Epidural analgesia for traumatic rib fractures is associated with worse outcomes: a matched analysis

Katherine M McKendy; Lawrence F Lee; Kerianne Boulva; Dan L Deckelbaum; David S Mulder; Tarek S Razek; Jeremy R Grushka

doi:10.1016/j.jss.2017.02.057

Epidural analgesia for traumatic rib fractures is associated with worse outcomes: a matched analysis

J Surg Res. 2017 Jun 15:214:117-123. doi: 10.1016/j.jss.2017.02.057. Epub 2017 Mar 6.

Authors

Katherine M McKendy¹, Lawrence F Lee¹, Kerianne Boulva¹, Dan L Deckelbaum¹, David S Mulder², Tarek S Razek¹, Jeremy R Grushka³

Affiliations

¹ Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
² Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
³ Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada. Electronic address: jeremy.grushka@mcgill.ca.

PMID: 28624032
DOI: 10.1016/j.jss.2017.02.057

Abstract

Background: The optimal method of pain control for patients with traumatic rib fractures is unknown. The aim of this study was to determine the effect of epidural analgesia on respiratory complications and in-hospital mortality in patients with rib fractures.

Methods: Adult patients at a level I trauma center with ≥1 rib fracture from blunt trauma were included (2004-2013). Those with a blunt-penetrating mechanism, traumatic brain injury, or underwent a laparotomy or thoracotomy were excluded. Patients who were treated with epidural analgesia (EPI) were compared with those were not treated with epidural analgesia (NEPI) using coarsened exact matching. Primary outcomes were respiratory complications (pneumonia, deep vein thrombosis/pulmonary embolus, and respiratory failure) and 30-d in-hospital mortality. Secondary outcomes were total hospital and intensive care unit length of stay, and duration of ventilator support.

Results: About 1360 patients (EPI: 329 and NEPI: 1031) met inclusion criteria (mean age: 54.2 y; standard deviation [SD]: 19.7; 68% male). The mean number of rib fractures was 4.8 (SD: 3.3; 21% bilateral) with a high total burden of injury (mean Injury Severity Score: 19.9 [SD: 8.9]). The overall incidence of respiratory complications was 13% and mortality was 4%. After matching, 204 EPI patients were compared with 204 NEPI patients, with no differences in baseline characteristics. EPI patients experienced more respiratory complications (19% versus 10%, P = 0.009), but no differences in 30-d mortality (5% versus 2%, P = 0.159), duration of mechanical ventilation (EPI: 148 h [SD: 167] versus NEPI: 117 h [SD: 187], P = 0.434), or duration of intensive care unit length of stay (6.5 d [SD: 7.6] versus 5.8 d [SD: 9.1], P = 0.626). Hospital stay was higher in the EPI group (16.6 d [SD: 19.6] vs 12.7 d [SD: 15.2], P = 0.026).

Conclusions: Epidural analgesia is associated with increased respiratory complications without providing mortality benefit after traumatic rib fractures. Alternate analgesic strategies should be investigated to treat these severely injured patients.

Keywords: Analgesia; Epidural; Respiratory complications; Rib fractures; Trauma.

Publication types

Observational Study

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Analgesia, Epidural / adverse effects*
Databases, Factual
Female
Hospital Mortality*
Humans
Incidence
Male
Matched-Pair Analysis
Middle Aged
Respiratory Tract Diseases / epidemiology
Respiratory Tract Diseases / etiology*
Rib Fractures / complications
Rib Fractures / mortality
Rib Fractures / therapy*
Treatment Outcome
Wounds, Nonpenetrating / complications
Wounds, Nonpenetrating / mortality
Wounds, Nonpenetrating / therapy*
Young Adult