Posterior paramedian subrhomboidal analgesia versus thoracic epidural analgesia for pain control in patients with multiple rib fractures

Shelley, Casey; Berry, Stepheny; Howard, James L.; Ruyter, Martin De; Thepthepha, Melissa; Nazir, Niaman; McDonald, Tracy; Dalton, Annemarie; Moncure, Michael

doi:10.1097/ta.0000000000001147

Cited by 20 publications

(9 citation statements)

References 12 publications

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“…Conceivably, the use of more peripheral regional anesthesia approaches might provide better pain control than EA. Examples include the posterior paramedian sub rhomboidal block [34] and the erector spinae plane block [35]. However, data on these two methods are still scarce.…”

Section: Discussionmentioning

confidence: 99%

Epidural analgesia in ICU chest trauma patients with fractured ribs: retrospective study of pain control and intubation requirements

Bachoumas

Levrat

Thuaut

et al. 2020

Ann. Intensive Care

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Background: Nonintubated chest trauma patients with fractured ribs admitted to the intensive care unit (ICU) are at risk for complications and may require invasive ventilation at some point. Effective pain control is essential. We assessed whether epidural analgesia (EA) in patients with fractured ribs who were not intubated at ICU admission decreased the need for invasive mechanical ventilation (IMV). We also looked for risk factors for IMV. Study design and methods: This retrospective, observational, multicenter study conducted in 40 ICUs in France included consecutive patients with three or more fractured ribs who were not intubated at admission between July 2013 and July 2015. Results: Of the 974 study patients, 788 were included in the analysis of intubation predictors. EA was used in 130 (16.5%) patients, and 65 (8.2%) patients required IMV. Factors independently associated with IMV were chronic respiratory disease (P = 0.008), worse SAPS II (P < 0.0001), flail chest (P = 0.02), worse Injury Severity Score (P = 0.0003), higher respiratory rate at admission (P = 0.02), alcohol withdrawal syndrome (P < 0.001), and noninvasive ventilation (P = 0.04). EA was not associated with decreases in IMV requirements, median numerical rating scale pain score, or intravenous morphine requirements from day 1 to day 7. Conclusions: EA was not associated with a lower risk of IMV in chest trauma patients with at least 3 fractured ribs, moderate pain, and no intubation on admission. Further studies are needed to clarify the optimal pain control strategy in chest trauma patients admitted to the ICU, notably those with severe pain or high opioid requirements.

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Section: Discussionmentioning

confidence: 99%

Epidural analgesia in ICU chest trauma patients with fractured ribs: retrospective study of pain control and intubation requirements

Bachoumas

Levrat

Thuaut

et al. 2020

Ann. Intensive Care

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“…This approach, when compared to EA, showed a similar analgesic profile; moreover, it can be used in patients with either brain trauma, vertebral and spinal cord injury (1,16).…”

Section: Sub-rhomboidal Analgesiamentioning

confidence: 93%

“…Easier to perform than thoracic EA, it can also be performed in patients heavily sedated or with a low Glasgow Coma Scale because of the absent danger of spinal cord injury and a very low incidence of hypotension because of the unilateral sympathetic block (1,2,8,13,16).…”

Section: Pvbmentioning

confidence: 99%

Chest wall pain management after chest wall trauma

Lovisari¹,

Favarato²,

Giovannini³

et al. 2020

J Vis Surg

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Blunt chest trauma is defined as a high energy injury to the thorax and its structures, and it is usually a strong indicator of severe injury. Its clinical presentation can vary from rib fractures to pneumothorax, hemothorax, lung and soft tissue contusion; these lesions and consequential pain predispose to respiratory failure by compromising respiratory mechanics and by exacerbating pre-existing lung disease.This picture can lead to a number of complications, such as pneumonia or ARDS, that have a significant impact on patients' morbidity and mortality. One of the cornerstones of blunt chest trauma management is providing early and effective analgesia: pain control improves respiratory mechanics, reduces possible complications and allows effective and aggressive physiotherapy. In literature, there are few clinical trials comparing different analgesic techniques for pain relief in blunt thoracic trauma; our review aims to detail the clinical implication, adequacy and possible complications of different analgesic approaches commonly used in thoracic trauma management, such as epidural anesthesia, regional anesthesia, endovenous and intrathecal analgesia. This review is also focused on management and prevention of chronic pain. Pain management, lung toilet, aggressive respiratory therapy and early mobilization are key to a successful patient recovery. In selected patients, operative fixation may lead to better outcomes although further research is needed to clearly identify the category of patients and the ideal timing for surgical intervention. Chronic pain develops in up to 50% of the patients after a thoracic trauma. A multimodal approach tackling both its somatic and neuropathic component is essential to chronic pain prevention. Early and effective pain control demonstrated to have a pivotal role on patient recovery. While endovenous analgesia constitutes the method of choice for intensive care unit (ICU) sedated patients, regional unilateral analgesia should be considered in awake and spontaneously breathing patients. The approach of choice should be tailored on the single patient and, if possible, a multimodal strategy should be established.

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“…1). The first described technique involved surface landmark-guided insertion of a tunnelled multi-orifice catheter into this plane, to provide 'continuous intercostal nerve' blockade for rib fractures [111,112]. The same technique (under a different name) was used in another non-randomised comparative study of rib fractures which demonstrated equivalent analgesia compared with thoracic epidural anaesthesia [113].…”

Section: Posterior Chest Wallmentioning

confidence: 99%

Ultrasound‐guided fascial plane blocks of the chest wall: a state‐of‐the‐art review

2021

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Summary Ultrasound‐guided fascial plane blocks of the chest wall are increasingly popular alternatives to established techniques such as thoracic epidural or paravertebral blockade, as they are simple to perform and have an appealing safety profile. Many different techniques have been described, which can be broadly categorised into anteromedial, anterolateral and posterior chest wall blocks. Understanding the relevant clinical anatomy is critical not only for block performance, but also to match block techniques appropriately with surgical procedures. The sensory innervation of tissues deep to the skin (e.g. muscles, ligaments and bone) can be overlooked, but is often a significant source of pain. The primary mechanism of action for these blocks is a conduction blockade of sensory afferents travelling in the targeted fascial planes, as well as of peripheral nociceptors in the surrounding tissues. A systemic action of absorbed local anaesthetic is plausible but unlikely to be a major contributor. The current evidence for their clinical applications indicates that certain chest wall techniques provide significant benefit in breast and thoracic surgery, similar to that provided by thoracic paravertebral blockade. Their role in trauma and cardiac surgery is evolving and holds great potential. Further avenues of research into these versatile techniques include: optimal local anaesthetic dosing strategies; high‐quality randomised controlled trials focusing on patient‐centred outcomes beyond acute pain; and comparative studies to determine which of the myriad blocks currently on offer should be core competencies in anaesthetic practice.

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Posterior paramedian subrhomboidal analgesia versus thoracic epidural analgesia for pain control in patients with multiple rib fractures

Abstract: Therapeutic study, level IV.

Cited by 20 publications

References 12 publications

Epidural analgesia in ICU chest trauma patients with fractured ribs: retrospective study of pain control and intubation requirements

Epidural analgesia in ICU chest trauma patients with fractured ribs: retrospective study of pain control and intubation requirements

Chest wall pain management after chest wall trauma

Ultrasound‐guided fascial plane blocks of the chest wall: a state‐of‐the‐art review

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