Thoracic Epidural Analgesia for Chest Trauma

OVERVIEW

• rib fractures are associated with significant morbidity, especially in the elderly and especially if multiple fractures are present.
• apart from being humane, optimal analgesia may help prevent respiratory deterioration

PROS AND CONS OF TEA VERSUS OPIOID PCA

CONSIDERATIONS FOR TEA

•  other injuries need to be accounted for that may have implications (spinal injuries, intra-abdominal injury – though abdo pain from intra-abdo injury not likely to be totally masked by epidural local anaesthetic)
•  coagulopathy is a contraindication
•  epidural local anaesthetic / opiate combination at thoracic level likely to be associated with hypotension / bradycardia, needing volume and likely inotropic support
•  consideration for infusion vrs bolus vrs PCEA
•  other epidural analgesics – opiate alone eg fentanyl, pethidine or epidural clonidine – doses and frequency need consideration
• consider whether paravertebral is more appropriate

COMPLICATIONS OF TEA

•  hypotension, bradycardia
•  masking of other injuries and evolving neurological signs
•  inadequate analgesia due to limited / patchy block
•  increased pain in unblocked areas (relative phenomenon esp with bony injury eg shoulder
• short duration of blockade possible (usually removed at 3 days – then what?)
•  epidural haematoma or abscess
•  – drug side effects eg pruritis, nausea, respiratory depression
•  – hypotension on mobilisation
•  – respiratory muscle weakness

EVIDENCE

For thoracic epidural anesthesia/ analgesia:

• TEA for open abdominal aortic surgery reduces the duration of tracheal intubation and mechanical ventilation, as well as the incidence of MI, acute respiratory failure, GI complications and renal insufficiency (Level 1)
• High TEA used for CABG reduces  postoperative pain, risk of dysrhythmias, pulmonary complications and time to extubation when compared with IV opioid analgesia (Level 1)
• Epidural local anaesthetics improve oxygenation and reduce pulmonary infections and other pulmonary complications compared with parenteral opioids (Level I)
• TEA improves bowel recovery after abdominal surgery (including colorectal surgery Level I).
• TEA extended for more than 24 hours reduces the incidence of  postoperative MI (Level I)
• TEA reduces need for ventilation in patients with multiple rib fractures  (Level I) and reduces incidence of pneumonia (Level II)
• Compared with TEA, continuous thoracic paravertebral analgesia results in comparable analgesia but has a better side effect profile (less urinary retention,  hypotension, nausea, and vomiting) than epidural analgesia and leads to a lower incidence of postoperative pulmonary complications (Level I)

VIDEO

Thoracic epidural anesthesia by the ERS:

https://www.youtube.com/watch?v=4LG-XacV1WA

References and Links

• Acute pain management (ANZCA guideline 2010)
• Clemente A, Carli F. The physiological effects of thoracic epidural anesthesia and analgesia on the cardiovascular, respiratory and gastrointestinal systems. Minerva Anestesiol. 2008 Oct;74(10):549-63. PMID: 18854796.
• Freise H, Van Aken HK. Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth. 2011 Dec;107(6):859-68. PMID: 22058144.
• Manion SC, Brennan TJ. Thoracic epidural analgesia and acute pain management. Anesthesiology. 2011 Jul;115(1):181-8. PMID: 21606825.
• Parris R. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Epidural analgesia/anaesthesia versus systemic intravenous opioid analgesia in the management of blunt thoracic trauma. Emerg Med J. 2007 Dec;24(12):848-9. PMC2658360.
• Scarci M, Joshi A, Attia R. In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management? Interact Cardiovasc Thorac Surg. 2010 Jan;10(1):92-6. PMID: 19854794.