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

Laura Beard, Carl Hillermann, Emma Beard, Sue Millerchip, Rajneesh Sachdeva, Fang Gao Smith, Tonny Veenith, Laura Beard, Carl Hillermann, Emma Beard, Sue Millerchip, Rajneesh Sachdeva, Fang Gao Smith, Tonny Veenith

Abstract

Background: There is a paucity of data comparing effectiveness of various techniques for pain management of traumatic rib fractures. This study compared the quality of analgesia provided by serratus anterior plane (SAP) catheters against thoracic epidural (TEA) or paravertebral catheters (PA) in patients with multiple traumatic rib fractures (MRFs).

Methods: 354 patients who received either SAP, TEA or PA at two tertiary referral major trauma centers in the UK were included (2016-2018). Primary outcome were change in inspiratory volumes and pain scores. Secondary outcomes included in-hospital mortality, along with the length of stay in hospital and critical care. Data were analyzed using linear, log-binomial and negative binomial regression models.

Main results: Across all blocks, there was a mean (SD) increase in inspiratory volume postblock of 789.4 mL (479.7). Ninety-eight per cent of all participants reported moderate/severe pain prior to regional analgesia, which was reduced to 34% postblock. There was no significant difference in the change in inspiratory volume or pain scores between the TEA, PA or SAP groups. Overall crude mortality was 13.2% (95% CI 7.8% to 18.7%). In an adjusted analysis and compared with TEA, in-hospital mortality was similar between groups (relative risk (RR) 0.4, 95% CI 0.1 to 1.0) and (RR 0.5, 95% CI 0.2 to 1.6) for SAP and PA, respectively.

Conclusion: SAP, TEA and PA all appear to offer the ability to reduce pain scores and improve respiratory function.

Keywords: acute pain; regional anesthesia; truncal blocks.

Conflict of interest statement

Competing interests: C Hillermann, L Beard, S Millerchip have had conference travel fees funded by Pajunk. E Beard has received unrestricted research funding from Pfizer for the Smoking Toolkit study (www.smokinginengland.info) outside of the period of this study. E Beard has no conflicts of interest to declare for this study.

© American Society of Regional Anesthesia & Pain Medicine 2020. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1
Figure 1
Inclusion criteria for each stage of the analysis. PA, paravertebral catheter; SAP, serratus anterior plane; TEA, thoracic epidural.
Figure 2
Figure 2
Mean difference (CIs) in inspiratory volume changes between block types for the unadjusted and adjusted linear regression models. Adjusted covariates: age, gender, ISS and RFS score. ISS, injury severity score; RFS, rib fracture score.
Figure 3
Figure 3
Relative risks (CIs) for the unadjusted and adjusted log binomial models comparing the number of participants reporting a change in their pain scores from severe/ moderate to mild/none. Adjusted covariates: age, gender, ISS and RFS score. ISS, injury severity score; RFS, rib fracture score.
Figure 4
Figure 4
Relative risks (CIs) for the unadjusted and adjusted log binomial models comparing in-hospital mortality risk. Adjusted covariates: age, gender, ISS, RFS score, CCI, most severely injured body region (head, chest and other), surgical rib fixation and isolated chest injury versus polytrauma. CCI, Charlson Comorbidity Index; ISS, injury severity score; RFS, rib fracture score.
Figure 5
Figure 5
Incidence rate ratio (CIs) for the unadjusted and adjusted negative binomial model comparing length of stay hospital. Adjusted covariates: age, gender, ISS, RFS score, CCI, most severely injured body region (head, chest and other), surgical rib fixation and isolated chest injury versus polytrauma. CCI, Charlson Comorbidity Index; ISS, injury severity score; RFS, rib fracture score.
Figure 6
Figure 6
Incidence rate ratio (CIs) for the unadjusted and adjusted negative binomial model comparing length of stay in critical care. Adjusted covariates: age, gender, ISS, RFS score, CCI, most severely injured body region (head, chest and other), surgical rib fixation and isolated chest injury versus polytrauma. CCI, Charlson Comorbidity Index; ISS, injury severity score; RFS, rib fracture score.

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Source: PubMed

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