|Year : 2018 | Volume
| Issue : 1 | Page : 199-204
Comparison of thoracic epidural analgesia versus parenteral analgesia for traumatic multiple rib fractures
Ashraf A Zein Eldin1, Moharram A Mohamed2, Mohamed S Abdelmotelb2, Mohamed M Abdelsabour2
1 Department of Cardiothoracic Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Menoufia, Egypt
2 Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Menoufia, Egypt
|Date of Submission||15-Dec-2016|
|Date of Acceptance||27-Feb-2017|
|Date of Web Publication||11-Jun-2018|
Mohamed M Abdelsabour
Shebeen El-Kom, Menoufia
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare between epidural analgesia and parenteral analgesia for management of traumatic multiple rib fractures.
Chest wall trauma is most commonly seen after motor vehicle collision and accounts for 8% of all trauma admissions. It is a marker of severity and contributes to the morbidity and mortality of injured patients, with the elderly and patients with poor respiratory reserve being most vulnerable. Rib fractures are the commonest of all chest injuries and are identified in 10% of patients after trauma. Pain limits one's ability to cough and breathe deeply, resulting in sputum retention and atelectasis. These factors result in decreased lung compliance, ventilation-perfusion mismatch, and respiratory distress. This can result in serious respiratory complications.
Patients and methods
We conducted a prospective, randomized study of 30 patients complaining of multiple rib fractures who were admitted to the thoracic surgery unit in Menoufia University hospitals between December 2015 and July 2016. The patients were randomly divided into two equal groups of 15 patients. The first group was subjected to epidural analgesia, and the second group was given ketorolac tromethamine, a NSAID.
Our study included 21 males and nine females, with a mean age of 41.8 years. The epidural group showed that the pain score significantly lowered than systemic analgesia group at 6 and 24 h after treatment, along with a significant improvement in arterial blood gases, duration of hospital, and ICU stay.
Thoracic epidural analgesia is more effective regarding pain score, arterial blood gases, hospital stay, ICU stay, and duration of mechanical ventilation but has no significant value in need for ICU stay, need for mechanical ventilation, or improvement in pH.
Keywords: multiple rib fractures, thoracic epidural analgesia, trauma
|How to cite this article:|
Zein Eldin AA, Mohamed MA, Abdelmotelb MS, Abdelsabour MM. Comparison of thoracic epidural analgesia versus parenteral analgesia for traumatic multiple rib fractures. Menoufia Med J 2018;31:199-204
|How to cite this URL:|
Zein Eldin AA, Mohamed MA, Abdelmotelb MS, Abdelsabour MM. Comparison of thoracic epidural analgesia versus parenteral analgesia for traumatic multiple rib fractures. Menoufia Med J [serial online] 2018 [cited 2020 Feb 28];31:199-204. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/199/234249
| Introduction|| |
Thoracic trauma is very variable ranging from mild skin laceration and contusion to acute respiratory distress syndrome and major vessel injury. Blunt trauma to the chest wall can disrupt respiratory mechanics and lead to poor pulmonary toilet and significant morbidity. Chest wall trauma alone occurs in only 16% of cases and is a marker of more serious visceral injury in the thoracic cage or below the diaphragm . Fracture of the ribs is the most common blunt thoracic injury, occurring in 39% of patients admitted to major trauma centers ,. Rib fractures are an important indicator of trauma severity. The greater the number of ribs fractured, the higher is the patient's morbidity and mortality, especially if six or more ribs are broken. The first rib fracture has particular significance because of the great force required for it to occur and the likelihood that intrathoracic visceral injury has also taken place ,.
Initially, an upright chest radiography is performed as a routine examination. The addition of computed tomography to the trauma evaluation improves the sensitivity of the diagnosis of rib fractures ,.
The aim of the treatment is relief pain, prevention of atelectasis, and optimization of pulmonary toilet. Management modalities include thoracic epidural analgesia, intercostal nerve blocks, intrapleural instillation of anesthesia, and intravenous opiates and NSAIDs ,.
During the primary survey of a patient who has suffered blunt trauma, careful observation for the presence of a flail chest is important . This injury usually occurs with the fracture of three or more ribs at two sites, either unilateral or bilateral, showing paradoxical motion locally. This impairs respiratory mechanics and results in hypoventilation, poor pulmonary drainage, and atelectasis. Patient with flail chest are at a higher risk of respiratory compromise and often require early intubation . Pneumothorax or hemothorax is a common acute sequela, and acute respiratory distress syndrome occurs in about third of these patients and results in mortality rates as high as 33% .
Some studies like Waqar et al.  and Pierre et al.  showed that pain score, hospital stay, and ICU stay were better with the use of epidural analgesia, but other studies like Bulger et al.  showed that pain, ICU stay, and mechanical ventilation were almost the same in both groups.
We aim to compare between epidural analgesia and parenteral analgesia in the management of traumatic multiple rib fractures with pain score, arterial blood gases, hospital stay, ICU stay, and duration of mechanical ventilation.
| Patients and Methods|| |
After approval of the Menoufia Ethics Committee for the study proposal, this prospective observational study was conducted in Menoufia University hospitals between December 2015 and July 2016. A total of 76 patients with multiple rib fractures were admitted to the hospital within this time frame. Only 30 patients met the inclusion criteria and were included in this study.
The study was time linked, and the included patients are allocated as one patient for epidural analgesia and the other for systemic analgesia.
We considered that the number of patients would be sufficient, as Moon et al.  also conducted a study on 24 patients to compare epidural versus parenteral opioid analgesia in the treatment of thoracic trauma.
Written informed consent was obtained from each patient before his or her enrollment in the trial. Patients older than 18 years with three or more fractured ribs were included in the study, which had either epidural analgesia or systemic analgesia as a pain relief modality. Patients who are mechanically ventilated from the start or underwent exploration for other causes were excluded from the study. The patients were randomly divided into two equal groups of 15 patients. The first group was subjected to epidural analgesia on arrival (10 ml 0.125–0.25% bupivacaine), which was repeated after 4–6 h (group A). The other group were given ketorolac tromethamine, which is a nonsteroidal anti-inflammatory drug, 30 mg intravenously on arrival and repeated every 8 h (group B). Each patient was subjected to full history taking, thorough clinical examination, laboratory examination, and radiological investigation in the form of chest radiography and computed tomography of chest. Patients' demographics like age and sex, pain score, length of ICU and hospital stay, and type of pain control used (epidural analgesia or systemic analgesia) were recorded. Progress of the patient was noted through case files during the hospital stay and follow-up chest radiography. All patients had initiation of thoracic epidural analgesia with bupivacaine or systemic analgesia immediately after admission. Epidural catheter was placed by anesthesiologists. Catheters were inserted with a standard loss-of-resistance technique. Pain was assessed by visual analog scale (VAS), which was graded from 0 (no pain) to 10 (most severe pain). The VAS for pain was explained to the patients on their arrival to hospital and was administered before doing any maneuver (analgesia or epidural analgesia) and at 6 and 24 h after the maneuver. Arterial blood gases were measured before doing any maneuver (thoracic epidural analgesia and systemic analgesia) and at 6 and 24 h after the maneuver. Length of ICU stay (days) was defined as the time from admission to ICU to transfer to surgical ward, and length of hospital stay (days) was defined as the time the patient was admitted to emergency till the time of discharge from the hospital [Table 1], [Table 2], [Table 3] and [Figure 1].
|Table 3: Comparison between both groups regarding hospital, ICU stay, and need for mechanical ventilation|
Click here to view
The primary outcome of the study is to compare pain through VAS between both the groups.
The secondary outcome is to compare arterial blood gases, hospital stay, and ICU stay between both the groups.
Two types of statistical analysis were done:
- Descriptive statistics was expressed in number, percentage, mean, and SD
- Analytic statistics included the following:
Student's t-test is a test of significance used for comparison of quantitative variables between two groups of normally distributed data, whereas Mann–Whitney test was used for comparison of quantitative variables between two groups of non-normally distributed data.
Paired t-test was used to compare different readings of normally distributed data in the same group (e.g., before and after treatment), and Wilcoxon's test was used to compare different readings of non-normally distributed data in the same group.
χ2-Test was used to study association between qualitative variables. Whenever any of the expected cells were less than five, Fischer's exact test was used.
Wilcoxon's test was used to compare two consecutive readings of non-normally distributed data in the same group. P value of less than 0.05 was considered statistically significant.
| Results|| |
Results were collected, tabulated, and statistically analyzed by an IBM compatible personal computer with statistical package for the social sciences version 20 (SPSS, released 2011; SPSS Inc., Chicago, Illinois, USA. IBM SPSS statistics for windows, version 20.0; IBM Corp, Armonk, New York, USA).
This study was conducted on 30 patients experiencing multiple rib fractures aged between 25 and 60 years. This group included 21 males and nine females. Overall, 11 patients experienced diabetes, nine hypertension, three asthma, seven chronic obstructive pulmonary disease, and one tuberculosis. The cause of the rib fractures was road traffic accidents in 20 patients, falling from height in five patients, and quarrel in five patients. The number of fractured ribs was between three and seven. A total of six patients had pneumothorax only, six had hemothorax only, two had lung contusion, and 16 had more than one lesion.
In case of epidural analgesia pain, the VAS score improved from a mean of 4.87 to 2.07 at 6 h and 2.27 at 24 h after treatment, and in the case of systemic analgesia pain, it improved from a mean of 4.8 to 3.6 at 6 h and 4 at 24 h after treatment. It is also found that it is significantly lower in epidural group than systemic analgesia group after treatment by 6 and 24 h (P = 0.002 and 0.001, respectively).
Regarding, arterial blood gases, it was found that in case of epidural treatment, the level of oxygen improved from an average of 73.5 to 83.6 after 6 h to 87.4 after 24 h, and also the level of CO2 declined from mean of 41.7 to 37 after 6 h and then increased slightly to 37.5 after 24 h. In the case of systemic analgesia, oxygen level improved from mean of 70 to 78.5 after 6 h to 80.4 after 24 h and also the level of the CO2 decreased from an average of 41.2 to 39.8 after 6 h and then 38.8 after 24 h. Therefore, PO2 is significantly higher in the epidural group than in systemic analgesia group at 6 and 24 h after treatment (P = 0.001 and <0.001, respectively), and also PCO2 is significantly lower in the epidural group than in the systemic analgesia group at 6 h after treatment (P < 0.001), whereas there is no significant difference between the two groups regarding PCO2 level at 24 h after treatment (P = 0.065).
Duration of hospital stay ranged between 4 and 16 days with 12 patients admitted in ICU, nine of them had been ventilated. Hospital stay, ICU stay, and duration of mechanical ventilation are significantly lower in the epidural group than systemic analgesia group (P = 0.042, 0.456, and 0.009, respectively). However, there is no significant difference between the two groups regarding the need for mechanical ventilation (P = 0.109).
| Discussion|| |
Chest wall trauma and rib fractures are significant sources of morbidity and mortality in countries in which motor vehicle accidents are prevalent. Incidence of thoracic trauma has rapidly increased in this century of high-speed vehicles, violence, and various other disasters. Thoracic traumas comprise 10–15% of all traumas and are the causes of death in 25% of all fatalities due to trauma. Rib fractures are common thoracic injury associated with significant pulmonary morbidity .
Pain associated with flail chest or multiple rib fractures can result in voluntary splinting and muscle spasm, which leads to decreased ventilation and atelectasis. Compromise of pulmonary function can cause hypoxemia or pneumonia, which may require mechanical ventilation .
The 30 patients in our study were randomly divided into two equal groups of 15 patients. The first group was subjected to epidural analgesia (10 ml 0.125–0.25% bupivacaine) (group A), and the other group was given ketorolac tromethamine, which is a nonsteroidal anti-inflammatory drug, 30 mg intravenously (group B).
Moon et al.  had also conducted a study on 24 patients to compare epidural versus parenteral opioid analgesia in thoracic trauma.
In our study, age distribution was nonsignificantly lower in epidural group (37.93 ± 12.69) than in systemic analgesia group (45.73 ± 12.35). This is because the patients were randomly divided between both groups.
The number of males exceeded that of females in both groups of the study (epidural group had 10 males and five females, whereas systemic analgesia group had 11 males and four females). This was expected as male individuals are more exposed to trauma. However, there was no significant overall sex difference between the groups.
This finding is similar to Waqar et al.  who worked on 85 patients, where the mean age was 54 ± 17 years in epidural group and 45 ± 22 years in the systemic analgesia group, with no significant difference (P = 0.4), whereas male to female ratio was 3: 1 (64 male and 21 female), which was not significant between the groups.
There was no significant difference between the studied groups regarding medical problems (diabetes mellitus, hypertension, tuberculosis, chronic obstructive pulmonary disease, and asthma).
The cause of trauma in 73% of group A and 60% of group B was because of road traffic accidents, which was owing to increased urbanization.
This corresponds with Waqar et al.  who worked on 85 patients, and the cause of trauma in 70% of patients in epidural group and 55% in systemic analgesia group was because of road traffic accidents, which was nonsignificantly different between the groups.
Fall from height was responsible for trauma in 13% of group A and 20% of group B patients. Quarrel was responsible for trauma in 13% of group A and 20% of group B patients.
There was no significant difference between the studied groups regarding the cause of trauma.
In our study, there was no significant difference between the two groups regarding coincident lesions (pneumothorax, hemothorax, and lung contusion); this coincides with the findings of Waqar et al.  who worked on 85 patients and showed no significant difference regarding these lesions.
Moreover, there was no significant difference between both the groups regarding the number of fractured ribs in our study (4.53 ± 1.19 in the epidural group, whereas 4.60 ± 1.55 in the systemic analgesia group). This finding is similar to that obtained by Waqar et al. , as the number of fractured ribs was 6.4 ± 2.1 in the epidural group and 5.2 ± 2.5 in systemic analgesia group, which was nonsignificantly different.
We tried to select the patients with isolated chest injury, but this was very difficult. Therefore, we selected only those with mild associated injury that will not affect the results, and we excluded those with moderate and severe injuries. In our study, there was no significant difference between both groups regarding associated system injury.
The random division of the patients between both groups resulted in a nonsignificant difference in pain scoring between them before maneuvers, although it was slightly higher in epidural group (4.87 ± 1.68) than systemic analgesia group (4.80 ± 1.61).
In the present study, 6 h after maneuvers, the pain score was lower in the epidural group (2.07 ± 0.79) than in the analgesic group (3.60 ± 1.45), and the difference between both the groups was highly significant.
Moreover, 24 h after maneuvers, pain score was lower in the epidural group (2.27 ± 0.96) than in the analgesic group (4.00 ± 1.4), and the difference between both the groups was highly significant.
These findings are similar to Pierre et al.  who reported that VAS scores improved significantly in epidural group after 6 and 24 h (in epidural group, before, VAS = 8.3 ± 0.45; after 6 h, VAS = 2.9 ± 0.7; and after 24 h, VAS = 0.6 ± 0.45 whereas in systemic analgesia group, before, VAS = 8.0 ± 0.3; after 6 h, VAS = 3.7 ± 0.7; and after 24 h, VAS = 3.3 ± 0.7).
Our study showed that there was no significant difference between both groups regarding arterial blood gases (PO2, PCO2, and pH) before the maneuvers.
It also showed that PO2 was significantly higher in the epidural group than in systemic analgesia group after the maneuvers by 6 and 24 h.
On the contrary, it showed that PCO2 was significantly lower in the epidural group than in systemic analgesia group at 6 h after treatment, whereas there is no significant difference between the two groups regarding PCO2 level at 24 h after treatment.
In addition, there was no significant difference between the two groups regarding pH at 6 and 24 h after treatment.
Our study shows that hospital stay was significantly lower in the epidural group than in systemic analgesia group.
ICU stay was significantly lower in the epidural group than in systemic analgesia group; however, there was no significant difference between the two groups regarding the need for ICU admission.
Duration of MV was significantly lower in the epidural group than systemic analgesia group. However, there was no significant difference between the two groups regarding the need for MV.
Pierre et al.  showed that hospital stay was less in the epidural group in comparison with systemic analgesia group (10.8 and 15.9 days, respectively), and ICU stay was less in the epidural group in comparison with systemic analgesia group (3.1 and 6.6 days, respectively).
Bulger et al.  showed that ICU stay was nonsignificantly lower in the epidural group in comparison with systemic analgesia group, and also the duration of mechanical ventilation was nonsignificantly lower in the epidural group in comparison with the systemic analgesia group.
On the contrary, Waqar et al.  showed that hospital stay was significantly lower in the epidural group (19 ± 3.1) in comparison with the systemic analgesia group (21 ± 4.1), and also ICU stay was significantly lower in the epidural group (12 ± 2.4) in comparison with the systemic analgesia group (14 ± 3.5).
The study has the following limitations:
- Fewer number of patients admitted at this time period
- Short follow-up time
- Single-center results only
- Did not consider other intervention procedures
- Used only one functional score (VAS).
| Conclusion|| |
We concluded that thoracic epidural analgesia is better than systemic analgesia as it improves pain, arterial blood gases, duration of hospital stay, ICU stay, and need for mechanical ventilation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg 1987; 206
Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? J Trauma 2003; 54
Sirmali M, Türüt H, Topcu S, Gulhan E, Yazici U, Kaya S, Tastepe I. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg 2003; 24
Sharma OP, Oswanski MF, Jolly S, Lauer SK, Dressel R, Stombaugh HA. The Perils of rib fractures. Am Surg 2008; 74
Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, Gamelli RL. Half a dozen ribs: the breakpoint for mortality. Surgery 2005; 138
Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. J Cardiothorac Surg 2003; 23
Livingston DH, Shogan B, John P, Lavery RF. CT diagnosis of rib fracture and the prediction of acute respiratory failure. J Trauma 2008; 64
Gabram SG, Schwartz RJ, Jacobs LM, Lawrence D, Murphy MA, Morrow JS, et al.
Clinical management of blunt trauma patients with unilateral rib fractures: a randomized trial. World J Surg 1995; 19
Haenel JB, Moore FA, Moore EE, Sauaia A, Read RA, Burch JM. Extrapleural bupivacaine for amelioration of multiple rib fracture pain. J Trauma 1995; 38
Bastos R, Calhoun JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg 2008; 20
Velmahos GC, Vassiliu P, Chan LS, Murray JA, Berne TV, Demetriades D. Influence of flail chest on outcome among patients with severe thoracic cage trauma. Int Surg 2002; 87
Ciraulo DL, Elliott D, Mitchell KA, Rodriguez A. Flail chest as a marker for significant injuries. J Am Coll Surg 1994; 178
Waqar SH, Nasir K, Zahid MA. Thoracic epidural analgesia versus intravenous opioid analgesia for the treatment of rib fracture pain. Int J Collab Res Intern Med Public Health 2013; 5
Pierre EJ, Martin P, Frohock JM, Vron AJ, Barquist E. Lumbar epidural morphine versus patient-controlled analgesia morphine in patients with multiple rib fractures. Anesthesiology 2005; 103
Bulger E, Edwards T, Klotz P, Jurkovich G. Epidural analgesia improves outcome after multiple rib fractures. Surgery 2004; 136
Moon M, Luchette F, Gibson S, Crews J, Sudarshan G, Hurst JM, et al.
Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic. Ann Surg 1999; 229
[Table 1], [Table 2], [Table 3]