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.
Thoracic epidural |
Systemic opiates via PCA |
|
Advantages |
• Can provide excellent analgesia |
• Staff very familiar with use |
Disadvantages |
• Requires skill for placement |
• Increasing age associated with increasing adverse effects from opiates, especially bowel dysfunction, nausea, drowiness |
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:
Thus:
Thoracic epidural |
Systemic opiates via PCA |
|
Advantages |
|
Staff very familiar with use |
Disadvantages |
|
• Increasing age associated with increasing adverse effects from opiates, especially bowel dysfunction, nausea, drowiness |
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.