Research Article| Volume 43, ISSUE 10, P1667-1671, October 2012

Download started.


Epidural analgesia for blunt thoracic injury—Which patients benefit most?



      Epidural analgesia for blunt thoracic injury has been demonstrated to be beneficial for pulmonary function, analgesia, and subjective pain; however the optimal patient selection and timing of thoracic epidural placement have not been well studied. We hypothesised that early (<48 h) epidural analgesia (EA) as compared with usual care involving oral and intravenous narcotics delivered by patient-controlled analgesia (PCA) in patients with blunt thoracic trauma (>3 ribs fractured) is associated with fewer pulmonary complications and lower resource utilisation as measured by ICU and hospital length of stay.


      This is a retrospective review of all non-intubated patients suffering from blunt thoracic injury with 3 or more rib fractures requiring hospital admission for >24 h over a recent 5-year period. Pulmonary complications were defined as pneumonia, empyema, hypoxia, and need for delayed intubation. Logistic regression was utilised to analyse patient and injury characteristics associated with pulmonary complications.


      187 patients were included in the analysis; early thoracic epidural was utilised in 18% (n = 34). There was no difference in age, ISS, ICU length of stay (LOS), or pulmonary complications between patients who received an epidural (EPI) compared with those who did not (NO EPI). A significantly increased incidence of pulmonary complications was noted in patients who required tube thoracostomy (p = 0.017).


      In our experience, insertion of a thoracic epidural catheter early post-injury failed to reduce the incidence of pulmonary complications, ICU and hospital LOS. However, since pulmonary complications are more frequent in patients requiring tube thoracostomy, the cost-effectiveness of epidural analgesia in these patients warrants further investigation.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ziegler D.
        • Agarwal N.
        The morbidity and mortality of rib fractures.
        Journal of Trauma. 1994; 37: 975-979
        • Bulger E.
        • Arneson M.
        • Mock C.
        • Jurkovich G.
        Rib fractures in the elderly.
        Journal of Trauma. 2000; 48: 1040-1047
        • Holcomb J.B.
        • McMullin N.R.
        • Kozar R.A.
        • Lygas M.H.
        • Moore F.A.
        Morbidity from rib fractures increases after age 45.
        Journal of the American College of Surgeons. 2003; 196: 549-555
        • Lee R.B.
        • Morris J.A.
        • Parker R.A.
        Presence of three or more rib fracturs as an indicator of need for interhospital transfer.
        Journal of Trauma. 1989; 29: 795-800
        • Shorr R.M.
        • Rodriguez A.
        • Indeck M.C.
        • Crittenden M.D.
        • Hartunian S.
        • Cowley R.A.
        Blunt chest trauma in the elderly.
        Journal of Trauma. 1989; 29: 234-237
        • Lee R.B.
        • Bass S.M.
        • Morris J.A.
        • MacKenzie E.J.
        Three or more rib fractures as an indicator for transfer to a level 1 trauma center: a population-based study.
        Journal of Trauma. 1990; 30: 689-694
        • Stawicki S.
        • Grossman M.D.
        • Hoey B.A.
        • Miller D.L.
        • Reed J.F.
        Rib fractures in the elderly: a marker of injury severity.
        Journal of the American Geriatrics Society. 2004; 52: 805-808
        • Sirmali M.
        • Turut H.
        • Topcu S.
        • Gulhan E.
        • Yazici U.
        • Kaya S.
        • et al.
        A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management.
        European Journal of Cardio-Thoracic Surgery. 2003; 24: 133-138
        • Flagel B.T.
        • Luchette F.A.
        • Reed L.
        • Esposito T.J.
        • Davis F.A.
        • Santaniello J.M.
        • et al.
        Half-a-dozen ribs: the breakpoint for mortality.
        Surgery. 2005; 138: 717-723
        • Bergeron E.
        • Lavoie A.
        • Clas D.
        • Moore L.
        • Ratte S.
        • Tetreault T.
        • et al.
        Elderly trauma patients with rib fractures are at greater risk of death and pneumonia.
        Journal of Trauma. 2003; 54: 478-485
        • Brasel K.J.
        • Guse C.E.
        • Layde P.
        • Weigelt J.A.
        Rib fractures: relationship with pneumonia and mortality.
        Critical Care Medicine. 2006; 34: 1642-1646
        • Karmakar M.K.
        Thoracic paravertebral block.
        Anesthesiology. 2001; 95: 771-780
        • Karmakar M.K.
        • Critchley L.
        • Ho A.M.
        • Gin T.
        • Lee T.W.
        • Tim A.P.
        Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs.
        Chest. 2003; 123: 424-431
        • Mohta M.
        • Verma P.
        • Saxena A.K.
        • Sethi A.K.
        • Tyagi A.
        • Girota G.
        Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with nilateral multiple fractured ribs – a pilot study.
        Journal of Trauma. 2009; 66: 1096-1101
        • Asantila R.
        • Rosenberg P.H.
        • Scheinin B.
        Comparison of diffrent methods of postoperative analgesia after thoracotomy.
        Acta Anaesthesiologica Scandinavica. 1986; 30: 421-425
        • Logas W.G.
        • El-Baz N.
        • El-Ganzouri A.
        • Cullen M.
        • Staren E.
        • Faber P.
        • et al.
        Continuous thoracic epidural analgesia for postoperative pain relief following thoracotomy: a randomized prospective study.
        Anesthesiology. 1987; 67: 787-791
        • Zwarts S.J.
        • Hasenbros M.A.
        • Gielen M.
        • Kho H.
        The effect of continuous epidural analgesia with sufentanil and bupivacaine during and after thoracic surgery on the plasma cortisol concentration and pain relief.
        Regional Anesthesia. 1989; 14: 183-188
        • Shulman M.
        • Sandler A.N.
        • Bradley J.W.
        • Young P.S.
        • Brebner J.
        Postthoracotomy pain and pulmonary function following epidural and systemic morphine.
        Anesthesiology. 1984; 61: 569-575
        • Torda T.A.
        • Pybus D.A.
        Extradural administration of morphine and bupivacaine: a controlled.
        British Journal of Anaesthesia. 1984; 56: 141-146
        • Bromage P.R.
        • Camporesi E.
        • Chestnut D.
        Epidural narcotics for postoperative analgesia.
        Anesthesia and Analgesia. 1980; 59: 473-480
        • Wu C.L.
        • Jani N.D.
        • Perkins F.M.
        • Barquist E.
        Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash.
        Journal of Trauma. 1999; 47: 564-567
        • Wisner D.
        A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: effect of epidural analgesia.
        Journal of Trauma. 1990; 30: 799-805
        • Mackersie R.C.
        • Karagianes T.G.
        • Hoyt D.B.
        • Davis J.W.
        Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures.
        Journal of Trauma. 1991; 31: 443-451
        • Bulger E.
        • Edwards T.
        • Klotz P.
        • Jurkovich G.J.
        Epidural analgesia improves outcome after multiple rib fractures.
        Surgery. 2004; 136: 426-430
        • Ullman D.A.
        • Wimpy R.E.
        • Fortune J.B.
        • Kennedy T.M.
        • Greenhouse B.B.
        The treatment of patients with multiple rib fractures using continuous thoracic epidural narcotic infusion.
        Regional Anesthesia. 1989; 14: 43-47
        • Moon M.R.
        • Luchette F.A.
        • Gibson S.W.
        • Crews J.
        • Sudarshan G.
        • Hurst J.M.
        • et al.
        Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic.
        Annals of Surgery. 1999; 229: 684-692
        • Todd S.R.
        • McNally M.M.
        • Holcomb J.B.
        • Kozar R.A.
        • Kao L.S.
        • Gonzalez E.A.
        • et al.
        A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients.
        American Journal of Surgery. 2006; 192: 806-811
        • Traub M.
        • Stevenson M.
        • McEvoy S.
        • Briggs G.
        • Lo S.K.
        • Leibman S.
        • et al.
        The use of chest computed tomography versus chest X-ray in patients with major blunt trauma.
        Injury. 2007; 38: 43-47
        • Kieninger A.N.
        • Bair H.A.
        • Bendick P.J.
        • Howells G.A.
        Epidural versus intravenous pain control in elderly patients with rib fractures.
        American Journal of Surgery. 2005; 189: 327-330
        • Carrier F.M.
        • Turgeon A.F.
        • Nicole P.C.
        • Trepanier C.A.
        • Fergusson D.A.
        • Thauvette D.
        • et al.
        Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials.
        Canadian Journal of Anaesthesia. 2009; 56: 230-242
        • Bakhos C.
        • O’Connor J.
        • Kyriakides T.
        • Abou-Nukta F.
        • Bonadies J.
        Vital capacity as a predictor of outcome in elderly patients with rib fractures.
        Journal of Trauma. 2006; 61: 131-134
        • Bulger E.M.
        • Edwards W.T.
        • de Pinto M.
        • Klotz P.
        • Jurkovich G.J.
        Indications and contraindications for thoracic epidural analgesia in multiply injured patients.
        Acute Pain. 2008; 10: 15-22
        • Auroy Y.
        • Narchi P.
        • Messiah A.
        • Litt L.
        • Rouvier B.
        • Samii K.
        Serious complications related to regional anesthesia – results of a prospective survey in France.
        Anesthesiology. 1997; 87: 479-486
        • Rigg J.R.
        • Jamrozik K.
        • Myles P.S.
        • Silbert B.S.
        • Peyton P.J.
        • Parsons R.W.
        • et al.
        Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial.
        Lancet. 2002; 359: 1276-1282