Background: Traumatic rib fractures put patients at risk for respiratory complications in the form of pneumonia, respiratory failure, and increased mortality. Patients with increased number of rib fractures, flail segments, and bilateral rib fractures are at higher likelihood of respiratory complications. Patients with concurrent injuries, elderly, and other significant preexisting comorbidities are also at elevated risk of respiratory complications and elevated mortality risk. Mechanistically regional analgesic therapy specifically targets the sites of pain and is superior to oral or intravenous analgesics.
Intervention:
• Insertion of Erector Spinae Plane (ESP) catheter, serratus anterior catheter, Paravertebral Catheter, or Thoracic Epidural Catheter for management of rib fracture/chest tube pain
Indications:
• Inability to perform deep inspiration due to pain
• Moderate to severe pain with deep respiration
• Inability to generate at least moderate effort cough to clear secretions
**Regional analgesia will NOT prevent patients from impending respiratory failure. Regional analgesia may be deferred to a later time, i.e. days 3-5 after fracture when pain is expected to peak, or closer to the time of extubation.
Standard of care:
• ESP catheter insertion should be the default regional analgesic technique due to ease and limited contraindications
o Patients can be fully anticoagulated with ESP/serratus anterior catheters in situ
• Single bolus of 20cc of solution via ESP catheter is expected to cover ~5 rib levels
• Consider insertion of two ESP catheters if >8 unilateral rib levels involved. If only one ESP catheter is to be inserted in the setting of >5 unilateral rib levels involved, consider insertion of catheter to cover middle (T4-8) to lower (9-12) ribs due to the relatively increased pain caused by excursion of the chest wall from respiratory mechanics
• Consider thoracic epidural when bilateral rib fractures are present (MUST follow ASRA or institutional anticoagulation guidelines)
Absolute contraindications:
• Patient refusal
• Infection at site of injection
**Anticoagulation may be a relative contraindication to ESP block - no specific guidelines. ASRA 2018 consensus statement does not specifically address paraspinal blocks and anticoagulation. The ESP block should be considered as a peripheral nerve block as it is a compressible space.
Catheter orders:
• ESP catheter infusion: ropivacaine 0.2% 2cc/hr, bolus 15cc q2h, no PCRA function
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