Comparative Effectiveness of Continuous Thoracic Paravertebral Blocks Versus Thoracic Epidural and Continuous Intercostal Blocks Versus Patient-Controlled Anesthesia in Traumatic Rib Fracture Patients

Rib fractures are the most common injury sustained following blunt trauma. Ziegler and Agarwal noted that in a population of more than 7000 trauma patients, 10% had fractured ribs. These injuries are normally the hallmark of significant chest trauma; and as the number of fractured ribs increases, there is an exponential increase in morbidity and mortality.

This injury therefore poses a challenging problem from both pulmonary and analgesia standpoints. Significant morbidity is often the result of hypoventilation leading to atelectasis, pneumonia, and respiratory failure. Pain management has been recognized as an important factor in preventing these complications.

Good analgesia may help to improve a patient's respiratory mechanics, leading to a decreased need for mechanical ventilatory support, a shortened hospital stay, and can dramatically alter the course of recovery impacting both morbidity and mortality.

For healthy patients with one to two fractured ribs, systemic analgesics may suffice. For more than three to four fractured ribs, studies and experience have reaffirmed the superior analgesia made possible with continuous thoracic epidural, continuous thoracic paravertebral, and continuous intercostal block, however, a comparative head to head trial comparing the relative merits and disadvantages of each technique has not been undertaken in multiple rib fracture patients. Placing a catheter, which is possible with the use of all three techniques, allows the continuation of analgesia for multiple days with just one block, which is an essential option when treating patients that are likely to need extended analgesia.

All options are not available for all patients, however, as the current American Society of Regional Anesthesiology advises against the performance of epidural or paravertebral blocks in patients with abnormal INR (at the BWH, equal or above 1.2, and/or treatment with other anticoagulants such gpIIb/IIIa inhibitors (heparin and heparin-like medications are usually acceptable within certain dosing time frames).