American Society of Regional Anesthesia and Pain Medicine August 2017 - 18
Commentators:
Jocelyn Blake, MD
Assistant Professor
University of Wisconsin
Madison, WI
Twitter Poll:
Rahul Guha, MD
Assistant Professor
University of Illinois
Chicago, IL
Connie Gilloon, MD
Private Practice at Northwest
Anesthesia
Minneapolis, MN
Dr. Jacob: I believe a midthoracic epidural would probably provide
the most effective and durable pain relief option for his bilateral
rib fractures, but I am hesitant to proceed without clarifying
his medication list (specifically, whether he has been taking
anticoagulant or antiplatelet medications) and laboratory studies.
If his family is available later in the day to clarify his medical
history and medications, then I would temporize his pain relief with
multiple level intercostal blocks with bupivacaine or ropivacaine in
addition to multimodal, non-opiate systemic analgesia.
Anne Rustameyer, MD
Private Practice at Kaiser
Permanente
Denver, CO
Adam Jacob, MD
Associate Professor
Department of Anesthesiology
Mayo Clinic, Rochester, MN
platelets to assess the risk of bleeding. However, the benefits would
outweigh the risks in my mind.
Dr. Gilloon: A ketamine infusion is a noninvasive method to help
control the patient's pain. Unlike opioids, it will not suppress
respiratory drive, which is particularly important in the setting
of rib fractures. Although ketamine can have dissociative side
effects, in my experience, patients typically tolerate it well on the
floor.
Dr. Blake: This patient does not know which medications he is
taking, and given his history of a stroke, I am concerned that he
may be on an anticoagulant. I would not want to place an epidural
or paravertebral blocks if the patient were in fact anticoagulated.
I would want to check with the patient's family and primary care
provider first to confirm medications and history. I would also have
an INR and platelets checked. Until further evaluation is possible, I
would proceed with multimodal analgesia but try to avoid opioids. I
would definitely consider a ketamine infusion as well.
Dr. Rustameyer: I would like to perform an epidural for this
patient's rib fractures.
2. What are the unique risks and benefits associated your
choice of proposed therapy, and why did you choose it?
Dr. Guha: Epidural analgesia would provide superior pain control
to opiates, ketamine infusion, or multimodal analgesia. In addition,
it causes much less sedation and respiratory depression (it would
cause none if the infusion consists only of local anesthetic and
no opiates). Risks include nerve injury, bleeding, or infection. This
patient has preexisting weakness in his left foot and hand, so
further nerve injury could be potentially debilitating. If the patient's
medical history suggests a coagulopathy, I would check an INR and
18
Amit Pawa, BSc MBBS FRCA EDRA
Consultant Anaesthetist
Guy's & St Thomas' NHS
Foundation Trust
Department of Anaesthesia
St Thomas' Hospital, London, UK
American Society of Regional Anesthesia and Pain Medicine
2017
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