American Society of Regional Anesthesia and Pain Medicine May 2015 - (Page 17)

Regional Analgesia for Patients With Acute Rib Fractures T horacic trauma is the second most common unintentional traumatic injury causing death in the United States. Inadequate pain control after thoracic trauma has been associated with higher morbidity and mortality.1 Uncontrolled rib fracture pain impairs respiratory mechanics, decreases clearance of secretions, and is associated with an increased incidence of pulmonary complications.2 The prevalence of rib fractures among trauma admissions is 10-15%, while pulmonary complication rates range from 16-60% and mortality from 3-13%.2 Pulmonary complications from acute rib fractures include flail chest, pulmonary contusion, pneumothorax, hemothorax, pneumonia, and atelectasis.3 The rate of pulmonary complications rises with the number of rib fractures: one to two fractures have a 16.4% complication rate, three to five fractures have a 33.6% rate, and six or more have a 52.7% rate.3 Patients 65 years and older are especially vulnerable to complications and have significantly higher mortality rates.4 Current pain management strategies range from oral and intravenous medications to regional analgesic procedures. The least invasive and most widely available treatments for acute rib fracture pain are oral and intravenous medications including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase COX-1 and COX-2 inhibitors, and opioids. A recent trial by Bayouth et al 5 has demonstrated the benefits of including intravenous NSAIDS in the treatment of acute pain from rib fractures. Patients who receive NSAIDs have a decreased overall length of hospital stay and morphine requirements without an increased risk of bleeding complications. 5 Lidocaine patches have also been studied in the treatment of rib fracture pain, but the results of these studies do not consistently demonstrate improvement. 6 Strategies for opioid administration include oral, intravenous bolus, and patient-controlled analgesia. Systemic side effects from opioids are well known and include sedation, hypoxemia, respiratory depression, and nausea and vomiting. 6,7 Jennifer Bunch, MD Anesthesiology Resident, CA-3 Department of Anesthesiology, University of Florida, Gainesville, Florida Melanie Donnelly, MD, MPH Assistant Professor Department of Anesthesiology, University of Colorado, Aurora, Colorado Section Editor: Steven Orebaugh, MD analysis of studies using epidurals in rib fracture patients and point out that there has not been consistent proof of benefit in terms of the outcomes of mortality, ICU and hospital length of stay, and duration of mechanical ventilation. The authors also note that there may be increased risks associated with TEA in this group of patients, who are frequently mechanically ventilated and sedated during placement.1 However, there have not been large-scale prospective studies of these patients, and, therefore, it is difficult to assess any specific increased risks. The authors also demonstrate an increased risk of hypotension associated with the use of TEA.1 "While evidence for equivalent analgesia or respiratory outcomes between TEA and PVB is scarce, there are clear situations in which a practitioner may prefer a PVB catheter over TEA due to the lower risk of hypotension and ability to directly visualize placement with ultrasound." Several investigators have compared the efficacy of optimized pharmacologic therapy with systemic opioids to that of thoracic epidural analgesia (TEA) and have concluded that TEA is superior for pain control.1,3,4,8-10 However, there has been some criticism of the evidence supporting the widespread use of epidurals in rib fracture patients. Carrier and colleagues1 performed a meta- In the wake of this metaanalysis, a large study using a national trauma database was carried out by Gage and colleagues. 11 These authors demonstrated lower mortality in patients receiving TEA who have three or more rib fractures at 30, 90, and 365 days post injury after controlling for location (trauma center versus a nondesignated trauma center). The authors speculated that TEA may improve mortality by reducing the need for opioid therapy, thereby avoiding opioid-related side effects. They also hypothesized that there may be benefits from reductions in sympathetic hyperactivity and stress response, which can be triggered by poorly controlled pain. 11 Todd and colleagues 2 have shown that TEA, as part of a multidisciplinary intervention in patients > 45 years of age and with four or more American Society of Regional Anesthesia and Pain Medicine 2015 17 3

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine May 2015

President’s Message
Editorial
Pharmacogenetics in Monitoring of Chronic Pain Patients: Are We There Yet?
Phrenic Nerve Injury and Interscalene Nerve Block: Have We Learned Anything From the Surgical Treatment of Over 150 Cases of Diaphragmatic Paralysis From Multiple Etiologies?
An Exercise in Negotiation: The Success of the Pain Medicine Fellowship Match
Regional Analgesia for Patients with Acute Rib Fractures
Application of Regional Anesthetic Techniques for Cancer Pain

American Society of Regional Anesthesia and Pain Medicine May 2015