Comparative effectiveness analysis of two regional analgesia techniques for the pain management of isolated multiple rib fractures

Neal Lynch,1 Kristin Salottolo,1–4 Krislyn Foster,2 Alessandro Orlando,1–4 Catherine Koola,1–4 Victor Portillo,3 Allen Tanner II,1 Charles W Mains,4,5 David Bar-Or1–41Trauma Services Department, Penrose-St. Francis Health Services, Colorado Springs, CO, USA; 2Swedish Medical Center, Trauma Research Department, Englewood, CO, USA; 3Medical City Plano, Trauma Research Department, Plano, TX, USA; 4St. Anthony Hospital, Trauma Research Department, Lakewood, CO, USA; 5Centura Health, Trauma Services Department, Englewood, CO, USABackground: Catheter-based regional analgesia has been proposed as an alternative to systemic analgesia for patients with multiple rib fractures (MRF). This study sought to compare the efficacy of regional techniques for decreasing pain and improving clinical outcomes.Study design: This was a multi-institutional, retrospective cohort study of adult (≥18 years) patients admitted to four nonacademic trauma centers over two years (from 07/1/2014 to 06/30/2016). Study inclusion was MRF (≥3 fractures) with no other severe injuries. Two primary regional analgesia techniques were utilized and compared: continuous intercostal nerve blocks (CINB) and epidural (EPI) analgesia. The primary outcome, average pain scores on treatment, was examined using a repeated measures, linear regression mixed model. Secondary outcomes included hospital LOS, ICU LOS, ICU admission and hospital readmission, pulmonary complications, and incentive spirometry volumes during treatment, and were examined with univariate statistics.Results: There were 339 patients with isolated MRF; 85 (25%) required regional analgesia (CINB, n=41; EPI, n=44) and the remaining 75% received systemic analgesia only (IV, n=195; PO, n=59). There were demographic and clinical differences between regional analgesia and systemic analgesia groups; on the contrary, there were no demographic or clinical differences between the CINB and EPI groups. Adjusted pain scores were similar for the EPI and CINB groups (4.0 vs 4.4, p=0.49). Secondary outcomes were worse in the EPI group compared to the CINB group: less improvement in incentive spirometry volume (p=0.004), longer ICU LOS (p=0.03), longer hospital LOS (p<0.001), and more ICU admission (p<0.001).Conclusion: In patients requiring regional analgesia, pain management was equivalent with CINB and EPI, but CINB was associated with significantly better clinical outcomes. CINB might offer an efficient alternative for pain control in patients with MRF.Keywords: rib fractures, nerve block, epidural analgesia, trauma managemen