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

Konstantinos Bachoumas, Albrice Levrat, Aurélie Le Thuaut, Stéphane Rouleau, Samuel Groyer, Hervé Dupont, Paul Rooze, Nathanael Eisenmann, Timothée Trampont, Julien Bohé, Benjamin Rieu, Jean-Charles Chakarian, Aurélie Godard, Laura Frederici, Stephanie Gélinotte, Aurélie Joret, Pascale Roques, Benoit Painvin, Christophe Leroy, Marcel Benedit, Loic Dopeux, Edouard Soum, Vlad Botoc, Muriel Fartoukh, Marie-Hélène Hausermann, Toufik Kamel, Jean Morin, Roland De Varax, Gaetan Plantefève, Alexandre Herbland, Matthieu Jabaudon, Thibault Duburcq, Christelle Simon, Russell Chabanne, Francis Schneider, Frederique Ganster, Cedric Bruel, Ahmed-Saïd Laggoune, Delphine Bregeaud, Bertrand Souweine, Jean Reignier, Jean-Baptiste Lascarrou, Konstantinos Bachoumas, Albrice Levrat, Aurélie Le Thuaut, Stéphane Rouleau, Samuel Groyer, Hervé Dupont, Paul Rooze, Nathanael Eisenmann, Timothée Trampont, Julien Bohé, Benjamin Rieu, Jean-Charles Chakarian, Aurélie Godard, Laura Frederici, Stephanie Gélinotte, Aurélie Joret, Pascale Roques, Benoit Painvin, Christophe Leroy, Marcel Benedit, Loic Dopeux, Edouard Soum, Vlad Botoc, Muriel Fartoukh, Marie-Hélène Hausermann, Toufik Kamel, Jean Morin, Roland De Varax, Gaetan Plantefève, Alexandre Herbland, Matthieu Jabaudon, Thibault Duburcq, Christelle Simon, Russell Chabanne, Francis Schneider, Frederique Ganster, Cedric Bruel, Ahmed-Saïd Laggoune, Delphine Bregeaud, Bertrand Souweine, Jean Reignier, Jean-Baptiste Lascarrou

Abstract

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.

Keywords: Chest trauma; Epidural analgesia.

Conflict of interest statement

The authors have no competing interests to declare.

Figures

Fig. 1
Fig. 1
Cumulative incidence of invasive mechanical ventilation

References

    1. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975–979.
    1. Flagel BT, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138(4):717–723.
    1. Bolliger CT, Van Eeden SF. Treatment of multiple rib fractures. Randomized controlled trial comparing ventilatory with nonventilatory management. Chest. 1990;97(4):943–948.
    1. Horst K, et al. Thoracic trauma now and then: a 10 year experience from 16,773 severely injured patients. PLoS ONE. 2017;12(10):e0186712.
    1. Birkner DR, et al. Mortality of adult respiratory distress syndrome in trauma patients: a systematic review over a period of four decades. World J Surg. 2020;44(7):2243–2254.
    1. Dehghan N, et al. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76(2):462–468.
    1. Huber S, et al. Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®) Scand J Trauma Resusc Emerg Med. 2014;22:52.
    1. Bulger EM, et al. Rib fractures in the elderly. J Trauma. 2000;48(6):1040–1046.
    1. Brasel KJ, et al. Rib fractures: relationship with pneumonia and mortality. Crit Care Med. 2006;34(6):1642–1646.
    1. Chen J, et al. A chest trauma scoring system to predict outcomes. Surgery. 2014;156(4):988–993.
    1. Papazian L, et al. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):69.
    1. Battle C, et al. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. Crit Care. 2014;18(3):R98.
    1. Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012;43(1):8–17.
    1. Simon BJ, et al. Pain management guidelines for blunt thoracic trauma. J Trauma. 2005;59(5):1256–1267.
    1. Wisner DH. A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: effect of epidural analgesia. J Trauma. 1990;30(7):799–804.
    1. Galvagno SM, et al. Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936–951.
    1. Bouzat P, et al. Chest trauma: first 48hours management. Anaesth Crit Care Pain Med. 2017;36(2):135–145.
    1. Peek J, et al. Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2019;45(4):597–622.
    1. Malekpour M, et al. Analgesic choice in management of rib fractures: paravertebral block or epidural analgesia? Anesth Analg. 2017;124(6):1906–1911.
    1. Gage A, et al. The effect of epidural placement in patients after blunt thoracic trauma. J Trauma Acute Care Surg. 2014;76(1):39–45.
    1. Bulger EM, et al. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004;136(2):426–430.
    1. Spies CD, et al. Intercurrent complications in chronic alcoholic men admitted to the intensive care unit following trauma. Intensive Care Med. 1996;22(4):286–293.
    1. Narouze S, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (Second Edition): guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2018;43(3):225–262.
    1. Rice TW, et al. Comparison of the Spo2/Fio2 ratio and the Pao2/Fio2 ratio in patients with acute lung injury or ARDS. Chest. 2007;132(2):410–417.
    1. Coudroy R, et al. Reliability of methods to estimate the fraction of inspired oxygen in patients with acute respiratory failure breathing through non-rebreather reservoir bag oxygen mask. Thorax. 2020 doi: 10.1136/thoraxjnl-2020-214863.
    1. Abbreviated Injury Scale (AIS). Association for the Advancement of Automotive Medicine.
    1. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270(24):2957–2963.
    1. Yeh DD, et al. Epidural analgesia for blunt thoracic injury—which patients benefit most? Injury. 2012;43(10):1667–1671.
    1. Baker EJ, Lee GA. A retrospective observational study examining the effect of thoracic epidural and patient controlled analgesia on short-term outcomes in blunt thoracic trauma injuries. Medicine. 2016;95(2):e2374.
    1. Mayall MF, Calder I. Spinal cord injury following an attempted thoracic epidural. Anaesthesia. 1999;54(10):990–994.
    1. Kindler CH, Seeberger MD, Staender SE. Epidural abscess complicating epidural anesthesia and analgesia. An analysis of the literature. Acta Anaesthesiol Scand. 1998;42(6):614–620.
    1. Zaw AA, et al. Epidural analgesia after rib fractures. Am Surg. 2015;81(10):950–954.
    1. Carrier FM, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. 2009;56(3):230–242.
    1. Shelley CL, et al. Posterior paramedian subrhomboidal analgesia versus thoracic epidural analgesia for pain control in patients with multiple rib fractures. J Trauma Acute Care Surg. 2016;81(3):463–467.
    1. Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth. 2017;118(3):474–475.
    1. Wu CL, et al. Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash. J Trauma. 1999;47(3):564–567.
    1. Ullman DA, et al. The treatment of patients with multiple rib fractures using continuous thoracic epidural narcotic infusion. Reg Anesth. 1989;14(1):43–47.
    1. Mackersie RC, et al. Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures. J Trauma. 1991;31(4):443–449.
    1. Kieninger AN, et al. Epidural versus intravenous pain control in elderly patients with rib fractures. Am J Surg. 2005;189(3):327–330.
    1. Duch P, Møller MH. Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials. Acta Anaesthesiol Scand. 2015;59(6):698–709.
    1. Moon MR, et al. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg. 1999;229(5):684–691.
    1. Luchette FA, et al. Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma. J Trauma. 1994;36(6):865–869.
    1. Daurat A, et al. Thoracic Trauma Severity score on admission allows to determine the risk of delayed ARDS in trauma patients with pulmonary contusion. Injury. 2016;47(1):147–153.
    1. Ramin S, et al. Acute respiratory distress syndrome after chest trauma: epidemiology, specific physiopathology and ventilation strategies. Anaesth Crit Care Pain Med. 2019;38(3):265–276.
    1. Easter A. Management of patients with multiple rib fractures. Am J Crit Care. 2001;10(5):320–327.
    1. Vartanyan P, et al. Chronic alcoholism is bad for broken ribs: a nationwide analysis of 20,120 patients with rib fractures. J Am Coll Surg. 2019;229(4):S289–S290.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir