Indications and contraindications for thoracic epidural analgesia in multiply injured patients
Introduction
Rib fractures have been associated with significant morbidity and mortality following traumatic injury. The presence of three or more rib fractures has been associated with increased mortality and duration of ICU and hospital care [1], [2]. A recent analysis of the National Trauma Databank demonstrated a significant increase in mortality and pulmonary morbidity for each additional rib fracture [3]. The elderly are particularly susceptible to complications of rib fractures with nosocomial pneumonia rates reported as high as 31% [4]. The pain associated with rib fractures leads to impaired ventilatory function and thus increases pulmonary morbidity. Management of these patients is therefore focused on achieving adequate analgesia and clearance of pulmonary secretions. Previous studies have demonstrated that epidural analgesia provides superior pain relief, improved pulmonary function tests, reduced the risk of developing nosocomial pneumonia and led to a shorter duration of mechanical ventilation compared to intravenous opioids [5], [6], [7], [8], [9]. Despite these advantages only 2% of patients with rib fractures in the National Trauma Databank received epidural analgesia [3]. This may be due in large part to controversy regarding the indications and contraindications for the use of epidural analgesia in patients with multiple injuries. We sought to define the current practice in the United States by surveying pain service directors at Level 1 trauma centers regarding their current guidelines for the use of epidural analgesia in this patient population and to assess the level of agreement regarding indications and contraindications for its use.
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Methods
A list of all Level 1 trauma centers in the United States was obtained from the American College of Surgeons Committee on Trauma. A written survey was sent to the pain service directors at all centers in September of 2004. Respondents were asked whether epidural analgesia was used for the management of pain following rib fractures and if so were there established institutional guidelines regarding the indications and contraindications for its use. They were asked to consider seven potential
Results
Responses were received from 81/188 (43%) of US Level 1 trauma centers. Seventy-seven of the centers indicated that epidural analgesia is used at their institution for management of pain after rib fractures (95%). Twelve centers (15%) reported that they had developed institutional guidelines regarding the indications and contraindications for the use of epidural analgesia in this patient population. As illustrated in Table 1, there was general agreement regarding the indications for the use of
Discussion
The use of epidural analgesia in the multiply injured patient with rib fractures is limited by several potential contraindications to the placement of an epidural catheter. The risks of catheter placement must be weighed against the benefits from improved pain control and the reduction in pulmonary morbidity reported in recent studies [5], [6], [7], [8], [9], [10]. The contraindications for thoracic epidural placement relate to the major complications that have been reported in association with
Conflict of interest statement
There is no conflict of interest.
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