Regional anaesthesia in the critically ill

The college has frequently shown interest in the management of analgesia, particularly in the setting of chest injuries. For whatever reason, the thoracic epidural seems to come up very often. Of the three specific questions about analgesia in trauma, the thoracic epidural has come up in two.  Question 13 from the second paper of 2002 asked to compare PCA and thoracic epidural in the setting of rib fractures; Question 6 from the second paper of 2007 asked about the potential complications of a thoracic epidural. For a change, Question 20 from the second paper of 2005 asked more broadly about the role of regional anaesthesia in the critically ill.

Advantages of regional anaesthesia in the critically ill

  • less respiratory depression (less opiates)with chest injury
  • improved respiratory function post laparotomy (The MASTER trial, 2002)
  • Less opiate side effects
  • less delirium
  • reduced used of non-opioids, eg. NSAIDs and tramadol.

Disadvantages of regional anaesthesia in the critically ill

Patient and critical illness factors

  • Difficult to position
  • Expertise required
  • Redundant in sedated, ventilated patients
  • No difference in hard outcomes
  • May still need opioids
  • Difficult covering multiple sources of pain
  • Obscures the early signs of compartment syndrome
  • Monitoring of blockade in uncooperative patient maybe impossible
  • Removal with DVT prophylaxis may be an issue


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.

Scherer, R., et al. "Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients." Acta anaesthesiologica scandinavica 37.4 (1993): 370-374.

Kapral, Stephan, et al. "The effects of thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism." Anesthesia & Analgesia 88.2 (1999): 402-406.