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Three Part Question

In a [patient with blunt thoracic injury] is an [epidural infusion rather than intravenous administration of opioids] [superior in relieving pain or reducing complications] from his chest wall trauma?

Clinical Scenario

A 65 year old pedestrian involved in a road traffic 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 pain or reducing complications from his injury.

Search Strategy

MEDLINE: [rib fracture.exp OR thoracic injuries.exp] AND [injections,epidural exp OR analgesic epidural exp]
EMBASE: [Thorax blunt trauma OR thorax injury OR rib fracture] 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]

Search Outcome

Medline produced 56 papers, EMBASE 103, of which four were relevant and of sufficient quality.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mackersie et al 1991 USA	32 patients recruited with: - 3 or more rib fractures - two or more rib fractures with pulmonary contusion - flail chest/sternum - two or more rib fractures with exploratory laparotomy. Randomly assigned to physician controlled iv fentanyl analgesia vs. fentanyl epidural analgesia sited in lumbar area. Excluded if age < 18, pregnancy, substance abuse, psychiatric disorder, spinal injury, chronic pain, particularly painful limb injury.	Prospective block randomised study over 36 months.	10 point VAS score Pulmonary function tests Complications Length of stay	Non-significant difference in mean time 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 level Significant increase in PaCO2 (5.6+/-4.2 torr) and decrease of Pa O2 (-19+/-14 torr) with iv analgesia Significant decrease in pain 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>
Moon et al 1999 USA	34 patients with blunt thoracic trauma (rib fractures, sternal fractures, flail chest, pulmonary contusion) randomly assigned either to thoracic epidural infusion of bupivacaine/morphine or morphine PCA device. Excluded if had contra-indication to epidural catheter placement, GCS < 15, morbid obesity, pregnancy, labile blood pressure requiring vasopressors.	Prospective non-blinded block randomised study over 19 months.	10 point verbal rating pain scale performed at rest, on deep inspiration and movement Pulmonary function tests including Tidal Volume (TV), Forced Expiratory Volume (FEV) and Maximal Inspiratory Force (MIF)	Significant reduction of pain scores on day 1 (5.8 vs 7.4) and day 3 (3.8 vs 6.2 (p<0.05) favouring the epidural group Significant improvement in TV (590cc vs 327cc) and MIF (48cmH2O vs 34cmH2O favouring epidural group by day 3 No significant differences in FEV on any day between groups Non-significant increase in LOS in epidural group.	High patient withdrawal rate (10/34). Small numbers. No complications recorded. Results often shown graphically: values can only be estimated from graphs, or not put in at all. Study duration was only 3 days. No information on timing of epidurals or setting up of PCA devices.
Bulger et al, 2004, USA	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.	Prospective non-blinded block randomised over 45 months.	Primary endpoint was incidence of pneumonia as defined by Centre for Disease Control Duration of mechanical ventilation Length of stay (LOS) in hospital and ICU Mortality Complications	No significant differences in ISS between groups but non-significant increase in numbers with flail chest, pulmonary contusions and chest tubes in epidural group Significant 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 group IRR (incident rate ratio) 2.0 (95% CI 1.6-2.6 p<0.001) if groups stratified according to presence of pulmonary contusion No difference in mortality, hospital LOS or ICU LOS or complications.	Small numbers. Non-blinded. No sample size 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.
Ullman et al, 1989, USA	28 consecutive patients with multiple rib fractures randomly assigned to thoracic epidural opioid analgesia (n=15) within 72 hours or intravenous morphine (n=13). Patients had to have significant pain – excluded if pain only on coughing or deep inspiration. Excluded if patient had head injury.	Prospective, non-blinded randomised study over 2 years.	LOS in ICU and hospital LOS Duration of ventilation Need for tracheostomy	Epidural group had significant reduction in time on ICU (5.93 +/- 1.44 days vs. 18.69 +/- 5.25 days, p < 0.02) Epidural group had shorter hospital LOS (14.85 +/- 2.21 days vs. 47.69 +/- 14.67 days, p < 0.03) Epidural group had significantly less time ventilated (3.07 +/- 1.35 days vs. 18.23 +/- 8.12 days, p < 0.05) Epidural group had a lower incidence of tracheostomy (6.7 +/- 6.7% vs. 38.5 +/- 14.0%, p<0.05)	Small study in select ICU population. Did indicate timing of placement of epidural catheter. Unblinded Little information about other injuries though non-epidural group had a non-significantly higher ISS.

Comment(s)

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 evidence hints that epidural analgesia/anaesthesia is superior to intravenous analgesia. However, it is very difficult to be confident that epidural analgesia/anaesthesia offers superior pain relief and that this effect is translated into improved clinical outcomes with no significant side-effects.

Clinical Bottom Line

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.

References

1. Mackersie RC. Karagianes TG. Hoyt DB. Davis JW. Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures. Journal of Trauma, Injury, Infection and Critical Care 1991;31(4):443-9.
2. Moon MR. Luchette FA. Gibson SW. Prospective randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Annals of Surgery 1999;229(5):684-91.
3. Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery 2004;136(2):426-430.
4. Ullman DA, Fortune JB, Greenhouse BB, Wimpy RE, Kennedy TM. The treatment of patients with multiple rib fractures using continuous thoracic epidural narcotic infusion. Reg Anesth 1989;14(1):43-47.