Epidural analgesia in ICU chest trauma patients with fractured ribs: retrospective study of pain control and intubation requirements

Abstract

Background: Nonintubated chest trauma patients with fractured ribs admitted to the intensive care unit (ICU) are at risk for complications and may require invasive ventilation at some point. Effective pain control is essential. We assessed whether epidural analgesia (EA) in patients with fractured ribs who were not intubated at ICU admission decreased the need for invasive mechanical ventilation (IMV). We also looked for risk factors for IMV. Study design and methods: This retrospective, observational, multicenter study conducted in 40 ICUs in France included consecutive patients with three or more fractured ribs who were not intubated at admission between July 2013 and July 2015. Results: Of the 974 study patients, 788 were included in the analysis of intubation predictors. EA was used in 130 (16.5%) patients, and 65 (8.2%) patients required IMV. Factors independently associated with IMV were chronic respiratory disease (P = 0.008), worse SAPS II (P < 0.0001), flail chest (P = 0.02), worse Injury Severity Score (P = 0.0003), higher respiratory rate at admission (P = 0.02), alcohol withdrawal syndrome (P < 0.001), and noninvasive ventilation (P = 0.04). EA was not associated with decreases in IMV requirements, median numerical rating scale pain score, or intravenous morphine requirements from day 1 to day 7. Conclusions: EA was not associated with a lower risk of IMV in chest trauma patients with at least 3 fractured ribs, moderate pain, and no intubation on admission. Further studies are needed to clarify the optimal pain control strategy in chest trauma patients admitted to the ICU, notably those with severe pain or high opioid requirements.

Interest of Thoracic Trauma Severity (TTS) score for predict acute respiratory failure after mild blunt chest trauma : result of an observational study

“…COPD (6.3%) and asthma (5.3%) were the main respiratory diseases represented in our study and almost half of them (53%) presented an ARF. Preexisting respiratory disease is clearly established as a morbi-mortality risk factor, consistently with the results of previous studies (7,(18)(19)(20)(21). Subsequently, a careful questioning of the patient's respiratory history at ED admission including history of smoking and cardiovascular comorbidities is of the utmost importance.…”

“…Those data suggests that loco regional analgesia must be performed early in chest traumas. French guidelines(6) recommend locoregional anesthesia for patients with severity criteria (complex or bilateral injuries) or remaining pain after 12 hours of appropriate treatment based on large pain management literature (21,(25)(26)(27)(28)(29).…”

“…Discrepancies of SOFA scores (higher in the ARF group) might be explained by a greater severity of patients in the ARF group. Regarding the severity trauma injury scoring, the ISS score was already identi ed as a risk factor of morbidity and mortality in traumatology (21,23,24,35,36). On univariate analysis, ISS score was statistically signi cant for ARF occurrence.…”

Surgical and perioperative management of flail chest with titanium plates: a French cohort series from a thoracic referral center

“…The usual management of flail chest is based on measures including oxygen therapy, multimodal analgesia, respiratory physiotherapy and early rehabilitation [ 9 – 11 ]. The generalization of non-invasive ventilation has decreased the need for tracheal intubation and invasive ventilation, and its complications [ 12 ].…”

Surgical management of flail chest with titanium plates: a French cohort series from a thoracic referral center

“…The usual management of ail chest is based on measures including oxygen therapy, multimodal analgesia, respiratory physiotherapy and early rehabilitation 9,10,11 . The generalization of non-invasive ventilation has decreased the need for tracheal intubation and invasive ventilation, and its complications 12 .…”