Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis
Amy M. Jarvis, Charles H. Cook, David E. Lindsey, Thomas E. Reilley, Steven M. Steinberg, Paul R. Beery II, Melissa L. Whitmill, Thomas J. Papadimos, S. Peter Stawicki
Abstract
Introduction. Pain secondary to traumatic rib fractures (RFs) can be associated with serious adverse sequelae such as respiratory failure and pneumonia. The use of epidural analgesia for traumatic RFs continues to be controversial, especially since outcomes in published studies are variable and many reports lack the statistical power needed to detect differences in important outcome-related parameters. Our main objective was to determine benefits of epidural (epid) versus intravenous/intramuscular (iv/im) analgesia for traumatic RFs by performing a meta-analysis of published clinical studies on this topic.
Methods. A literature search identified eight studies comparing epid versus iv/im analgesia in the setting of post-traumatic RFs. Parameters examined included demographics (patient age and gender), physiologic scoring (APACHE II) and injury characteristics (Injury severity score – ISS, AIS chest, number of RFs, presence of chest tube, presence of pulmonary contusions). Outcome parameters included mortality, pulmonary status dynamics (change in tidal volume during the initial 24 hours of therapy and duration of mechanical ventilatory support), morbidity (pulmonary complications, cardiac complications), and resource-related variables (ICU/hospital lengths of stay). Univariate meta-analyses were performed with statistical significance set at α = 0.05 (2-tailed).
Results. Eight studies were analyzed, with a total of 217 patients in the epid and 432 in iv/im analgesia groups. There were no significant differences in patient age, gender distribution, or the presence of chest tube between the studies. Patients in the epid group had greater overall injury severity, more RFs, and higher APACHE II scores. In meta-analyses, there were no significant differences between the epid and iv/im analgesia groups in terms of mortality, incidence of ARDS, ICU/hospital length of stay (all, p>0.05). The epid group spent significantly less time on the ventilator, had lower incidence of pneumonia/pulmonary complications, and demonstrated greater increase in tidal volumes during the first 24 hours of therapy.
Conclusions. This meta-analysis demonstrated that despite more RFs, greater injury severity and physiologic acuity among patients receiving epidural analgesia, the use of this therapy results in less time spent on mechanical ventilation, greater improvement in ventilatory tidal volumes during the first 24 hours of therapy, as well as lower incidence of pneumonia and pulmonary complications. Well-designed, multi-institutional prospective randomized trials are needed to further delineate the benefits of epid versus iv/im analgesia in patients with RFs.
Citation: Jarvis AM, Cook CH, Lindsey DE, Reilley TE, Steinberg SM, Beery II PR, Whitmill ML, Papadimos TJ, Stawicki SP. Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis. OPUS 12 Scientist 2009; 3(3):50-57.
Keywords: Comparison study, Epidural analgesia, Meta-analysis, Parenteral analgesia, Rib fractures, Traumatic injury.
Copyright 2007-2010 OPUS 12 Foundation, Inc.
Methods. A literature search identified eight studies comparing epid versus iv/im analgesia in the setting of post-traumatic RFs. Parameters examined included demographics (patient age and gender), physiologic scoring (APACHE II) and injury characteristics (Injury severity score – ISS, AIS chest, number of RFs, presence of chest tube, presence of pulmonary contusions). Outcome parameters included mortality, pulmonary status dynamics (change in tidal volume during the initial 24 hours of therapy and duration of mechanical ventilatory support), morbidity (pulmonary complications, cardiac complications), and resource-related variables (ICU/hospital lengths of stay). Univariate meta-analyses were performed with statistical significance set at α = 0.05 (2-tailed).
Results. Eight studies were analyzed, with a total of 217 patients in the epid and 432 in iv/im analgesia groups. There were no significant differences in patient age, gender distribution, or the presence of chest tube between the studies. Patients in the epid group had greater overall injury severity, more RFs, and higher APACHE II scores. In meta-analyses, there were no significant differences between the epid and iv/im analgesia groups in terms of mortality, incidence of ARDS, ICU/hospital length of stay (all, p>0.05). The epid group spent significantly less time on the ventilator, had lower incidence of pneumonia/pulmonary complications, and demonstrated greater increase in tidal volumes during the first 24 hours of therapy.
Conclusions. This meta-analysis demonstrated that despite more RFs, greater injury severity and physiologic acuity among patients receiving epidural analgesia, the use of this therapy results in less time spent on mechanical ventilation, greater improvement in ventilatory tidal volumes during the first 24 hours of therapy, as well as lower incidence of pneumonia and pulmonary complications. Well-designed, multi-institutional prospective randomized trials are needed to further delineate the benefits of epid versus iv/im analgesia in patients with RFs.
Citation: Jarvis AM, Cook CH, Lindsey DE, Reilley TE, Steinberg SM, Beery II PR, Whitmill ML, Papadimos TJ, Stawicki SP. Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis. OPUS 12 Scientist 2009; 3(3):50-57.
Keywords: Comparison study, Epidural analgesia, Meta-analysis, Parenteral analgesia, Rib fractures, Traumatic injury.
Copyright 2007-2010 OPUS 12 Foundation, Inc.
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