A 65 year old pedestrian involved in a road merchandise accident has sustained four fractured ribs and has a small area of contused lung noted on the CXR. You wonder whether placement of an epidural catheter and infusion of opioid or local anaesthetic agents offers any benefit over intravenous opioid analgesics (by intermittent bolus or patient controlled analgesia) in relieving the patient''s hurt or reducing complications from his injury.
MEDLINE: [rib abuse exp OR thoracic injuries exp] AND [injections,epidural exp OR analgesic epidural exp]EMBASE: [Thorax blunt trauma OR thorax injury OR rib abuse] AND [epidural anaesthesia OR thorax epidural]COCHRANE: Thoracic trauma[exp thoracic injuries] AND [exp analgesia-epidural OR anaesthesia-epidural OR injection-epidural OR analgesia-patient controlled OR analgesics-opioid]
Non-significant difference in mean measure to initiation of analgesia for epidural and iv groups (7.9 +/- 7.0 hrs vs. 6.9 +/- 6.7 hrs respectively)Significant increases for both epidural and iv groups in maximum inspiratory pressures (MIP) (17+/- 20 and 5.3+/- 19 cm H2O respectively) and vital capacity (VC) (5.1+/- 6.5 cc/kg and 2.8+/-4.5cc/kg respectively) compared to pre-analgesia levelSignificant increase in PaCO2 (5.6+/-4.2 torr) and decrease of Pa O2 (-19+/-14 torr) with iv analgesiaSignificant change magnitude in hurt scores in both epidural and iv groups at rest (-32+/-24 and -27+/-27 respectively) and on coughing/deep breathing (-42+/-25 and -25+/-26 respectively)
Small unblinded study. Analgesia controlled by physician not patient. No statistical analysis of complications carried out. Groups matched for LOS no of rib fractures and ISS>
46 patients > 18 years of age with > 3 rib fractures randomised to thoracic epidural (n=22) (bupivacaine morphine or fentanyl) or systemic opioids (n=24) (morphine hydromorphone and fentanyl) (PCA or nurse administered if patient unable) (n=24)Excluded if had spinal injury brain or spinal cord injury altered mental state unstable pelvic fracture vascular instability. Also excluded if pain controlled with oral opioids or anti-inflammatory medication. Epidural consisted of bupivacaine morphine and fentanyl.
No significant differences in ISS between groups but non-significant increase in numbers with flail chest pulmonary contusions and chest tubes in epidural groupSignificant difference in the development of pneumonia in epidural group vs systemic opioid group only if stratified for presence of additional pulmonary injury (OR 6.0 95% CI 1-35 p=0.05)Significant increase in duration of ventilation for systemic opioid assort IRR (incident rate ratio) 2.0 (95% CI 1.6-2.6 p
Small numbers. Non-blinded. No sample coat calculation.408 patients initially eligible but epidural was contra-indicated in 282 and 80 refused consent. No details of timing of insertion of epidural or setting up of PCA or doses given.3 patients in each group crossed over.
The limited quantity and quality of evidence illustrates the difficulties in studying this patient group and determining the most relevant outcomes. A significant number of patients will be excluded due to the presence of contra-indications to epidural analgesia or to physician concerns that epidural analgesia may prevent continued assessment of the multiply injured patient. All 4 studies studied slightly different patient groups different treatment regimes and outcomes with consistently poor reporting of timing of placement of epidural catheters and administration of intravenous analgesics. Despite these limitations the bear witness hints that epidural analgesia/anaesthesia is superior to intravenous analgesia. However it is very difficult to be confident that epidural analgesia/anaesthesia offers superior hurt relief and that this cause is translated into improved clinical outcomes with no significant side-effects.
On limited evidence from moderate quality studies epidural analgesia/anaesthesia offers some benefits over intravenous analgesia but further studies are needed to strengthen this conclusion.
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