Analysing the Role and Trends of Neuraxial Analgesia in Patients With Rib Fractures With Low ISS Scores
Victoria Valdes1, Piyush Gupta2, Ruben Valera3, Eric Benoit2, Bedabrata Sarkar2
1Surgery, Lahey Hospital, Burlington, Massachusetts, United States, 2General Surgery, Lahey Clinic Hospital, Burlington, Massachusetts, United States, 3General Surgery, Tufts Medical School, Boston, Massachusetts, United States
Introduction: - It has been reported that elderly patients who sustain blunt chest trauma with rib fractures have twice the mortality and thoracic morbidity of younger patients with similar injuries. However recent studies have shown better outcomes than these previously reported ones though the exact improvement in the survival is yet unknown. This study aims to identify the current trends in morbidity and mortality in patients with rib fractures, role of neuraxial anesthesia in improving outcomes and identify factors associated with increased LOS and need for discharge to skilled nursing facilities.
Methods: A retrospective analysis was performed from a level 1 trauma center trauma quality improvement database to identify patients with rib fractures with ISS score < 16 who were admitted to the hospital. The patients were identified from 2010 to 2022. Patient demographics, trauma characteristics, initial admission disposition, use of multimodal pain therapy with or without neuraxial analgesia was identified. The primary outcomes analyzed were median morphine equivalents delivered (MMED) during the hospital stay, length of stay, discharge disposition and survival at 90 days from hospital admission. Multivariate analysis was performed to identify factors associated with discharge disposition (Home vs Skilled Nursing Facility) and 90 day survival.
Results:2131 patients were analyzed. The mean age group was 69 years (IQR 37 - 84 years) with 44% of patients > 75 years of age. We had a steady increase in number of admitted patients over the last 12 years with an average of 175 patients per year (Range 107-265 patients/year). The mean ISS was 9 with a SD of 3.4. 7% of patients were admitted to the ICU and 21% patients were admitted to the progressive care unit. 6% of patients had neuraxial analgesia placed rest received multimodal pain therapy only. The neuraxial anesthesia usage has increased significantly over the last 5 years (109/124 (85%) from 2017-2022). Of the two groups patients with multimodal pain therapy only and the one with epidural anesthesia the mean LOS was 5 days compared to 9 days respectively (p value < 0.001) and the difference persisted even when controlling for the initial ISS score. The MMED for multimodal pain therapy was 300 morphine equivalent units compared to 140 in patients with neuraxial analgesia. 39% of patients on multimodal therapy were discharged to skilled nursing facilities compared to 32% with neuraxial anesthesia (p < 0.001). 0.15% patients died at 90 days within the multimodal pain control group with no mortality in the neuraxial group. Patients with age > 75, Functionally dependent status prior to injury and use of multimodal therapy only was co-related with need for SNF at the time of discharge
Conclusion: On controlling for age, ISS, comorbidity index patients with neuraxial analgesia had lower MMED, higher LOS in the hospital, lower mortality and increased chance of discharge to home.
Comparison of Multimodal Therapy only with Neuraxial Analgesia for Management of Rib Fractures
| Multinodal Therapy vs Neuraxial Analgesia | Univariate Analysis | Multivariate Analysis | ||
| Variables | OR | P Value | OR | P Value |
| MMED | 0.6 | 0.001 | 0.3 | 0.001 |
| LOS | 3.2 | 0.001 | 2.1 | 0.001 |
| Mortality - 90 day | 0.4 | 0.001 | 0.4 | 0.001 |
| Discharge to SNF | 0.8 | 0.001 | 0.9 | 0.015 |
MMED - Median Morphine equivalent delivered, LOS - Length of stay, SNF - Skilled nursing facility
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