Interpleural block for patients with multiple rib fractures: comparison with epidural block

Ultrasound guided erector spinae plane block versus thoracic epidural analgesia in traumatic flail chest, a prospective randomized trial

Background and Aims

Pain contributes to flail chest morbidities. The aim of this study was to compare the analgesic effects of ultrasound-guided erector spinae plane block (ESPB) with thoracic epidural analgesia (TEA) in patients with traumatic flail chest.

Material and Methods

Sixty patients aged 18 - 60 years, ASA I-II, with unilateral flail chest were allocated into TEA group with a loading dose of 6 ml bupivacaine 0.25% and 2 μg/ml fentanyl and ESPB group with a loading dose of 20 ml bupivacaine 0.25% and 2 μg/ml fentanyl. This was followed by continuous infusion of 6 ml/hour bupivacaine 0.125% and 2 μg/ml fentanyl in both groups for 4 days. Pain scores at rest and on coughing, rescue analgesic consumption, PaO2/FIO2 ratio, PaCO2, pulmonary functions and adverse events were recorded.

Results

In both groups, Visual Analog Scale (VAS) scores at rest and on coughing were significantly decreased after block initiation as compared to pre-block value. At all-time points, VAS scores at rest and on coughing were insignificantly different between both groups. PaO2/FIO2 ratio, forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were significantly increased and respiratory rate, PaCO2, were significantly decreased as compared to pre-block values of the same group without significant difference between both groups. The incidence of hypotension was significantly higher in TEA group than ESPB group.

Conclusions

ESPB can achieve adequate analgesia in traumatic flail chest equivalent to that of TEA with significant improvement of arterial oxygenation and pulmonary functions and without serious adverse effects.

Development of a blunt chest injury care bundle: An integrative review

BACKGROUND

Blunt chest injuries (BCI) are associated with high rates of morbidity and mortality. There are many interventions for BCI which may be able to be combined as a care bundle for improved and more consistent outcomes.

OBJECTIVE

To review and integrate the BCI management interventions to inform the development of a BCI care bundle.

METHODS

A structured search of the literature was conducted to identify studies evaluating interventions for patients with BCI. Databases MEDLINE, CINAHL, PubMed and Scopus were searched from 1990-April 2017. A two-step data extraction process was conducted using pre-defined data fields, including research quality indicators. Each study was appraised using a quality assessment tool, scored for level of evidence, then data collated into categories. Interventions were also assessed using the APEASE criteria then integrated to develop a BCI care bundle.

RESULTS

Eighty-one articles were included in the final analysis. Interventions that improved BCI outcomes were grouped into three categories; respiratory intervention, analgesia and surgical intervention. Respiratory interventions included continuous positive airway pressure and high flow nasal oxygen. Analgesia interventions included regular multi-modal analgesia and paravertebral or epidural analgesia. Surgical fixation was supported for use in moderate to severe rib fractures/BCI. Interventions supported by evidence and that met APEASE criteria were combined into a BCI care bundle with four components: respiratory adjuncts, analgesia, complication prevention, and surgical fixation.

CONCLUSIONS

The key components of a BCI care bundle are respiratory support, analgesia, complication prevention including chest physiotherapy and surgical fixation.

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.

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.

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment

Context. Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one. Objectives. To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions. Methods. Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article. Results. Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels—from peripheral branches on the diaphragm to its entrance in the cervical spine—could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient. Conclusion. Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed.

Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials

BACKGROUND

Traumatic rib fractures are a common condition associated with considerable morbidity and mortality. Observational studies have suggested improved outcome in patients receiving continuous epidural analgesia (CEA). The aim of the present systematic review of randomised controlled trials (RCTs) was to assess the benefit and harm of CEA compared with other analgesic interventions in patients with traumatic rib fractures.

METHODS

We performed a systematic review with meta-analysis and trial sequential analysis (TSA). Eligible trials were RCTs comparing CEA with other analgesic interventions in patients with traumatic rib fractures. Cumulative relative risks (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were estimated, and risk of systematic and random errors was assessed. The predefined primary outcome measures were mortality, pneumonia and duration of mechanical ventilation.

RESULTS

A total of six trials (n = 223) were included; all were judged as having a high risk of bias. In the conventional meta-analyses, there was no statistically significant difference in mortality (RR 2.18, 95% CI 0.21-22.42; P = 0.51; I(2)  = 0%), duration of mechanical ventilation (MD -7.53, 95% CI -16.32 to 1.26; P = 0.09; I(2)  = 91%) or pneumonia (RR 0.49, 95% CI 0.19-1.25; P = 0.13; I(2)  = 0%) between CEA and other analgesic interventions. Subgroup analyses and sensitivity analyses, including TSA confirmed the results.

CONCLUSION

The quality and quantity of evidence for the use of CEA in patients with traumatic rib fractures is low, and there is no firm evidence for benefit or harm of CEA compared with other analgesic interventions. Well-powered RCTs with low risk of bias reporting clinically relevant patient-centred outcome measures are needed.

A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture

OBJECTIVE

To compare the intensity of pain and duration of return to normal activity in patients with rib fractures treated with surgical stabilization with plating versus conventional treatment modalities.

PATIENTS AND METHODS

This study was conducted over a 12 month period. Patients with rib fractures were assessed by numerical pain scale. Patients having pain scale less than 5 were excluded from study. Patients having pain scale of 5 or more than 5 were treated with conventional treatment for next 10 days. On 11th day patients were again assessed by numerical pain scale and patients having score less than 5 were excluded from study. Patients having pain scale of 5, 6, and 7 were treated with conventional treatment and patients having pain scale of 8, 9, and 10 were selected for operative management. Operative and control group were compared on basis of intensity of pain and duration of return to normal activity. Follow up was done on 5, 15, and 30 post operative day.

RESULTS

There was less pain in operative group as compared to control group. Mean rib fracture pain in operative group was 9.15, 2.31, 1.12 as compared to 6.25, 5.96, 4.50 in control group on 5, 15 and 30 post operative days. Also there was early return to normal activity in operative group.

CONCLUSION

Surgical stabilization of rib fracture, an underutilized intervention is better than conventional conservative management in terms of both, decrease in intensity of pain and early return to normal activity.

Management of the crushed chest

Thoracic injuries are very common among trauma victims. This article reviews the current literature on the management of multiple aspects of the care of the patient with severe chest injury. The mechanics of chest injury are complex and varied. Chest wall injuries are the most common and noticeable manifestation of thoracic trauma. Overall morbidity and mortality are primarily determined by associated injuries. New ventilatory strategies permit oxygenation of the severely hypoxic patient. Acute pain management modalities offer the potential of decreasing associated pulmonary complications. Surgical chest wall fixation is clearly indicated in extreme cases of pulmonary herniation and chest wall disruption. There are potential benefits of surgical fixation in other settings, although further trials are needed.

Epidural versus intravenous pain control in elderly patients with rib fractures

BACKGROUND

Epidural catheters are used in older patients with rib fractures to improve outcome. We reviewed the efficacy of epidural analgesia (EA) compared with intravenous narcotics (IVN) in this population.

METHODS

Rib fracture patients >55 years old admitted to our level I trauma center from 1999 through 2002 were reviewed for demographics, Injury Severity Score (ISS), Abbreviated Injury Score for chest, length of stay, cardiopulmonary comorbidities, complications, and type of analgesia.

RESULTS

There were 187 patients: 72 men and 115 women. The mean age was 77 years. For ISS <9, length of stay for EA patients was 12 +/- 5 days versus 5 +/- 4 days for IVN patients (P < 0.001). Complications occurred in 9 of 10 EA patients versus 21 of 52 IVN patients (P < 0.001). No difference was noted in length of stay for patients with ISS > or =9. Complications in the high ISS group occurred in 29 of 43 EA patients versus 37 of 82 IVN patients (P <0.05). Stratification of patients based on low versus high Abbreviated Injury Score for chest yielded similar results.

CONCLUSIONS

EA is associated with prolonged length of stay and increased complications in elderly patients, particularly those with less significant injuries, regardless of cardiopulmonary comorbidities. EA for elderly patients with rib fractures should be prospectively re-evaluated.

Rib fracture pain and disability: can we do better?

OBJECTIVE

The purpose of this study was to determine the magnitude and duration of pain and disability in patients with rib fractures treated using current standard therapy. This was a prospective case series.

METHODS

Injured patients with a chest radiographic diagnosis of one or more rib fractures between June 1, 2001, and October 31, 2001, were asked to participate. Pain levels were assessed at days 1, 5, 30, and 120 after injury using a visual pain scale (0-10). Disability at 30 days was assessed using the SF-36 Health Status Survey, and the total number of days lost from work/usual activity was recorded at day 120. The setting was a university-based Level I trauma center.

RESULTS

Forty patients with a mean of 2.7 +/- 1.6 rib fractures were enrolled. Twenty-three patients had isolated rib fractures and 17 patients had associated extrathoracic injuries. Mean rib fracture pain was 3.5 +/- 2.1 at 30 days and 1.0 +/- 1.4 at 120 days. For patients with associated extrathoracic injuries, rib pain was equivalent to pain in the rest of the body at all intervals. When compared with the chronically ill reference population of the RAND Medical Outcomes Study, our patients as a group were more disabled at 30 days (p < 0.001) in all categories except emotional stability, where they showed equivalent disability, and in their perception of general health, where they were significantly less disabled (p < 0.001). The total mean days lost from work/usual activity was 70 +/- 41. Patients with isolated rib fractures went back to work/usual activity at a mean of 51 +/- 39 days compared with 91 +/- 33 days in patients with associated extrathoracic injuries (p < 0.01).

CONCLUSION

Rib fractures are a significant cause of pain and disability in patients with isolated thoracic injury and in patients with associated extrathoracic injuries. Developing new therapies to accelerate pain relief and healing would substantially improve the outcome of patients with rib fractures.

Acute pain management of patients with multiple fractured ribs

BACKGROUND

Multiple rib fracture causes severe pain that can seriously compromise respiratory mechanics and exacerbate underlying lung injury and pre-existing respiratory disease, predisposing to respiratory failure. The cornerstone of management is early institution of effective pain relief, the subject of this review.

METHODS

A MEDLINE search was conducted for the years 1966 through and up to December 2002 for human studies written in English using the keywords "rib fractures", "analgesia", "blunt chest trauma", "thoracic injury", and "nerve block". The reference list of key articles was also searched for relevant articles. The various analgesic techniques used in patients with multiple fractured ribs were summarized.

RESULTS

Analgesia could be provided using systemic opioids, transcutaneous electrical nerve stimulation or non steroidal anti-inflammatory drugs. Alternatively, regional analgesic techniques such as intercostal nerve block, epidural analgesia, intrathecal opioids, interpleural analgesia and thoracic paravertebral block have been used effectively. Although invasive, in general, regional blocks tend to be more effective than systemic opioids, and produce less systemic side effects.

CONCLUSION

Based on current evidence it is difficult to recommend a single method that can be safely and effectively used for analgesia in all circumstances in patients with multiple fractured ribs. By understanding the strengths and weaknesses of each analgesic technique, the clinician can weigh the risks and benefits and individualize pain management based on the clinical setting and the extent of trauma.