A 75-year-old male is admitted to your ICU for management of severe chest pain from unilateral rib fractures with a flail segment following major blunt chest trauma. He has no other injuries. He is haemodynamically stable with a respiratory rate of 30 breaths/min and oxygen saturation of 99% on room air.
Discuss the available options for analgesia, including their advantages and disadvantages.
Intravenous opioid PCA
IV ketamine infusion 4-16 mg/h
These have the advantages of simplicity and familiarity.
Disadvantages include lack of efficacy, and side effects of sedation, impaired cough, respiratory depression, and agitation or delirium.
Regional anaesthetic techniques
Analgesia is better than with PCA
Better MIP (maximum inspiratory pressure) than with PCA
Avoidance of sedation
Less risk of respiratory depression
Insertion requires expertise
Risk of failure
Risk of infection
Risk of epidural haematoma
Bradycardia in case of a high block
Intercostal nerve block
Simpler than epidural
May require multiple intercostal levels (risk of local anaesthetic toxicity)
Paravertebral catheter infusion
Less effective than epidural, but lower rate of systemic hypotension.
Patients can be discharged to home with a paravertebral catheter in place.
Relatively contraindicated – NSAIDs, COX-2 inhibitors (risk of renal failure and/or GI bleed)
Although there are no randomized trials comparing the efficacy of these modalities, trauma guidelines recommend epidural analgesia for patients with four or more rib fractures and suggest its use in those with fewer fractures who are older than 65 years or who have significant cardiopulmonary disease or diabetes mellitus.
Although not a primary analgesic option, invasive or non-invasive mechanical ventilation may reduce analgesic requirements by splinting a large flail segment. Disadvantages of complexity, risks associated with intubation, and IMV, as well as patient discomfort and aspiration risk in NIV
Surgical fixation of the fractures
This has been shown to reduce the chronic pain with non-union and help with the weaning of patients with rib fractures causing flail chest, prevents traumatic thoracoplasty
Disadvantages of invasive procedure with associated risks, may require post-operative ventilation.
Anything that asks for you to discuss advantages and disadvantages of a series of therapeutic options would benefit from a tabulated answer.
|Systemic opiates +paracetamol||
Adverse effects from opiates, especially:
|Gabapentin and pregabalin||
Analgesia is better than with PCA
|Regional techniques (paraveretebral, intrapleural)||
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