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

Abstract

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.

Multicenter longitudinal cross-sectional study comparing effectiveness of serratus anterior plane, paravertebral and thoracic epidural for the analgesia of multiple rib fractures

“…The secondary aim was to investigate if there was a difference in patient outcome between the three groups by analyzing the length of stay (LOS) and mortality data. Although systematic reviews have analyzed studies comparing TEA, PA, intercostal nerve blocks and opiate based treatments, to our knowledge, this is the first study to compare the effectiveness of SAP to PA or TEA 12 13…”

Anaesthetic and surgical management of rib fractures

“…Local anaesthesia catheter-based techniques have been demonstrated to provide superior þ1 per 10 yrs over 10 þ2 per 5% reduction in oxygen saturations <95% breathing room air þ3 per individual fracture (two fractures on one rib¼þ6) þ4 anticoagulant or antiplatelet drugs þ5 chronic lung disease pain relief and a lower incidence of pulmonary complications when compared with systemic opioids in the context of rib fractures, although there is no proven effect on mortality. 16 More severely injured patients and those at higher risk of complications attributable to comorbidities should be transferred to a high-dependency area that can provide noninvasive respiratory support.…”

“…analgesia. 16 However, concerns around spinal neurological damage and the cardiovascular consequences have led to a decrease in epidural use in this setting over the years. Paravertebral, erector spinae plane (ESP) blocks and serratus anterior plane blocks may all be as efficacious as epidurals in appropriate patients.…”

“…These blocks are increasingly being used despite a lack of evidence base. 16 The ESP block was first described in 2016. Local anaesthetic (LA) is injected under ultrasound (US) guidance deep to the erector spinae muscles (iliocostalis, longissimus and costalis).…”

Focus on rib fracture fixation after trauma

“…Until now, there has not been a comprehensive overview of the different techniques used to relieve the burden of pain in these patients. Peek et al evaluated in a systematic review and meta-analysis, the contribution of several analgesic interventions and their respective success [3]. They conclude that there still is no single hammer to hit the nail in this respect, however, that until now, epidural analgesia seems to be the most effective treatment, when successfully applied.…”