Regional analgesia for patients with traumatic rib fractures: A narrative review

Ho, Anthony M.‐H.; Ho, Adrienne K.; Mizubuti, Glenio B.; Klar, Gregory; Karmakar, Manoj K.

doi:10.1097/ta.0000000000002524

Cited by 21 publications

(15 citation statements)

References 63 publications

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“…Many of the strategies discussed herein for inpatient postoperative patients may also be applied to various special populations, including trauma/emergent surgical patients, the elderly, the obese, obstetric populations, and pediatrics, as discussed in more detail elsewhere [293,300,[365][366][367][368][369][370][371][372][373][374][375][376][377].…”

Section: Postoperative Phasementioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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Section: Postoperative Phasementioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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“…The choice of block is based on the location of rib fractures and includes the erector spinae plane block, retrolaminar block, interpleural block, paraspinal/ intercostal block, and serratus anterior plane block. 30 Compared with epidural and paravertebral catheters, these newer blocks are more superficial and thus carry less risk of serious complications, are technically simpler to perform, and can be administered by emergency physicians, intensivists, and surgeons using ultrasound guidance. Although research is emerging on the efficacy of these techniques, they are promising alternatives.…”

Section: Discussionmentioning

confidence: 99%

Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study

O’Connell

Patel

Powelson

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND:Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers. METHODS:Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence. RESULTS:Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16). CONCLUSION:In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury.

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“…Chest wall injury with rib fracture is one of the most common traumatic injuries in the USA, occurring in 10%–15% of all trauma admissions with a rising incidence over time 1–3…”

Section: Introductionmentioning

confidence: 99%

“…Inadequate pain control can lead to impaired cough, progressive atelectasis, compromised respiration, and pulmonary morbidity. The incidence of pneumonia in the elderly population with 3–4 and >6 rib fractures is 31% and 51%, respectively 3–5. A National Trauma Data Bank review of 64,750 rib fracture patients revealed an all-cause mortality rate of 5.8% among those who sustained a single traumatic rib fracture 4.…”

Section: Introductionmentioning

confidence: 99%

“…A National Trauma Data Bank review of 64,750 rib fracture patients revealed an all-cause mortality rate of 5.8% among those who sustained a single traumatic rib fracture 4. For each additional rib fractured in the elderly, the risk of pneumonia and mortality increases by 27% and 19%, respectively 3–5. The all-cause mortality of patients with ≥3 fractured ribs is 10% for patients <65 years old and 20% if ≥65 years old, rising to 33% mortality if >6 rib fractures are present 3–5…”

Section: Introductionmentioning

confidence: 99%

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Acute pain consult and management is associated with improved mortality in rib fracture patients

Sborov

Dennis

Filho

et al. 2022

Reg Anesth Pain Med

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IntroductionTraumatic rib fractures result in significant patient morbidity and mortality, which increases with patient age and number of rib fractures. A dedicated acute pain service (APS) providing expertize in multimodal pain management may reduce these risks and improve outcomes. We aimed to test the hypothesis that protocolized APS consultation decreases mortality and morbidity in traumatic rib fracture patients.MethodsThis is a retrospective observational, propensity-matched cohort study of adult patients with trauma with rib fractures from 2012 to 2015, at a single, large level 1 trauma center corresponding to introduction and incorporation of APS consultation into the institutional rib fracture pathway. Using electronic medical records and trauma registry data, we identified adult patients presenting with traumatic rib fractures. Patients with hospital length of stay (LOS) ≥2 days were split into two cohorts based on presence of APS consult using 1:1 propensity matching of age, gender, comorbidities and injury severity. The primary outcome was difference in hospital mortality. Secondary outcomes included LOS and pulmonary morbidity.Results2486 patients were identified, with a final matched cohort of 621 patients receiving APS consult and 621 control patients. The mortality rate was 1.8% among consult patients and 6.6% among control patients (adjusted OR 0.25, 95% CI 0.13 to 0.50; p=0.001). The average treatment effect of consult on mortality was 4.8% (95% CI 1.2% to 8.5%;. p<0.001). APS consultation was associated with increased intensive care unit (ICU) LOS (1.19 day; 95% CI 0.48 to 1.90; p=0.001) and hospital LOS (1.61 days; 95% CI 0.81 to 2.41 days; p<0.001). No difference in pulmonary complications was observed.DiscussionAn APS consult in rib fracture patients is associated with decreased mortality and no difference in pulmonary complications yet increased ICU and hospital LOS.

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Regional analgesia for patients with traumatic rib fractures: A narrative review

Cited by 21 publications

References 63 publications

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study

Acute pain consult and management is associated with improved mortality in rib fracture patients

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