Continuous Thoracic Paravertebral Infusion of Bupivacaine for Pain Management in Patients With Multiple Fractured Ribs*

Karmakar, Manoj K.; Critchley, Lester A. H.; Ho, Anthony M.‐H.; Gin, Tony; Lee, Tak Wai; Yim, Anthony P.C.

doi:10.1378/chest.123.2.424

Cited by 121 publications

(63 citation statements)

References 24 publications

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“…[1][2][3][4][5][6][7] Pain is recognized as a contributing factor for most of this associated morbidity, [6][7][8][9] and analgesia is a core intervention in managing these patients. 5,7 Multiple analgesic modalities have been used in patients with rib fractures, 4 such as oral analgesics, 10 intravenous opioids, 7,11 patient-controlled opioid analgesia, 12 interpleural blocks, 11 intercostal blocks, 11,13 paravertebral blocks, 11,14 and epidural analgesia. 6,7,10,11,15,16 Recent studies and metaanalyses have suggested that epidural analgesia reduces morbidity after major abdominal, [17][18][19][20] vascular, 18,20,21 and thoracic surgeries, 17,18,20 overcoming the potential risk of complications associated with this technique.…”

Section: Résumémentioning

confidence: 99%

Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials

Carrier

Turgeon

Nicole

et al. 2009

Can J Anesth/J Can Anesth

171

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Purpose A consensus group recently proposed epidural analgesia as the optimal analgesic modality for patients with multiple traumatic rib fractures. However, its beneficial effects are not consistently recognized in the literature. We performed a systematic review and a meta-analysis of randomized controlled trials (RCT) of epidural analgesia in adult patients with traumatic rib fractures. Methods A systematic search strategy was applied to MEDLINE, EMBASE, the Cochrane Library and to the annual meeting of relevant societies (up to July 2008). All randomized controlled trials comparing epidural analgesia with other analgesic modalities in adult patients with traumatic rib fractures were included. Primary outcomes were mortality, ICU length of stay (LOS), hospital LOS and duration of mechanical ventilation. Results Eight studies (232 patients) met eligibility criteria. Epidural analgesia did not significantly affect mortality (odds ratio [OR] 1.6, 95% CI, 0.3, 9.3, 3 studies, n = 89), ICU LOS (weighted mean difference [WMD] -3.7 days, 95% CI, -11.4, 4.0, 4 studies, n = 135), hospital LOS (WMD -6.7, 95% CI, -19.8, 6.4, 4 studies, n = 140) or duration of mechanical ventilation (WMD -7.5, 95% CI, -16.3, 1.2, 3 studies, n = 101). Duration of mechanical ventilation was decreased when only studies using thoracic epidural analgesia with local anesthetics were evaluated (WMD -4.2, 95% CI, -5.5, -2.9, 2 studies, n = 73). However, hypotension was significantly associated with the use of thoracic epidural analgesia with local anesthetics (OR 13.76, 95% CI, 2.89, 65.51, 3 studies, n = 99).Abstract presentation: Presented in part at the Residents' Competition at the 62nd Annual Meeting of the Canadian Anesthesiologists' Society,

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Section: Résumémentioning

confidence: 99%

Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials

Carrier

Turgeon

Nicole

et al. 2009

Can J Anesth/J Can Anesth

171

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“…According to Kamarka's study, in the fifteen patients with unilateral MRF, there was significant improvement in pain scores measured both at rest and during coughing (p<0.001) after the initial treatment, and the improvements in pain scores were sustained for 4 days (p<0.01) that thoracic paravertebral infusion was in used [12]. Pain score at rest and during coughing had a significant improved after injecting bupivacaine solution in three consecutive days.…”

Section: Discussionmentioning

confidence: 99%

“…According to recently studies, the severe pain correlated with the number of rib broken and pain management is cornerstone of treatment for blunt chest trauma patients with multiple rib fractures [7,9].…”

Section: Discussionmentioning

confidence: 99%

“…Mohta [9] had been compared thoracic paravertebral analgesia with thoracic epidural analgesia in terms of efficacy and outcome in patients with fractured ribs (n=30). The findings that both TEA and TPVB provided good pain relief and improved respiratory function, as evident by improvement in VAS scores at rest and during coughing, respiratory rate, and peak expiratory flow rate.…”

Section: Discussionmentioning

confidence: 99%

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Thoracic Paravertebral Analgesia for Treatment Blunt Chest Trauma with Multiple Rib Fractures

Giang¹,

Nam²,

Trung³

et al. 2017

J Clin Trial

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Multiple rib fracture (MRF) causes severe pain that compromise respiratory mechanics. We evaluated the efficacy of thoracic paravertebral block with bupivacaine -fentanyl mixture in patients with unilateral MRF. The study was carried out on 172 blunt chest trauma patients in prospective nonrandomized case series. An initial bolus dose of 0.3 ml/kg of bupivacaine 0.25% plus fentanyl 2 μg/ml was used following by continuous infusion with 0.1 ml/kg/h of bupivacaine 0.125% plus fentanyl 2 μg/ml. Pain severity was assessed by visual analogue scale (VAS) at rest and during coughing; bedside spirometry was measured 5 times in 3 consecutive days after paravertebral block. Traffic accidents (69.1%) was major reason for blunt chest trauma; the number of ribs fracture ranged from 3-5 (76.1%) and 6-8 (23.9%). The rate of hemothorax, pneumothorax and the combination hemothorax-pneumothorax were 64.5%, 7.6% and 27.9% respectively. There was significant improvement in pain score at rest and during coughing, respiratory rate, FVC and FEV1 (p<0.05) 30 min after initial bolus dose, which were sustained during continuous thoracic paravertebral infusion 72 h (p<0.05). The rate of analgesic rescue by paracetamol infusion was 6.4%. No patient had respiratory depression or respiratory failure or signs of local anesthetic toxicity. The result shows that thoracic paravertebral analgesia with bupivacaine and fentanyl provided a good efficacy for pain management in patients with unilateral MRF.

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“…Also, they indicated that the patients enjoyed sustained improvement in the respiratory parameters and oxygenation. 8 The present case report describes use of US guidance to achieve TPVB using continuous bupivacaine infusion in patient with multiple ribs fracture. The TPVB provided pain free extubation conditions and the trachea was extubated successfully.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound-Guided Thoracic Paravertebral Block: The Direction of Local Anaesthetic Spread

Eldawlatly¹,

Hajjar²,

Abodonya³

et al. 2010

IJUTPC

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Chest wall trauma following motor vehicle accident can lead to prolonged ventilator support with subsequent pulmonary complications and delayed weaning off the mechanical ventilation. Patients with multiple rib fractures usually present with severe pain which impairs their respiratory mechanics. There are different methods of pain relief for patients with rib fractures. In this report, we present a case of rib fractures where pain was treated successfully with continuous local anaesthetic infusion using ultrasound guided thoracic paravertebral block (TPVB). A 28-year-old male was brought to Accident and Emergency department. The patient was resuscitated and as he was irritable and presented with poor GCS (Glasgow coma scale) score, so the trachea was intubated and he was put on mechanical ventilator. Following failed multiple attempts to wean off from the ventilator mainly due to patient getting restless coupled with desaturations at each attempt the insertion of TPVB catheter with continuous bupivacaine infusion to facilitate weaning off ventilator process was planned. Under ultrasound (US) guidance, a catheter was placed at D5-6 vertebrae level. It was noticed that most of the local anaesthetics (mixed with Omnipaque dye) spreaded towards caudal than the cephalad direction. Continuous infusion of bupivacaine 0.25%, 4-6 ml/hour was started to provide pain relief. The trachea was extubated on 5th post-admission day in SICU. In conclusion, continuous local anaesthetic infusion via US guided TPVB catheter technique proved very effective in pain relief following multiple rib fractures. Also in contrary to other reports, we have noticed more caudal than cephalad spread of the TPVB injectate.

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Continuous Thoracic Paravertebral Infusion of Bupivacaine for Pain Management in Patients With Multiple Fractured Ribs*

Cited by 121 publications

References 24 publications

Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials

Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials

Thoracic Paravertebral Analgesia for Treatment Blunt Chest Trauma with Multiple Rib Fractures

Ultrasound-Guided Thoracic Paravertebral Block: The Direction of Local Anaesthetic Spread

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