A Retrospective Review of Rib Fracture Pain Management at a London Major Trauma Centre

Study Overview
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Brief Summary
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Thoracic epidural analgesia (TEA) is widely considered to be the current gold standard treatment for rib fracture pain and is used in the Imperial invasive treatment pathway for rib fractures. However, TEA are often contraindicated due to other injuries or the use of anticoagulant medications, which also contraindicates other invasive nerve block techniques e.g. paravertebral catheters. A number of case reports have reported the safe use of alternative techniques such as Serratus Anterior Blocks (SAPB) and Erector Spinae Blocks (ESPB) and the anaesthesia community has taken them up widely based on this relatively limited evidence. In view of this, Womack et al recently published a large retrospective review examining the safety and efficacy of ultrasound guided paravertebral catheter analgesia techniques in rib fracture management along with small numbers of ESPBs. However, this data did not report the analgesic efficacy, patient reported pain relief or respiratory complications.The goal is to advance this body of evidence by reviewing our larger data set concerning the use of TEA and alternative regional techniques such as ESPB and SAPB. This comprehensive review will benefit patients by documenting the efficacy and safety of these techniques for clinicians managing rib fracture patients.

Detailed Description
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Primary Objective The primary objective is to examine whether novel fascial plane blocks, e.g. SAPB and ESPB, are effective pain relief modalities in patients with rib fractures - the proportion of patients with a reduction in pain. Secondary Objectives The investigators review the safety profile and complications of TEA and alternative analgesic techniques such as ESPB and SAPB used for rib fracture management in our trauma centre. In particular the effects of regional anaesthesia techniques on: Opioid use Nausea & vomiting Respiratory complications Intubation & non-invasive ventilation (NIV) ICU admission for respiratory complications The investigators will assess the duration of use and complication profile of regional anaesthetic techniques, including infection, analgesic failure and damage to other structures during insertion e.g. the lung.

Official Title
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A Retrospective Review of Rib Fracture Pain Management at a London Major Trauma Centre Comparing Erector Spinae Plane Blocks, Serratus Anterior Plane Blocks and Epidurals

Conditions
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Rib Fractures, Pain, Acute

Intervention / Treatment
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* Procedure: Regional Anaesthesia


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients aged > 18 years of age presenting with traumatic rib fractures in a major trauma centre over the past 5 years Meet the criteria for the Imperial College Healthcare NHS Trust 'Invasive rib fracture management pathway' Exclusion Criteria: Under 18 years old Prisoners Pregnant Private patients Meet the criteria for the Imperial College Healthcare NHS Trust 'Non-invasive rib fracture management pathway'

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Thoracic epidural for rib fracture management<br>Patients aged > 18 years of age presenting with traumatic rib fractures in a major trauma centre over the past 5 years that meet the criteria for the Imperial College Healthcare National Health Service (NHS) Trust 'Invasive rib fracture management pathway' | Procedure: Regional Anaesthesia<br>* Thoracic epidural/Erector Spinae block/Serratus Anterior block<br>|
| Erector Spinae block for rib fracture management<br>Patients aged > 18 years of age presenting with traumatic rib fractures in a major trauma centre over the past 5 years that meet the criteria for the Imperial College Healthcare NHS Trust 'Invasive rib fracture management pathway' | Procedure: Regional Anaesthesia<br>* Thoracic epidural/Erector Spinae block/Serratus Anterior block<br>|
| Serratus Anterior block for rib fracture management<br>Patients aged > 18 years of age presenting with traumatic rib fractures in a major trauma centre over the past 5 years that meet the criteria for the Imperial College Healthcare NHS Trust 'Invasive rib fracture management pathway' | Procedure: Regional Anaesthesia<br>* Thoracic epidural/Erector Spinae block/Serratus Anterior block<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The proportion of patients with a reduction in pain | The investigators will review pain scores as recorded by clinical staff over 72 hours to assess pain relief efficacy, A verbal rating scale classifying pain as mild, moderate or severe is used at Imperial Data from the acute pain round records will also provide details regarding breathing comfort levels of the patient, coughing ability and deep inspiratory effort. These are recorded as yes/no answers and the team will assess the proportion of patients showing a reduction in pain scores. | 72 hours | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Opioid Type | Data regarding type of opiate use | 72 hours | 
| Opioid mode of delivery | Mode of delivery of opioids | 72 hours | 
| Opioid use | Dosage requirement every 24 hours for a total of 72 hours | 72 hours | 
| Opioid complication(s) | Complications associated with opiates such as constipation, delirium and respiratory depression. | 72 hours | 
| Nausea and vomiting | The incidence of nausea and vomiting pre-chest wall block | Time zero | 
| NUmber of nausea and vomiting episodes | The incidence of nausea in the 72 hours post block will be recorded with the number of episodes | 72 hours post block | 
| Anti-emetic(s) used | The incidence of nausea in the 72 hours post block will be recorded with the number of anti-emetic medications required to treat. | 72 hours post block | 
| Lower respiratory tract infections | Lower Respiratory Tract Infection (LRTI): for this study is defined as patients showing clinical features of chest infection including pyrexia (temperature >37.5°C), an increase in oxygen requirements from baseline, radiological evidence of chest infection or antimicrobial treatment of an LRTI started by the treating team. | Length of stay up 8 weeks | 
| Respiratory complication(s) | Empyema/Parapneumonic effusions: defined as radiological evidence of fluid collections within the pleural space and therapeutic interventions required for treatment e.g. aspiration and drainage. | Length of stay up to 8 weeks | 
| Intensive care admission for respiratory complications | ICU admission for respiratory complications | Length of stay up to 8 weeks | 
| Intensive care admission | Number of patients requiring intubation and ventilation | Length of stay up to 8 weeks | 
| Intensive care mechanical ventilation | Number of days of mechanical ventilation | Length of stay up to 8 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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epidural, erector spinae block, serratus anterior block