Continuous Intercostal Nerve Blockade for Rib Fractures: Ready for Primetime?

Methodist Dallas Medical Center, Dallas, Texas, United States
The Journal of trauma (Impact Factor: 2.96). 12/2011; 71(6):1548-52; discussion 1552. DOI: 10.1097/TA.0b013e31823c96e0
Source: PubMed


Providing analgesia for patients with rib fractures continues to be a management challenge. The objective of this study was to examine our experience with the use of a continuous intercostal nerve block (CINB). Although this technique is being used, little data have been published documenting its use and efficacy. We hypothesized that a CINB would provide excellent analgesia, improve pulmonary function, and decrease length of stay (LOS).
Consecutive adult blunt trauma patients with three or more unilateral rib fractures were prospectively studied over 24 months. The catheters were placed at the bedside in the extrathoracic, paravertebral location, and 0.2% ropivacaine was infused. Respiratory rate, preplacement (PRE) numeric pain scale (NPS) scores, and sustained maximal inspiration (SMI) lung volumes were determined at rest and after coughing. Parameters were repeated 60 minutes after catheter placement (POST). Hospital LOS comparison was made with historical controls using epidural analgesia.
Over the study period, 102 patients met inclusion criteria. Mean age was 69 (21-96) years, mean injury severity score was 14 (9-16), and the mean number of rib fractures was 5.8 (3-10). Mean NPS improved significantly (PRE NPS at rest = 7.5 vs. POST NPS at rest = 2.6, p < 0.05, PRE NPS after cough = 9.4, POST after cough = 3.6, p < 0.05) which was associated with an increase in the SMI (PRE SMI = 0.4 L and POST SMI = 1.3 L, p < 0.05). Respiratory rate decreased significantly (p < 0.05) and only 2 of 102 required mechanical ventilation. Average LOS for the study population was 2.9 days compared with 5.9 days in the historical control. No procedural or drug-related complications occurred.
Utilization of CINB significantly improved pulmonary function, pain control, and shortens LOS in patients with rib fractures.

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    • "It is possible that more aggressive pain management in the acute phase could impact on longer-term pain and functional outcomes. Although different studies have shown benefits of various analgesic regimens in the acute phase (such as intravenous ibuprofen, intercostal nerve blocks, lidocaine topical patch), none of them have followed the patients to monitor whether there is any difference in longer term pain syndromes [19] [20] [21]. A meta-analysis of epidural analgesia in patients with traumatic rib fractures showed no significant benefit on mortality, ICU or hospital length of stay [22]. "
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