Epidural analgesia improves outcome after multiple rib fractures

Eileen M. Bulger, Thomas Edwards, Patricia Klotz, Gregory Jurkovich

Research output: Contribution to journalArticle

165 Citations (Scopus)

Abstract

Background Rib fractures are common and associated with significant pulmonary morbidity. We hypothesized that epidural analgesia would provide superior pain relief, and reduce the risk of subsequent pneumonia. Methods A prospective, randomized trial of epidural analgesia versus IV opioids for the management of chest wall pain after rib fractures was carried out. Entry criteria included patients older than 18 years with more than 3 rib fractures and no contraindications to epidural catheter placement. Results From March 2000 to December 2003, 408 patients were admitted with more than 3 rib fractures; 282 met exclusion criteria, 80 could not be consented, and 46 were enrolled (epidural n=22, opioids n=24). The groups were comparable for mean age, injury severity score, gender, chest Abbreviated Injury Scale, and mean number of rib fractures. The epidural group tended to have more flail segments (38% vs 21%, P=.20) and pulmonary contusions (59% vs 38%, P=.14), and required more chest tubes (95% vs 71%, P=.03) Despite the greater direct pulmonary injury in the epidural group, their rate of pneumonia was 18% versus 38% for the intravenous opioid group. When adjusted for direct pulmonary injury, there was a greater risk of pneumonia in the opioid group: OR, 6.0; 95% CI, 1.0-35; P=.05. When stratified for the presence of pulmonary contusion there was a 2.0-fold increase in the number of ventilator days for the opioid group: incident rate ratio, 2.0; 95% CI, 1.6-2.6; P<.001. Conclusions The use of epidural analgesia is limited in the trauma population due to numerous exclusion criteria. However, when feasible, epidural analgesia is associated with a decrease in the rate of nosocomial pneumonia and a shorter duration of mechanical ventilation after rib fractures.

Original languageEnglish (US)
Pages (from-to)426-430
Number of pages5
JournalSurgery
Volume136
Issue number2
DOIs
StatePublished - Aug 1 2004
Externally publishedYes

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Rib Fractures
Epidural Analgesia
Opioid Analgesics
Pneumonia
Contusions
Lung Injury
Lung
Abbreviated Injury Scale
Chest Tubes
Thoracic Injuries
Injury Severity Score
Thoracic Wall
Mechanical Ventilators
Chest Pain
Artificial Respiration
Multiple Fractures
Catheters
Morbidity
Pain
Wounds and Injuries

ASJC Scopus subject areas

  • Surgery

Cite this

Epidural analgesia improves outcome after multiple rib fractures. / Bulger, Eileen M.; Edwards, Thomas; Klotz, Patricia; Jurkovich, Gregory.

In: Surgery, Vol. 136, No. 2, 01.08.2004, p. 426-430.

Research output: Contribution to journalArticle

Bulger, Eileen M. ; Edwards, Thomas ; Klotz, Patricia ; Jurkovich, Gregory. / Epidural analgesia improves outcome after multiple rib fractures. In: Surgery. 2004 ; Vol. 136, No. 2. pp. 426-430.
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abstract = "Background Rib fractures are common and associated with significant pulmonary morbidity. We hypothesized that epidural analgesia would provide superior pain relief, and reduce the risk of subsequent pneumonia. Methods A prospective, randomized trial of epidural analgesia versus IV opioids for the management of chest wall pain after rib fractures was carried out. Entry criteria included patients older than 18 years with more than 3 rib fractures and no contraindications to epidural catheter placement. Results From March 2000 to December 2003, 408 patients were admitted with more than 3 rib fractures; 282 met exclusion criteria, 80 could not be consented, and 46 were enrolled (epidural n=22, opioids n=24). The groups were comparable for mean age, injury severity score, gender, chest Abbreviated Injury Scale, and mean number of rib fractures. The epidural group tended to have more flail segments (38{\%} vs 21{\%}, P=.20) and pulmonary contusions (59{\%} vs 38{\%}, P=.14), and required more chest tubes (95{\%} vs 71{\%}, P=.03) Despite the greater direct pulmonary injury in the epidural group, their rate of pneumonia was 18{\%} versus 38{\%} for the intravenous opioid group. When adjusted for direct pulmonary injury, there was a greater risk of pneumonia in the opioid group: OR, 6.0; 95{\%} CI, 1.0-35; P=.05. When stratified for the presence of pulmonary contusion there was a 2.0-fold increase in the number of ventilator days for the opioid group: incident rate ratio, 2.0; 95{\%} CI, 1.6-2.6; P<.001. Conclusions The use of epidural analgesia is limited in the trauma population due to numerous exclusion criteria. However, when feasible, epidural analgesia is associated with a decrease in the rate of nosocomial pneumonia and a shorter duration of mechanical ventilation after rib fractures.",
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AB - Background Rib fractures are common and associated with significant pulmonary morbidity. We hypothesized that epidural analgesia would provide superior pain relief, and reduce the risk of subsequent pneumonia. Methods A prospective, randomized trial of epidural analgesia versus IV opioids for the management of chest wall pain after rib fractures was carried out. Entry criteria included patients older than 18 years with more than 3 rib fractures and no contraindications to epidural catheter placement. Results From March 2000 to December 2003, 408 patients were admitted with more than 3 rib fractures; 282 met exclusion criteria, 80 could not be consented, and 46 were enrolled (epidural n=22, opioids n=24). The groups were comparable for mean age, injury severity score, gender, chest Abbreviated Injury Scale, and mean number of rib fractures. The epidural group tended to have more flail segments (38% vs 21%, P=.20) and pulmonary contusions (59% vs 38%, P=.14), and required more chest tubes (95% vs 71%, P=.03) Despite the greater direct pulmonary injury in the epidural group, their rate of pneumonia was 18% versus 38% for the intravenous opioid group. When adjusted for direct pulmonary injury, there was a greater risk of pneumonia in the opioid group: OR, 6.0; 95% CI, 1.0-35; P=.05. When stratified for the presence of pulmonary contusion there was a 2.0-fold increase in the number of ventilator days for the opioid group: incident rate ratio, 2.0; 95% CI, 1.6-2.6; P<.001. Conclusions The use of epidural analgesia is limited in the trauma population due to numerous exclusion criteria. However, when feasible, epidural analgesia is associated with a decrease in the rate of nosocomial pneumonia and a shorter duration of mechanical ventilation after rib fractures.

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