Question 26

A 78 year old female is admitted to the ICU following a motor vehicle collision. She has sustained multiple left sided rib fractures, pulmonary contusion and has severe pain.

Outline the relative advantages and disadvantages of thoracic epidural analgesia compared to systemic opioid analgesia via a PCA (Patient Controlled Analgesia) for her pain management.

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College Answer

	Thoracic epidural	Systemic opiates via PCA
Advantages	• Can provide excellent analgesia • Avoidance of sedation • Less delirium • Less risk of respiratory depression • If local anaesthetic used alone, possible to avoid opiate side effects • Lower incidence of DVT	• Staff very familiar with use • Can provide good analgesia • Less problem with hypotension • Safe • Could be used in any ICU
Disadvantages	• Requires skill for placement • Not always effective (can get patchy block) • Hypotension may require excessive fluid administration or pressor support • May mask other associated injuries, e.g. ruptured spleen in this case • Risk of epidural haematoma • If opiate used in epidural infusion, opiate side effects such as itch, nausea, still a problem.	• Increasing age associated with increasing adverse effects from opiates, especially bowel dysfunction, nausea, drowiness • Delirium a major potential problem in this patient • Respiratory depression a potential problem, particularly if background infusion utilised • Potential for drug interactions

Discussion

The college table is well organised, and little can be added to it, other than some literature references. In summary, a couple of biggish meta-analysis papers from 2009 both discovered the following key features:

There was no mortality difference
There was no ICU length of stay difference
There was no hospital length of stay difference
Epidural was associated with more hypotension
PCA was associated with more pneumonia
Pain control was better with epidural.

Thus:

Comparison of PCA and Epidural in Management of Multiple Rib Fractures
	Thoracic epidural	Systemic opiates via PCA
Advantages	Analgesia is better than with PCA Better MIP (maximum inspiratory pressure) than with PCA Overall improved respiratory function More rapid weaning from ventilator • Avoidance of sedation • Less delirium • Less risk of respiratory depression • If local anaesthetic used alone, possible to avoid opiate side effects • Lower incidence of DVT	Equivalent to epidural in terms of ICU length of stay and hospital length of stay Staff very familiar with use • Can provide good analgesia • Less problem with hypotension • Safe • Could be used in any ICU
Disadvantages	No mortality benefit No ICU length of stay reduction, or in hospital stay for that matter (in fact, a trend towards slightly longer hospital stay) Requires skill for placement Not always effective (can get patchy block) Hypotension may require excessive fluid administration or pressor support May mask other associated injuries, e.g. ruptured spleen in this case Risk of epidural haematoma If opiate used in epidural infusion, opiate side effects such as itch, nausea, still a problem.	• Increasing age associated with increasing adverse effects from opiates, especially bowel dysfunction, nausea, drowiness • Delirium a major potential problem in this patient • Respiratory depression a potential problem, particularly if background infusion utilised • Potential for drug interactions

References

Wu, Christopher L., et al. "Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash." Journal of Trauma-Injury, Infection, and Critical Care 47.3 (1999): 564-567.

MACKERSIE, ROBERT C., et al. "Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures." Journal of Trauma-Injury, Infection, and Critical Care 31.4 (1991): 443-451.

Kieninger, Alicia N., et al. "Epidural versus intravenous pain control in elderly patients with rib fractures." The American journal of surgery 189.3 (2005): 327-330.

Moon, M. Ryan, et al. "Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma." Annals of surgery 229.5 (1999): 684.

Jarvis, Amy M., et al. "Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis." OPUS 12 (2009): 50-57.

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