Indications and contraindications for thoracic epidural analgesia in multiply injured patients

Bulger, Eileen M.; Edwards, William T.; de Pinto, Mario; Klotz, Patricia; Jurkovich, Gregory J.

doi:10.1016/j.acpain.2007.10.019

« Previous Next »Acute Pain
Volume 10, Issue 1 , Pages 15-22, March 2008

Indications and contraindications for thoracic epidural analgesia in multiply injured patients

Presented at the American Society Regional Anesthesia and Pain Medicine, 2005 (poster)

Eileen M. Bulger
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
- Corresponding author at: Department of Surgery, Box 359796, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104, USA. Tel.: +1 206 731 6448; fax: +1 206 731 3656.
William T. Edwards
- Department of Anesthesiology, University of Washington, Harborview Medical Center, Seattle, WA, USA
Mario de Pinto
- Department of Anesthesiology, University of Washington, Harborview Medical Center, Seattle, WA, USA
Patricia Klotz
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
Gregory J. Jurkovich
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA

Received 21 July 2007; received in revised form 17 October 2007; accepted 21 October 2007.

Summary

Background and objectives

Rib fractures are associated with significant morbidity and mortality. Previous studies have demonstrated a significant reduction in pneumonia and duration of mechanical ventilation with epidural analgesia (EA) following multiple rib fractures. There remains controversy regarding the appropriate indications and contraindications for EA in multiply injured patients. We sought to determine the factors underlying the decision to use or not to use EA in these patients.

Methods

A survey was sent to the directors of pain management services at all American College of Surgeons Committee on Trauma (ACS-COT) designated Level I trauma centers in the U.S. The survey queried their opinion regarding the appropriateness of 33 contraindications and eight indications for EA after rib fractures.

Results

The response rate was 43% (81/188). Ninety-five percent of responding centers indicated that EA is used after rib fractures, but only 15% had guidelines defining the indications and contraindications. There was general agreement (>80%) regarding the indications for EA but disagreement regarding the contraindications. Contraindications were categorised based on the degree of agreement of respondents. The areas of greatest controversy involved minor spine injuries and minor coagulopathy.

Conclusions

There is wide variability regarding contraindications employed for thoracic epidural analgesia following rib fractures. These data support the need for evidenced based guidelines to define the use of EA in the multiply injured patient.

Keywords: Rib fractures, Epidural analgesia, Pain control