Analgesia of Patients with Multiple Rib Fractures in Critical Care: A Survey of Healthcare Professionals in the UK

Laura Beard, Billy Holt, Catherine Snelson, Chetan Parcha, Fang Gao Smith, Tonny Veenith, Laura Beard, Billy Holt, Catherine Snelson, Chetan Parcha, Fang Gao Smith, Tonny Veenith

Abstract

Introduction: Good analgesia has been shown to reduce the risk of pneumonia, chronic pain, and mortality in patients with multiple rib fractures (MRFs). This survey explores the current analgesic practice in the UK, protocol use, barriers to provision, and physician preferences.

Materials and methods: A web-based survey was distributed nationally to an enriched cohort of clinicians working in UK trauma units with an interest in MRF management.

Results: Seventy-nine healthcare professionals responded. A third (31.4%) reported that their department had a rib fracture pain protocol, 52.9% did not, and 15.7% were unsure. Significantly more respondents reported adequate pain control when a hospital protocol was present compared to when not (χ 2, p < 0.01). Inadequate analgesia, a poor cough, and inability to breathe deeply were the commonest complications reported by 81.4, 78.6, and 65.7%, respectively. Patient-controlled analgesia (PCA) was the most commonly used form of analgesia (38.6%) followed by thoracic epidural (TEA) (30.0%) and continuous opioid infusion (18.6%). However, TEA was the preferred method of analgesia among respondents (37.1%) followed by serratus block (21.4%), paravertebral block (17.1%), and PCA (14.3%).

Discussion: There is considerable variation among physicians in their current use of analgesic modalities, with opiate-based methods predominating despite a physician preference for regional techniques. Thoracic epidurals are preferred by physicians but of limited use as a result of contraindications, time pressures, and staff skill mix. Pain control is reported to be better handled when protocols are present. Further research focusing on currently utilized regional techniques is required in order to produce a validated standardized national protocol that is informed by the current practice, the evidence base, and limitations to service provision.

Key messages: There is considerable variation among physicians in their current use of analgesic modalities. Opiate-based methods dominate for thoracic trauma despite a physician preference for regional techniques, which can be challenging in this cohort due to contraindications, staff skill mix, and time pressures. Inadequate analgesia is common but is better managed when pain management protocols are available.

How to cite this article: Beard L, Holt B, Snelson C, Parcha C, Smith FG, Veenith T. Analgesia of Patients with Multiple Rib Fractures in Critical Care: A Survey of Healthcare Professionals in the UK. Indian J Crit Care Med 2020;24(3):184-189.

Keywords: Analgesia; Critical care; Pain relief; Rib fractures; Thorax trauma.

Conflict of interest statement

Source of support: Fang Gao Smith is supported by the NIHR Senior Investigator Award. Tonny Veenith is supported by NIHR, Clinical Research Network and the NIAA. Laura Beard has had conference travel fees funded by Pajunk. Conflict of interest: None

Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.

Figures

Figs 1A and B
Figs 1A and B
Access to and usage frequency of analgesia protocols for managing rib fracture-associated pain among respondents; (A) Accessibility; (B) Usage frequency among those with access
Figs 2A to C
Figs 2A to C
Most frequently used methods of analgesia for rib fracture-associated pain in intensive care; (A) Most commonly used; (B) Second most commonly used; (C) Third most commonly used
Fig. 3
Fig. 3
The respondents’ preferred method of choice for managing pain secondary to rib fractures in the absence of any contraindications
Fig. 4
Fig. 4
Frequency of adequate analgesia being achieved for multiple rib fracture patients in intensive care
Fig. 5
Fig. 5
Most frequent complications of rib fractures seen by respondents in intensive care (up to three complications selected per respondents)
Figs 6A and B
Figs 6A and B
(A) The percentages of respondents who have or have not experienced barriers to or challenges in providing analgesia for patients with rib fractures; (B) The most common barriers and challenges experienced by respondents in intensive care

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