVIEW

We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

FINDINGS

Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia.

CONCLUSION

Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.

Beyond the short-term relief: Outcomes of geriatric rib fracture patients receiving paravertebral nerve blocks and epidural analgesia

BACKGROUND

Adequate pain control is a critical component of rib fracture management. Our study aimed to evaluate the in-hospital and post-discharge outcomes of geriatric rib fracture patients who received paravertebral nerve block (PVNB) versus epidural analgesia (EA) on a national level.

METHODS

We performed a 5-year (2011-15) retrospective analysis of the Nationwide Readmission database. We included all the geriatric (≥65 years) blunt trauma patients with rib fractures who received a paravertebral nerve block (PVNB) or Epidural analgesia (EA) for chest injuries. We excluded patients who were dead on arrival, those with head AIS≥3, spine AIS >0, and those with cognitive impairment. Patients were stratified into two groups (PVNB and EA). A propensity score matching (1:2) was performed, and the two groups were compared. Our outcomes included delirium, hospital length of stay (LOS), 90-day readmissions, 90-day mechanical ventilation, and initial and 90-day mortality.

RESULTS

A total of 2,855 geriatric rib fracture patients were identified, out of which 352 (12 %) received PVNB and 2,503 (87 %) received EA. The mean (SD) age was 78 (8) years and 53 % were female. A total of 1,041 patients were matched (PVNB=347, EA=694 patients). The median [IQR] Injury severity score was 9 [3-15], median chest AIS was 3 [2-4], and 70 % had ≥3 rib fractures. The total mortality during index admission was 6 %, 13 % experienced delirium, and the median hospital LOS was 6 [4-10] days. There was no difference in the primary outcomes of the two groups including rates of index admission mortality (PVNB: 5.2% vs. EA:6.3 %, p = 0.548) and delirium (PVNB: 12.4% vs. EA:12.9 %, p = 0.862). We also found no statistically significant difference between these groups in terms of 90-day respiratory complications (p = 1.000), 90-day readmission (p = 0.111), 90-day mortality (p = 0.718), and 90-day need for mechanical ventilation (p = 1.000).

CONCLUSION

The use of PVNB in geriatric trauma patients with multiple rib fractures is associated with comparable in-hospital and post-discharge outcomes relative to EA. PVNB is relatively easy to perform and has a better side effect profile. The use of PVNB as part of rib fracture management protocols warrants further consideration.

LEVEL OF EVIDENCE

III STUDY TYPE: Therapeutic/Care Management.

Comparative Analysis of Intravenous Opioids Versus Thoracic Epidural Anesthesia in Fractured Rib Pain Management: A Systematic Review and Meta-Analysis

Rib fractures, common among trauma victims, lead to significant morbidity and mortality. Managing the associated pain is challenging, with IV opioids and thoracic epidural analgesia (TEA) being utilized. While epidural analgesia is often preferred for fractured rib pain, existing data encompasses both lumbar and thoracic approaches. This review aimed to compare TEA and IV opioids for persistent rib fracture pain. A comprehensive search across five databases yielded 987 articles, of which seven met the eligibility criteria. Outcomes were categorized into primary (pain reduction) and secondary (mortality, hospital/ICU stays, analgesia-related complications) endpoints. Analyzed with Review Manager (RevMan) Version 5.4.1 (2020; The Cochrane Collaboration, London, United Kingdom), the pooled data from two sources showed TEA significantly more effective in reducing pain than IV opioids (standardized mean difference (SMD): 2.23; 95%CI: 1.65-2.82; p < 0.00001). Similarly, TEA was associated with shorter ICU stays (SMD: 0.73; 95%CI: 0.33-1.13; p = 0.0004), while hospitalization duration showed no substantial difference (SMD: 0.82; 95%CI: -0.34-1.98). Mortality rates also did not significantly differ between TEA and IV opioids (risk ratio (RR): 1.20; 95%CI: 0.36-4.01; p = 0.77). Subgroup analysis revealed fewer pneumonia cases with TEA (RR: 2.06; 95%CI: 1.07-3.96; P = 0.03), with no notable disparities in other complications. While TEA's superiority in pain relief for rib fractures suggests it is the preferred analgesic, the recommendation's strength is tempered by the low methodological quality of supporting articles.

Comprehensive Review of Current Pain Management in Rib Fractures With Practical Guidelines for Clinicians

Rib fractures are present in 15% of all traumas and 60% of patients with chest traumas. Rib fractures are not life-threatening in isolation, but they can be quite painful which leads to splinting and compromise of respiratory function. Splinting limits the ability of a patient to take a deep breath, which leads to atelectasis, atelectasis to poor secretion removal, and poor secretion removal leads to pneumonia. Pneumonia is the common pathway to respiratory failure in patients with rib fractures. It is noted that in the elderly, each rib fracture increases developing pneumonia by 27% and the risk of dying by 19%. From a public health perspective, rib fractures have long-term implications with only 59% of patients returning to work at 6 months. In this review we will examine the state of art as it currently exists with regard to the management of pain associated with rib fractures. Included in this overview will be a brief review of the anatomy of the thorax and some important physiologic concepts, the latest trends in pharmacologic and noninvasive means of managing rib pain, a special section on epidural anesthesia, some other alternative invasive methods of pain control, and a review of the recent literature on rib plating. Finally, a practical, easy to follow guideline, to manage the patient with pain from rib fractures will be presented.

Rib fracture-related morbidity and mortality for older persons in the era of fascial plane blocks: A cohort study

Introduction

Analgesia is key to successful conservative, nonsurgical management of patients admitted to the hospital with multiple rib fractures. Recently, new fascial plane regional anesthesia techniques have become widely available. We hypothesized that since the introduction of these new regional analgesia techniques, for patients over the age of 65 years, the effect of increasing numbers of rib fractures has been mitigated.

Methods

A retrospective study of patients admitted for the management of rib fractures between 2017 and 2020 was performed. Patients not admitted to the hospital, under the age of 65 years, or with chest trauma other than rib fractures were not eligible for inclusion. The primary outcome of interest was mortality. The secondary outcomes were the incidence of pneumonia and intensive care unit admission. Results were reported as the odds ratio and its 95% confidence interval and associated p-value. Statistical significance was set at [Formula: see text] < 0.05.

Results

Overall, 252 patients were included and 142 patients received a regional anesthesia. The mortality rate was 4% (n = 10) with no association between mortality and number of rib fractures ( p = 0.215). Twenty-four patients (9.5%) developed pneumonia during their hospital stay, again with no association with an increasing number of rib fractures. The intensive care unit admission rate was 13.1% (n = 33) and correlated with an increasing number of fractures (odds ratio = 1.15; 95% confidence interval = 1.01 to 1.31; p = 0.038).

Conclusion

Management including liberal utilization of regional anesthesia for at-risk patients appears to mitigate the effect of increasing numbers of rib fractures on the incidence of mortality and pneumonia.

Comparison of Thoracic Epidural Analgesia and Thoracic Paravertebral Block Applications in the Treatment of Acute Pain After Thoracotomy in Geriatric Patients

Background

Thoracic epidural analgesia (TEA) and thoracic paravertebral block (TPVB) are commonly used in geriatric patients for pain management after thoracotomy. In this study, we aimed to investigate the effect of TEA and TPVB on postoperative analgesia in geriatric patients who underwent thoracotomy.

Methodology

Postoperative analgesia follow-up files of patients over 65 years of age who underwent thoracotomy were analyzed retrospectively. Patient’s demographic data, diagnosis, type of surgery, postoperative 24-hour mean arterial pressure (MAP), heart rate, respiratory rate, peripheral oxygen saturation, static/dynamic visual analog scale (VAS) scores, need for additional analgesics, global pain assessment, and side effects such as nausea, vomiting, hypotension, bradycardia, and respiratory depression were examined. The patients were divided into two groups: those treated with TEA (Group 1) and those treated with TPVB (Group 2).

Results

There was no statistically significant difference between the groups in terms of demographic data (p > 0.05). MAP in the TEA group was statistically significantly lower than in the second and sixth-hour TPVB group (p = 0.008, p < 0.001). VAS static scores in the TEA group were statistically significantly lower at 30 minutes (p = 0.001), and at one, two, six, twelve, and twenty-four hours compared to the TPVB group (p < 0.001, except at 30 minutes). VAS dynamic scores were statistically significantly lower in the TEA group at 30 minutes, and at one, two, six, twelve, and twenty-four hours compared to the TPVB group (p < 0.001). There was no statistically significant difference between the groups in terms of nausea, vomiting, hypotension, and bradycardia (p > 0.05). The use of additional analgesics in the TEA group was statistically significantly lower than in the TPVB group (p < 0.001).

Conclusions

More effective postoperative analgesia results with stable hemodynamic conditions were observed in geriatric patients who underwent TEA for thoracotomy compared to TPVB. Regarding side effects, although there was a lower incidence in TPVB, this was not statistically significant when compared to TEA. TEA, as a component of the multimodal analgesia approach, can be accepted as a safe and effective method in the elderly patient group who underwent thoracotomy.

The financial burden of rib fractures: National estimates 2007 to 2016

BACKGROUND

The aim of this study is to define the cost of rib fracture hospitalization by single, multiple, and flail type using a nationally representative sample.

METHODS

The national inpatient sample (NIS) was used to identify patients with a primary diagnosis of rib fracture hospitalization 2007-2016. International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes were used to characterize patients as having single, multiple, or flail chest rib fractures. Patients with only trauma related diagnosis groups (DRG) at the time discharge were included in the final sample. The cost of hospitalization was obtained by converting reported charges into cost using the all-payer inpatient cost-to-charge ratio (CCR) for all hospitals in the NIS data. The log of cost was modeled using multivariate linear regression. The rib fracture type was the primary predictor in the model.

RESULTS

There were 373,053 rib fracture admissions during 2007-2016. The average cost per hospitalization was $10,169 (95%Confidence Interval [CI]: 9,942-10,395), which translated into a national expenditure of $3.64 billion over 10 years. The cost of rib fracture hospitalization increased from $209 million in 2007 to $469 million in 2016. Compared to single rib fracture patients, the cost of hospitalization for multiple rib fractures and flail chest was 3% (p = 0.001) and 5% (p=0.02) higher, respectively. Higher injury severity score, total number of body regions injured and longer length of stay were associated with higher rib fracture hospitalization cost.

CONCLUSIONS

Rib fractures affect ~22,000-45,000 people per year in the United States. The cost of rib fractures is over $469 million per year and is increasing over time. Multiple rib fractures and flail chest rib fractures are associated with increased cost. Pathways to improve care in patients with rib fractures should consider the cost of treatment.

The effect of erector spinae block versus serratus plane block on pain scores and diaphragmatic excursion in multiple rib fractures. A prospective randomized trial

OBJECTIVES

We aimed to investigate whether ultrasound guided erector spinae plane block and serratus anterior plane block would provide effective and safe analgesia in patients with fracture ribs, and to detect their effects on diaphragmatic excursion in such cases.

DESIGN

Prospective double-blind randomized study.

SETTINGS

Tanta University Hospitals.

SUBJECT

Fifty adult patients ASA I, II with fracture ribs.

METHODS

Patients were randomized to receive either ultrasound guided erector spinae block (Group I) or serratus plane block (Group II) with injection of 19 ml bupivacaine 0.25% plus 1 ml dexamethasone (4 mg). Pain scores, 24 hour total analgesic requirements, diaphragmatic excursion and incidence of adverse events were recorded.

RESULTS

At rest and dynamic pain scores were significantly lower in Group I as compared to Group II from 2 hour up to 24 hour post block [median differences (95% CI): -1(-0.9999;0.0002), -1(-0.9999;0.0002), -1(-0.9998;0.0003), -1(-1.000;-0.000) and -1(-2.0000;-1.0000), -1(-0.9998;-0.0001), -1(-1.0001;-1.0002), -1(-2.000;0.000) respectively], with a significant reduction in 24h opioid consumption in Group I in comparison to Group II (P= 0.004*). Diaphragmatic excursion showed a significant improvement in Group I when compared to Group II at 2, 6, 12, and 24 hour after the block (p = 0.024*, 0.038*, 0.027*, 0.042* correspondingly). No adverse events were noted.

CONCLUSIONS

Both erector spinae block and serratus plane block provided safe and effective pain relief in traumatic rib fractures. Though the erector spinae group displayed significantly reduced pain scores, decreased analgesic needs and improved diaphragmatic excursion as compared to serratus group, nevertheless, this was of no clinical significance.

Paravertebral Block versus Thoracic Epidural Analgesia for Postthoracotomy Pain Relief: A Meta-Analysis of Randomized Trials

OBJECTIVE

 Paravertebral block (PVB) and thoracic epidural analgesia (TEA) are commonly used for postthoracotomy pain management. The purpose of this research is to evaluate the effects of TEA versus PVB for postthoracotomy pain relief.

METHODS

 A systematic literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library (last performed on August 2020) to identify randomized controlled trials comparing PVB and TEA for thoracotomy. The rest and dynamic visual analog scale (VAS) scores, rescue analgesic consumption, the incidences of side effects were pooled.

RESULTS

 Sixteen trials involving 1,000 patients were included in this meta-analysis. The pooled results showed that the rest and dynamic VAS at 12, 24, and rest VAS at 48 hours were similar between PVB and TEA groups. The rescue analgesic consumption (weighted mean differences: 3.81; 95% confidence interval [CI]: 0.982-6.638, p < 0.01) and the incidence of rescue analgesia (relative risk [RR]: 1.963; 95% CI: 1.336-2.884, p < 0.01) were less in TEA group. However, the incidence of hypotension (RR: 0.228; 95% CI: 0.137-0.380, p < 0.001), urinary retention (RR: 0.392; 95% CI: 0.198-0.776, p < 0.01), and vomiting (RR: 0.665; 95% CI: 0.451-0.981, p < 0.05) was less in PVB group.

CONCLUSION

 For thoracotomy, PVB may provide no superior analgesia compared with TEA but PVB can reduce side effects. Thus, individualized treatment is recommended. Further study is still necessary to determine which concentration of local anesthetics can be used for PVB and can provide equal analgesic efficiency to TEA.

Ultrasound-Guided Thoracic Paravertebral Block as a Sympathetic Blockade for Upper Extremity Neuropathic Pain: A Prospective Pilot Study

Purpose

Ultrasound-guided thoracic paravertebral block (US-TPVB) is considered a treatment option for the management of acute pain in various pain-related conditions. We conducted a prospective pilot study to evaluate the possibility of US-TPVB as a sympathetic blockade in patients with neuropathic pain disorders in the upper extremities.

Patients and Methods

A total of 12 patients underwent US-TPVB between the T2 and T3 paravertebral space with 10 mL of 1% mepivacaine. The temperature change (°C) before and after the procedure was compared between the ipsilateral and contralateral hands. We counted the proportion of patients showing a temperature increase ≥1.5°C and compared a change in the pain intensity before and after the procedure.

Results

The median increase in the temperature change between the ipsilateral and contralateral hands was 1.54°C (interquartile range, 1.28–2.20). There were seven patients (58.3%) who showed a temperature difference ≥1.5°C between both hands after the US-TPVB. Eleven patients (91.7%) reported a reduction in pain according to the score on the 11-point numerical rating scale. No serious complications relevant to the procedure were reported.

Conclusion

US-TPVB could be a useful technique for sympathetic blockade in patients with upper extremity pain.

Review of nonopioid multimodal analgesia for surgical and trauma patients

Purpose

Pain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion.

Summary

In response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents’ respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care.

Conclusion

Multimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.

Increasing Numbers of Rib Fractures Do Not Worsen Outcome: An Analysis of the National Trauma Data Bank

Increasing age and number of rib fractures are thought to portend a worse outcome with blunt chest trauma, although this is not clearly substantiated in the literature. We hypothesized that these parameters have a significant and synergistic effect, worsening patient outcome. Using the National Trauma Data Bank, we evaluated patients from 2002 to 2006. Patients with a rib fracture International Classification of Diseases, 9th Revision code were included; those with sternal fractures were excluded. Data on demographics, injury, comorbidity, complications, intensive care unit duration, ventilator duration, length of stay, and death were collected. Significant univariate predictors were included in the multivariate logistic regression analysis to adjust for any potential confounders. We identified 35,467 patients who met the inclusion. The mean age was 45.5 years with a mean Injury Severity Score of 19.3. There were 2.1 per cent open rib fractures. Using univariate analysis, rib fracture number was significant. However, once multivariate analyses were applied, the number of rib fractures was not found to be an independent predictor of outcome. The number of rib fractures is not an independent predictor of outcome. Age and overall trauma burden are more powerful predictors of poor outcomes. Treatment focus should shift from the chest to the broader scope of injuries and comorbidities.

Comparison of intravenous lidocaine versus epidural anesthesia for traumatic rib fracture pain: a retrospective cohort study

BACKGROUND

Effective analgesia is essential in managing traumatic rib fractures. Intravenous lidocaine (IVL) is effective in treating perioperative pain, acute pain in the emergency department, cancer pain in hospice, and outpatient chronic neuropathic pain. Our study examined the associations between IVL versus epidural analgesia (EA) and pain for the treatment of acute rib fracture in the inpatient setting.

METHODS

We performed a retrospective study involving adults admitted to an academic level I trauma center from June 1, 2011 to June 1, 2016 with consults to the pain service for acute rib fracture pain. Eighty-nine patients were included in the final analysis (54 IVL and 35 EA patients). Both groups had usual access to opioid medications. The primary outcome was absolute change in numeric pain scores during 0-24 and 24-48 hours after initiating IVL or EA, compared with baseline. Secondary outcomes include opioid consumption, incentive spirometry, supplemental oxygens, pneumonia, endotracheal intubation and length of hospital stay.

RESULTS

Numeric pain scores differed at baseline (mean 5.6 for IVL vs 4.5 for EA, p=0.01), while age, injury severity, and number of fractured ribs were similar. IVL and EA were associated with similar reductions in numeric pain scores within 0-24 and 24-48 hours (mean -2.9 for IVL vs -2.3 for EA during both periods, p=0.19 and p=0.17 respectively) . There was greater non-neuraxial opioid consumption with IVL compared with EA (98.6 vs 22.3 mg morphine equivalents (MME) at 0-24 hours, p=0.0005; 105.6 vs 18.9 MME at 24-48 hours, p<0.0001). When epidural opioids were analyzed, the EA group was exposed to higher total MME at 0-24 hours (655.2 vs 98.6 MME, p<0.0001) and 24-48 hours (586 vs 105.6 MME, p=0.0001), suggesting an opioid sparing effect of IVL.

CONCLUSION

Our results suggest that IVL is similar to EA in numeric pain score reduction, and that IVL may have an opioid sparing effect when taking neuraxial opioids into account. IVL may be an effective alternative to epidurals for the treatment of rib fracture pain. It should be considered for patients who have contraindications to epidurals or are unable to receive an epidural in a timely manner.

Complications in low-risk older adult trauma patients: A case-control study

BACKGROUND

Although some geriatric trauma patients may be at low risk of complications, poor outcomes are pronounced if complications do occur. Prevention in this group decreases the risk of excess morbidity and mortality.

METHODS

We performed a case-control study of trauma patients 65 years or older treated from January 2015 to August 2016 at a Level I trauma center with a Trauma Quality Improvement Program-predicted probability of complication of less than 20%. Cases had one of the following complications: unplanned admission to the intensive care unit (ICU), unplanned intubation, pneumonia, or unplanned return to the operating room. Two age-matched controls were randomly selected for each case. We collected information on comorbidities, home medications, and early medical care and calculated odds ratios using multivariable conditional logistic regression.

RESULTS

Ninety-four patients experienced unplanned admission to ICU (n = 51), unplanned intubation (n = 14), pneumonia (n = 21), and unplanned return to the operating room (n = 8). The 188 controls were more frequently intubated and had higher median ISS but were otherwise similar to cases. The adjusted odds of complication were higher for patients on a home β-blocker (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.2-4.0) and home anticoagulation (aOR, 2.2; 95% CI, 1.2-4.1). Patients with diabetes (aOR 2.0; 95% CI, 1.1-3.7) and dementia (aOR, 2.0; 95% CI, 1.0-4.3) also had higher odds of complication. The adjusted odds of complication for patients receiving geriatrics consultation was 0.4 (95% CI, 0.2-1.0; p = 0.05). Pain service consultation and indwelling pain catheter placement may be protective, but CIs included 1. There was no association between opiates, benzodiazepines, fluid administration, or blood products in the first 24 hours and odds of complication.

CONCLUSIONS

Geriatrics consultation was associated with lower odds of unplanned admission to the ICU, unplanned intubation, pneumonia, and unplanned return to the operating room in low-risk older adult trauma patients. Pathways that support expanding comanagement strategies with geriatricians are needed.

LEVEL OF EVIDENCE

Therapeutic/Care management, Level IV.

Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries

Purpose of Review

This article provides an overview of the common and important chest injuries that the anesthesiologist may encounter in patients following trauma including blunt injury, pneumothorax, hemothorax, blunt aortic injury, and blunt cardiac injury.

Recent Findings

Rib fractures are frequently associated with chest injury and are associated with significant pain and other complications. Regional anesthesia techniques combined with a multimodal analgesic strategy can improve patient outcomes and reduce complications. There is increasing evidence for paravertebral blocks for this indication, and the myofascial plane blocks are a popular emerging technique. Recent changes to recommended management of tension pneumothorax are also described.

Summary

Chest trauma is commonly encountered, and anesthesiologists have the potential to significantly improve morbidity and mortality in this group of patients.

Blunt chest wall trauma: an overview

Trauma affecting the chest wall, even in isolation, can carry a significant morbidity and mortality and thus appropriate management is vital. Consequences of chest wall trauma may include significant pain, altered chest wall mechanics, hypoventilation, infection and respiratory failure. In order to best determine the appropriate management, risk stratification tools have been developed to identify patients at highest risk of complications who would most benefit from more invasive management strategies. Early optimization of analgesia is vital both for patient experience and to reduce the risk of pulmonary complications. The analgesic options range from multimodal oral analgesia to invasive regional anaesthetic techniques such as thoracic epidurals, paravertebral catheters, intercostal nerve blocks and fascial plane blocks. Other important considerations include provision of appropriate oxygen therapy, ventilation support and physiotherapy. For a selected group of patients with the most significant injuries, surgical rib fixation may be appropriate if chest wall mechanics are sufficiently impaired.

Kinesiotaping for isolated rib fractures in emergency department

INTRODUCTION

Rib fractures, which are among the most common injuries in blunt thoracic trauma, are usually encountered in Emergency Departments. Kinesiotape (KT) is a drug-free elastic therapeutic tape used for treating various musculoskeletal problems such as injury, dysfunction and pain. We aimed to investigate whether kinesotaping should be used safely and effectively in rib fractures in emergency setting.

MATERIALS AND METHODS

This was a prospective, randomized controlled study conducted in an Emergency Department of a University Hospital. Patients diagnosed with isolated rib fractures were included in the study. Pain severity of patients assessed with 0-10 cm visual analog scale (VAS), then patients assigned into 2 treatment groups. One of them received treatment with flurbiprofen 200 mg/day and the other group received kinesiotaping in addition to the same oral therapy. On the 4th day of the procedure, both groups were assessed with VAS in the followup visit.

RESULTS

Total of 82 patients presented with rib fractures, 52 of them were excluded. Remaining 30 constituted the study group and randomly allocated to kinesiotaping (n = 16) or control group (n = 14). In both groups, pain intensity on the 4th day was significantly reduced when compared with baseline (p for both<0.01). Additionally, considering the reducing the pain intensity on 4th day, kinesiotaping was significantly superior than the control group (p < 0.01).

CONCLUSION

This study investigated the use of kinesiotaping in emergency departments. When compared to NSAID therapy alone, combined kinesiotaping and NSAID therapy appears to be more effective in terms of pain reduction in rib fractures.

Assessing outcome measures used after rib fracture: A COSMIN systematic review

PURPOSE

The incidence of invasive treatment of rib fracture has increased significantly over the last decade however the evidence of improved patient outcomes to support this is lacking. A systematic review was performed to identify patient reported outcome measures (PROMs) used in the assessment of outcomes following chest wall injury. The quality of evidence for the psychometric properties of the identified PROMs was graded using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.

METHODS

Rib fracture studies measuring patient reported outcomes were identified using PubMed/Medline, EMBASE, AMED and PsycINFO. Methodological quality of measurement properties was evaluated with the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist.

RESULTS

A total of 64 studies were identified including 19 different PROM instruments. Domains included in the reported PROMs included pain, breathlessness, general health quality of life, physical function and physiological health. No rib fracture specific PROM was identified. The most frequently reported instrument was the SF-36 reporting overall quality of life (HRQoL) although there was very low quality evidence for its content validity. There was low quality evidence to support good content validity for the Medical Research Council (MRC) dyspnoea scale, Brief Pain Index (BPI) and McGill Pain Questionnaire (MPQ). No PROM had undergone validation in a rib fracture population. The overall quality of the PROM development studies was poor. While we were unable to identify a clear "gold standard", based on the limited current evidence, we recommend that the EQ-5D-5L is used in combination with the MRC and BPI or MPQ for future rib fracture studies.

CONCLUSION

The lack of validated outcome measures for rib fracture patients is a significant limitation of the current literature. Further studies are needed to provide validated outcome measures to ensure accuracy of the reported results and conclusions. As interventions for rib fractures have become more common in both research and clinical practice this has become an urgent priority.

Impact of serratus plane block on pain scores and incentive spirometry volumes after chest trauma

Background: Adequate pain control is difficult to achieve in patients with multiple rib fractures (MRF). Serratus plane block (SPB) is a novel technique for alleviating rib fracture pain. Several published case reports support this hypothesis. Purpose: The purpose of this study was to evaluate the use of SPB in MRF at our level 1 trauma center. Methods: Our hospital's Regional Anesthesia Registry was queried for all trauma patients with MRF who underwent SPB between August 2014 and January 2018. Data were compared in each patient as a matched pair for the time periods before and after undergoing SPB. Thirty-four patients with similar baseline characteristics were enrolled. Results: The median number of rib fractures was 7. Ordinal pain scores were found to be improved 4 hrs after SPB from median 7/10 to 3/10 (P<0.001). Incentive spirometry (IS) volumes recorded 4 and 24 hrs postserratus plane block showed a median increase of 150 and 175 mL from baseline, respectively (P<0.001). IS volumes recorded at 48 hrs showed a median increase of 300 mL from baseline (P<0.001). Respiratory rate decreased from a median value of 24.5 to 16 breaths/min (P<0.001). SpO₂ was improved at 24 hrs from median 96% to 99% (P<0.001). Conclusion: SPB improves pain scores and IS volumes in MRF. Because it is not limited by patient positioning or anticoagulation and has a better safety profile, it may offer a viable alternative to neuraxial techniques. Additional studies are necessary to evaluate its efficacy compared to neuraxial techniques.

Regional Catheters for Outpatient Surgery-a Comprehensive Review

PURPOSE OF REVIEW

This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques.

RECENT FINDINGS

Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.

Addition of dexmedetomidine to bupivacaine in ultrasonography-guided paravertebral blockade potentiates postoperative pain relief among patients undergoing thoracotomy

Background and objective

Thoracic paravertebral blockade is an alternative regional technique for comforting post-thoracotomy pain, thereby decreasing opioid consumption, postoperative nausea and vomiting, dizziness, respiratory depression and health care costs. The objective of this study was to investigate the effects of bupivacaine and bupivacaine plus dexmedetomidine on postoperative pain score and analgesic consumption in thoracotomy patients who had undergone ultrasonography-guided paravertebral blockade.

Material and method

93 ASA I–II patients aged 18–65 years were included in the study and scheduled for thoracic surgery. Prior to anesthesia induction, the paravertebral blockade procedure was performed by an anesthetist with ultrasonography. Cases were randomly stratified into three groups. The paravertebral blockade procedure was performed with 20 mL 0.5% bupivacaine injection in Group B (n = 31) and 20 mL 0.5% bupivacaine + 1 mL dexmedetomidine (100 μg) injection in Group BD. Group C received postoperative i.v. morphine via patient-controlled analgesia without paravertebral blockade. Post-operative pain scores were recorded in the recovery room and post-operatively using a VAS. Hemodynamic parameters, adverse effects and morphine consumption were also recorded.

Results

No significant difference was determined between Group B and Group C regarding intra-operative adverse effects such as bradicardia and hypotension, while these adverse effects were significantly higher in Group BD (p = 0.04). VAS scores with rest and upon movement were significantly lower in Group BD compared to Group C (p < 0.001). Total morphine consumption was significantly lower in both Group B and Group BD in comparison with Group C (p < 0.001). In Group BD, HR and MAP were lower, but this was not clinically significant (p < 0.05).

Conclusion

The addition of dexmedetomidine to bupivacaine lowers postoperative pain scores and morphine consumption in thoracotomy patients who receive ultrasonography guided paravertebral blockade.

Safety, complications and clinical outcome after ultrasound-guided paravertebral catheter insertion for rib fracture analgesia: a single-centre retrospective observational study

Rib fractures are associated with significant morbidity and mortality. Ultrasound-guided thoracic paravertebral catheter insertion has been described for the management of pain secondary to rib fractures. We conducted a retrospective observational study of all patients with rib fractures who had a paravertebral catheter inserted for analgesia provision over a 4-year period. Data from the Trauma Audit and Research Network were used to compare patients with rib fractures who were managed with paravertebral catheters to those managed with systemic analgesia. A total of 314 consecutive paravertebral catheters were inserted in 290 patients. Five (1.9%) catheters were removed due to ineffective analgesia. Other minor complications occurred in three cases (0.96%). The proportion of rib fracture patients managed with paravertebral catheters increased from 31/200 (15.5%) in the first year of study to 81/168 (48.2%) in the fourth; over this time-period the observed:predicted mortality ratio fell from 1.04 to 0.66. Proportional hazard regression with and without propensity score matching demonstrated a reduction in mortality associated with paravertebral catheter use, but this became statistically non-significant when time-dependent analysis was used. Paravertebral catheters are a safe and effective technique for rib fracture analgesia; however, our data were insufficient to demonstrate any improvement in mortality.

[Addition of dexmedetomidine to bupivacaine in ultrasonography-guided paravertebral blockade potentiates postoperative pain relief among patients undergoing thoracotomy]

BACKGROUND AND OBJECTIVE

Thoracic paravertebral blockade is an alternative regional technique for comforting post-thoracotomy pain, thereby decreasing opioid consumption, postoperative nausea and vomiting, dizziness, respiratory depression and health care costs. The objective of this study was to investigate the effects of bupivacaine and bupivacaine plus dexmedetomidine on postoperative pain score and analgesic consumption in thoracotomy patients who had undergone ultrasonography-guided paravertebral blockade.

MATERIAL AND METHOD

93 ASA I-II patients aged 18-65 years were included in the study and scheduled for thoracic surgery. Prior to anesthesia induction, the paravertebral blockade procedure was performed by an anesthetist with ultrasonography. Cases were randomly stratified into three groups. The paravertebral blockade procedure was performed with 20mL 0.5% bupivacaine injection in Group B (n=31) and 20mL 0.5% bupivacaine+1mL dexmedetomidine (100μg) injection in Group BD. Group C received postoperative i.v. morphine via patient-controlled analgesia without paravertebral blockade. Post-operative pain scores were recorded in the recovery room and post-operatively using a VAS. Hemodynamic parameters, adverse effects and morphine consumption were also recorded.

RESULTS

No significant difference was determined between Group B and Group C regarding intra-operative adverse effects such as bradicardia and hypotension, while these adverse effects were significantly higher in Group BD (p=0.04). VAS scores with rest and upon movement were significantly lower in Group BD compared to Group C (p<0.001). Total morphine consumption was significantly lower in both Group B and Group BD in comparison with Group C (p<0.001). In Group BD, HR and MAP were lower, but this was not clinically significant (p<0.05).

CONCLUSION

The addition of dexmedetomidine to bupivacaine lowers postoperative pain scores and morphine consumption in thoracotomy patients who receive ultrasonography guided paravertebral blockade.

The ultrasound-guided retrolaminar block: volume-dependent injectate distribution

Purpose

The ultrasound-guided retrolaminar block is one of the newer and simpler alternatives to the traditional, often technically challenging, paravertebral (PV) block. Its feasibility, safety, and efficacy have already been clinically demonstrated in patients with multiple rib fractures using higher volumes of local anesthetic, when compared with the traditional approach. The primary aim of this observational anatomical study was to assess the spread of local anesthetic from the retrolaminar injection point to the PV space and its volume dependence. Second, we assessed the incidence of epidural and contralateral PV spread in the both groups.

Methods

Ten fresh porcine cadavers were randomized into 2 groups (n=5 each) to receive ultrasound-guided retrolaminar injections at Th4-Th5 level with either 10 mL (low-volume group) or 30 mL (high-volume group) of 2% lidocaine and methylene blue mixture. After the procedure, the cadavers were dissected and frozen. Cross-section cuts (~1 cm thick) were performed to evaluate the injectate spread.

Results

In the high-volume group, injectate spread from the retrolaminar to the PV space was observed in all specimens (5 out of 5; 100%), while in the low-volume group, no apparent spread to the PV space was found (0 out of 5; 0%). No epidural or contralateral PV spread was observed in any of the specimens.

Conclusion

Following ultrasound-guided retrolaminar injections in fresh porcine cadavers, injectate spread from the retrolaminar tissue plane to the PV space is strongly volume dependent, suggesting that, clinically, high local anesthetic volumes maybe critical for achieving regional anesthesia and analgesia consistent with traditional PV blockade.

Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis

Purpose

Many studies report on outcomes of analgesic therapy for (suspected) traumatic rib fractures. However, the literature is inconclusive and diverse regarding the management of pain and its effect on pain relief and associated complications. This systematic review and meta-analysis summarizes and compares reduction of pain for the different treatment modalities and as secondary outcome mortality during hospitalization, length of mechanical ventilation, length of hospital stay, length of intensive care unit stay (ICU) and complications such as respiratory, cardiovascular, and/or analgesia-related complications, for four different types of analgesic therapy: epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks.

Methods

PubMed, EMBASE and CENTRAL databases were searched to identify comparative studies investigating epidural, intravenous, paravertebral and intercostal interventions for traumatic rib fractures, without restriction for study type. The search strategy included keywords and MeSH or Emtree terms relating blunt chest trauma (including rib fractures), analgesic interventions, pain management and complications.

Results

A total of 19 papers met our inclusion criteria and were finally included in this systematic review. Significant differences were found in favor of epidural analgesia for the reduction of pain. No significant differences were observed between epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks, for the secondary outcomes.

Conclusions

Results of this study show that epidural analgesia provides better pain relief than the other modalities. No differences were observed for secondary endpoints like length of ICU stay, length of mechanical ventilation or pulmonary complications. However, the quality of the available evidence is low, and therefore, preclude strong recommendations.

Emergency department management of patients with rib fracture based on a clinical practice guideline

Background

Clinical practice guidelines (CPGs) have the ability to increase efficiency and standardize care. A CPG based on forced vital capacity (FVC) for rib fractures was developed as a tool for triage of these patients. The objectives of this study were to assess the efficacy and compliance of physicians with this rib fracture CPG.

Methods

Patients >18 that were discharged from an urban level 2 trauma center emergency department (ED) between the dates of January 1, 2014, to December 31, 2016, were eligible for the study. Demographics, mechanism, outcomes and FVC were abstracted by review of the electronic medical record. Compliance with the CPG was examined, and comparisons were made between patients successfully discharged and patients who returned.

Results

455 patients met were identified during the study period. 233 were eligible after exclusions. 64% of the cohort was male with median age of 53 years. Falls were the most common mechanism (59.6%). The median number of rib fractures was 2 and median FVC 2500 mL. 28 (12.0%) of the 233 returned to the ED after discharge. The groups were well matched with no significant differences. The most common reason for return was pain (95%). Adjusted analysis showed that increasing age (adjusted OR (AOR) 0.968) and FVC (AOR 0.999) were independent predictors. Adherence with the CPG was good for hemothorax/pneumothorax and bilateral fractures (96%), but lagged with the number of fractures (74%).

Conclusions

This study confirms that the rib fracture CPG is safe and an FVC of 1500 mL is a safe criterion for discharging patients with rib fractures. Interestingly, it appears that older age is protective. More work needs to be done on effective pain control to decrease return to ED visits using this CPG.

Level of evidence

IV.

Type of study

Therapeutic.

Guideline-Driven Care Improves Outcomes in Patients with Traumatic Rib Fractures

There is no established national standard for rib fracture management. A clinical practice guideline (CPG) for rib fractures, including monitoring of pulmonary function, early initiation of aggressive loco-regional analgesia, and early identification of deteriorating respiratory function, was implemented in 2013. The objective of the study was to evaluate the effect of the CPG on hospital length of stay. Hospital length of stay (LOS) was compared for adult patients admitted to the hospital with rib fracture(s) two years before and two years after CPG implementation. A separate analysis was done for the patients admitted to the intensive care unit (ICU). Over the 48-month study period, 571 patients met inclusion criteria for the study. Pre-CPG and CPG study groups were well matched with few differences. Multivariable regression did not demonstrate a difference in LOS (B = -0.838; P = 0.095) in the total study cohort. In the ICU cohort (n = 274), patients in the CPG group were older (57 vs 52 years; P = 0.023) and had more rib fractures (4 vs 3; P = 0.003). Multivariable regression identified a significant decrease in LOS for those patients admitted in the CPG period (B = -2.29; P = 0.019). Despite being significantly older with more rib fractures in the ICU cohort, patients admitted after implementation of the CPG had a significantly reduced LOS on multivariable analysis, reducing LOS by over two days. This structured intervention can limit narcotic usage, improve pulmonary function, and decrease LOS in the most injured patients with chest trauma.

Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society

INTRODUCTION

Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented.

METHODS

Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay.

RESULTS

Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel.

CONCLUSION

We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.

Thoracic paravertebral block versus intravenous patient-controlled analgesia for pain treatment in patients with multiple rib fractures

Objectives

To assess the effect of thoracic paravertebral block (PVB) on pain management and preservation of pulmonary function compared with intravenous, patient-controlled analgesia (IVPCA) in patients with multiple rib fractures (MRFs).

Methods

Ninety patients with unilateral MRFs were included in this prospective study and randomly assigned to the TPVB or IVPCA group. The visual analogue scale (VAS) pain score, blood gas analysis, and bedside spirometry were measured and recorded at different time points after analgesia.

Results

TPVB and IVPCA provided good pain relief. VAS scores were significantly lower in the TPVB group than in the IVPCA group at rest and during coughing (P < 0.05). Patients in the TPVB group had a higher PaO₂ and PaO₂/FiO₂ and lower P_(A–a)O₂ compared with the IVPCA group (P < 0.05). Moreover, patients in the TPVB group showed higher FVC, FEV1/FVC, and PEFR, and fewer complications than did the IVPCA group (P < 0.05).

Conclusion

TPVB is superior to IVPCA in pain relief and preservation of pulmonary function in patients with MRFs.

Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol

Rib fractures are common among patients sustaining blunt trauma, and are markers of severe bodily and solid organ injury. They are associated with high morbidity and mortality, including multiple pulmonary complications, and can lead to chronic pain and disability. Clinical and radiographic scoring systems have been developed at several institutions to predict risk of complications. Clinical strategies to reduce morbidity have been studied, including multimodal pain management, catheter-based analgesia, pulmonary hygiene, and operative stabilization. In this article, we review risk factors for morbidity and complications, intervention strategies, and discuss experience with bundled clinical pathways for rib fractures. In addition, we introduce the multidisciplinary rib fracture management protocol used at our level I trauma center.

Regional analgesia in postsurgical critically ill patients

Regional analgesia intrinsically, based on its physiological effects, is routinely used for the perioperative treatment of pain associated with surgical procedures. However, in other areas such as the non-surgical treatment of acute pain for patients in a critical condition, it has not been subjected to specific prospective studies. If we confine ourselves to the physiological effects of the nerve block, in a situation of stress, the indications for regional anaesthesia in this group of patients extend to the management of a wide variety of medical as well as postsurgical conditions, of trauma patients and of other painful procedures performed in the patient's bed. The critical patient certainly must be analyzed individually as their own primary conditions is of vital importance, as well as any associated conditions they have developed that can potentially increase the risk of systemic toxicity or morbidity, such as, coagulopathies, infection, immunosuppressive states, sedation and problems associated with mechanical ventilation. This review aims to assess the role of regional analgesia in critically ill patients, placing it within the algorithm decision tree of the professional responsible for patients in critical care units, all based on the evidence of potential benefits according to the published literature.

Regional anesthesia for management of acute pain in the intensive care unit

Pain is a major problem for Intensive Care Unit (ICU) patients. Despite numerous improvements it is estimated that as many as 70% of the patients experience moderate-to-severe postoperative pain during their stay in the ICU. Effective pain management means not only decreasing pain intensity, but also reducing the opioids’ side effects. Minimizing nausea, vomiting, urinary retention, and sedation may indeed facilitate patient recovery and it is likely to shorten the ICU and hospital stay. Adequate postoperative and post-trauma pain management is also crucial for the achievement of effective rehabilitation. Furthermore, recent studies suggest that effective acute pain management may be helpful in reducing the development of chronic pain. When used appropriately, and in combination with other treatment modalities, regional analgesia techniques (neuraxial and peripheral nerve blocks) have the potential to reduce or eliminate the physiological stress response to surgery and trauma, decreasing the possibility of surgical complications and improving the outcomes. Also they may reduce the total amount of opioid analgesics necessary to achieve adequate pain control and the development of potentially dangerous side effects.

Comparative evaluation of continuous intercostal nerve block or epidural analgesia on the rate of respiratory complications, intensive care unit, and hospital stay following traumatic rib fractures: a retrospective review

BACKGROUND

Thoracic trauma accounts for 10%-15% of all trauma admissions. Rib fractures are the most common injury following blunt thoracic trauma. Epidural analgesia improves patient outcomes but is not without problems. The use of continuous intercostal nerve blockade (CINB) may offer superior pain control with fewer side effects. This study's objective was to compare the rate of pulmonary complications when traumatic rib fractures were treated with CINB vs epidurals.

METHODS

A hospital trauma registry provided retrospective data from 2008 to 2013 for patients with 2 or more traumatic rib fractures. All subjects were admitted and were treated with either an epidural or a subcutaneously placed catheter for continuous intercostal nerve blockade. Our primary outcome was a composite of either pneumonia or respiratory failure. Secondary outcomes included total hospital days, total ICU days, and days on the ventilator.

RESULTS

12.5% (N=8) of the CINB group developed pneumonia or had respiratory failure compared to 16.3% (N=7) in the epidural group. No statistical difference (P=0.58) in the incidence of pneumonia or vent dependent respiratory failure was observed. There was a significant reduction (P=0.05) in hospital days from 9.72 (SD 9.98) in the epidural compared to 6.98 (SD 4.67) in the CINB group. The rest of our secondary outcomes showed no significant difference.

CONCLUSION

This study did not show a difference in the rate of pneumonia or ventilator-dependent respiratory failure in the CINB vs epidural groups. It was not sufficiently powered. Our data supports a reduction in hospital days when CINB is used vs epidural. CINB may have advantages over epidurals such as fewer complications, fewer contraindications, and a shorter time to placement. Further studies are needed to confirm these statements.

Epidural Analgesia after Rib Fractures

Pain associated with rib fractures impairs respiratory function and increases pulmonary morbidity. The purpose of this study was to determine how epidural catheters alter mortality and complications in trauma patients. We performed a retrospective study involving adult blunt trauma patients with moderate-to-severe injuries from January 1, 2004 to December 31, 2013. During the 10-year period, 526 patients met the inclusion criteria; 43/526 (8%) patients had a catheter placed. Mean age of patients with epidural catheter (CATH) was higher compared with patients without epidural catheter (NOCATH) (54 vs 48 years, P = 0.021), Injury Severity Score was similar (26 CATH vs 27 NOCATH, P = 0.84), and CATH had higher mean rib fractures (7.4 vs 4.1, P < 0.001). Mortality was lower in CATH (0% vs 13%, P = 0.006). Deep vein thrombosis (DVT) rate was higher in CATH (12% vs. 5%, P = 0.036). After regression analysis, we found catheter placement to be a predictor for DVT (adjusted odds ratios 2.80, P = 0.036). Our center noted increased use of epidural catheters in patients who present with moderate-to-severe injuries. Patients with catheters were older and had a mean of 7.4 ribs fractured. The epidural cohort had longer hospital LOS and decreased mortality. In contrast to other studies, DVT rates were increased in patients who received epidural catheters.