A Retrospective Review of Rib Fracture Pain Management at a London Major Trauma Centre

Completed

Brief Summary: Thoracic epidural analgesia (TEA) is widely considered to be the current gold standard treatment for rib fracture pain and is used in the Imperial invasive treatment pathway for rib fractures. However, TEA are often contraindicated due to other injuries or the use of anticoagulant medications, which also contraindicates other invasive nerve block techniques e.g. paravertebral catheters. A number of case reports have reported the safe use of alternative techniques such as Serratus Anterior Blocks (SAPB) and Erector Spinae Blocks (ESPB) and the anaesthesia community has taken them up widely based on this relatively limited evidence. In view of this, Womack et al recently published a large retrospective review examining the safety and efficacy of ultrasound guided paravertebral catheter analgesia techniques in rib fracture management along with small numbers of ESPBs. However, this data did not report the analgesic efficacy, patient reported pain relief or respiratory complications.The goal is to advance this body of evidence by reviewing our larger data set concerning the use of TEA and alternative regional techniques such as ESPB and SAPB. This comprehensive review will benefit patients by documenting the efficacy and safety of these techniques for clinicians managing rib fracture patients.

Detailed Description: Primary Objective The primary objective is to examine whether novel fascial plane blocks, e.g. SAPB and ESPB, are effective pain relief modalities in patients with rib fractures - the proportion of patients with a reduction in pain.

Secondary Objectives

The investigators review the safety profile and complications of TEA and alternative analgesic techniques such as ESPB and SAPB used for rib fracture management in our trauma centre. In particular the effects of regional anaesthesia techniques on:

1. Opioid use

2. Nausea \& vomiting

3. Respiratory complications

4. Intubation \& non-invasive ventilation (NIV)

5. ICU admission for respiratory complications

The investigators will assess the duration of use and complication profile of regional anaesthetic techniques, including infection, analgesic failure and damage to other structures during insertion e.g. the lung.

Recruitment & Eligibility

Inclusion Criteria

Patients aged > 18 years of age presenting with traumatic rib fractures in a major trauma centre over the past 5 years
Meet the criteria for the Imperial College Healthcare NHS Trust 'Invasive rib fracture management pathway'

Exclusion Criteria

Under 18 years old
Prisoners
Pregnant
Private patients
Meet the criteria for the Imperial College Healthcare NHS Trust 'Non-invasive rib fracture management pathway'

Arm && Interventions

Group	Intervention	Description
Thoracic epidural for rib fracture management	Regional Anaesthesia	Patients aged \> 18 years of age presenting with traumatic rib fractures in a major trauma centre over the past 5 years that meet the criteria for the Imperial College Healthcare National Health Service (NHS) Trust 'Invasive rib fracture management pathway'
Erector Spinae block for rib fracture management	Regional Anaesthesia	Patients aged \> 18 years of age presenting with traumatic rib fractures in a major trauma centre over the past 5 years that meet the criteria for the Imperial College Healthcare NHS Trust 'Invasive rib fracture management pathway'
Serratus Anterior block for rib fracture management	Regional Anaesthesia	Patients aged \> 18 years of age presenting with traumatic rib fractures in a major trauma centre over the past 5 years that meet the criteria for the Imperial College Healthcare NHS Trust 'Invasive rib fracture management pathway'

Primary Outcome Measures

Name	Time	Method
The Proportion of Patients With a Reduction in Pain	72 hours	The investigators will review pain scores as recorded by clinical staff over 72 hours to assess pain relief efficacy, A verbal rating scale classifying pain as mild, moderate or severe is used at Imperial Data from the acute pain round records will also provide details regarding breathing comfort levels of the patient, coughing ability and deep inspiratory effort. These are recorded as yes/no answers and the team will assess the proportion of patients showing a reduction in pain scores.

Secondary Outcome Measures

Name	Time	Method
Opioid Consumption (mg/24h)	72 hours	Data regarding type of opiate use
Nausea and Vomiting	72 hours post block	The incidence of nausea in the 72 hours post block will be recorded with the number of episodes in each patient
Number of Patients With Respiratory Complication(s)'	Length of stay up to 8 weeks	Lower respiratory tract infections: defined as raised CRP/ White Cell Count, new consolidation on CXR or antibiotics being started at clinician discretion. Empyema or parapneumonic effusions: defined as radiological evidence of fluid collections within the pleural space and therapeutic interventions required for treatment e.g. aspiration and drainage.
Intensive Care Admission	Length of stay up to 8 weeks in days	Number of patients requiring intubation and ventilation
Number of Days of Mechanical Ventilation	Length of stay up to 8 weeks in days	Number of days of mechanical ventilation for patients undergoing Intensive care mechanical ventilation

Locations (1): Imperiial Collge Healthcare NHS Trust
🇬🇧
London, United Kingdom