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Indications and Contraindications for Thoracic Epidural Analgesia in Multiply Injured Patients

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Indications and Contraindications for Thoracic Epidural Analgesia in Multiply Injured Patients Acute Pain (2008) 10, 15—22 Indications and contraindications for thoracic epidural analgesia in multiply injured patients Eileen M. Bulger a,∗, William T. Edwards b, Mario de Pinto b, Patricia Klotz a, Gregory J. Jurkovich a a Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA b Department of Anesthesiology, University of Washington, Harborview Medical Center, Seattle, WA, USA Received 21 July 2007; received in revised form 17 October 2007; accepted 21 October 2007 Available online 21 December 2007 Presented at the American Society Regional Anesthesia and Pain Medicine, 2005 (poster) KEYWORDS Summary Rib fractures; Background and objectives: Rib fractures are associated with significant morbid- Epidural analgesia; ity and mortality. Previous studies have demonstrated a significant reduction in Pain control pneumonia and duration of mechanical ventilation with epidural analgesia (EA) fol- lowing multiple rib fractures. There remains controversy regarding the appropriate indications and contraindications for EA in multiply injured patients. We sought to determine the factors underlying the decision to use or not to use EA in these patients. Methods: A survey was sent to the directors of pain management services at all Amer- ican College of Surgeons Committee on Trauma (ACS-COT) designated Level I trauma centers in the U.S. The survey queried their opinion regarding the appropriateness of 33 contraindications and eight indications for EA after rib fractures. Results: The response rate was 43% (81/188). Ninety-five percent of responding centers indicated that EA is used after rib fractures, but only 15% had guidelines defining the indications and contraindications. There was general agreement (>80%) regarding the indications for EA but disagreement regarding the contraindications. Contraindications were categorised based on the degree of agreement of respon- dents. The areas of greatest controversy involved minor spine injuries and minor coagulopathy. Conclusions: There is wide variability regarding contraindications employed for tho- racic epidural analgesia following rib fractures. These data support the need for evidenced based guidelines to define the use of EA in the multiply injured patient. © 2007 Elsevier B.V. All rights reserved. ∗ Corresponding author at: Department of Surgery, Box 359796, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104, USA. Tel.: +1 206 731 6448; fax: +1 206 731 3656. E-mail address: [email protected] (E.M. Bulger). 1366-0071/$ — see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.acpain.2007.10.019 16 E.M. Bulger et al. 1. Introduction relatively appropriate contraindication and com- monly applied (usually not ok to place epidural Rib fractures have been associated with signifi- catheter) and (D) inappropriate contraindication. cant morbidity and mortality following traumatic To develop a rank listing of contraindications, injury. The presence of three or more rib fractures answers A and C were pooled as general agree- has been associated with increased mortality and ment that a contraindication was appropriate and duration of ICU and hospital care [1,2]. A recent the percent of respondents in this category was analysis of the National Trauma Databank demon- listed in descending order. Indications were ranked strated a significant increase in mortality and as either appropriate or inappropriate. The indica- pulmonary morbidity for each additional rib frac- tions and contraindications included were based on ture [3]. The elderly are particularly susceptible our recent experience with a randomised controlled to complications of rib fractures with nosocomial trial of epidural analgesia in this patient popula- pneumonia rates reported as high as 31% [4]. The tion [5]. Respondents were not asked to suggest pain associated with rib fractures leads to impaired additional indications or contraindications but were ventilatory function and thus increases pulmonary asked to send their institutional guideline if avail- morbidity. Management of these patients is there- able. Review of these did not reveal any additional fore focused on achieving adequate analgesia and factors. Three mailings of the survey were sent to clearance of pulmonary secretions. Previous studies non-responders in an effort to improve the response have demonstrated that epidural analgesia provides rate, telephone calls to non-respondents were not superior pain relief, improved pulmonary function permitted. tests, reduced the risk of developing nosocomial pneumonia and led to a shorter duration of mechan- ical ventilation compared to intravenous opioids 3. Results [5—9]. Despite these advantages only 2% of patients with rib fractures in the National Trauma Databank Responses were received from 81/188 (43%) of US received epidural analgesia [3]. This may be due Level 1 trauma centers. Seventy-seven of the cen- in large part to controversy regarding the indica- ters indicated that epidural analgesia is used at tions and contraindications for the use of epidural their institution for management of pain after rib analgesia in patients with multiple injuries. We fractures (95%). Twelve centers (15%) reported that sought to define the current practice in the United they had developed institutional guidelines regard- States by surveying pain service directors at Level ing the indications and contraindications for the 1 trauma centers regarding their current guidelines use of epidural analgesia in this patient population. for the use of epidural analgesia in this patient As illustrated in Table 1, there was general agree- population and to assess the level of agreement ment regarding the indications for the use of EA regarding indications and contraindications for its use. Table 1 Rank list based on % of respondents support- ing each indication 2. Methods Indication Support (%) A list of all Level 1 trauma centers in the United Inadequate pain control with 98 States was obtained from the American College systemic analgesics of Surgeons Committee on Trauma. A written Patient sedated by systemic 95 survey was sent to the pain service directors analgesics at all centers in September of 2004. Respon- ≥3 rib fractures 83 dents were asked whether epidural analgesia was Request from physician team 83 used for the management of pain following rib providing primary post trauma fractures and if so were there established insti- care IRB approved research study of 81 tutional guidelines regarding the indications and effectiveness of epidural contraindications for its use. They were asked analgesia for pain relief to consider seven potential indications and 33 Request from nurses providing 43 contraindications. They were asked to rank the con- primary post trauma care traindications on a four point scale as either: (A) Demand from physician team 36 appropriate contraindication, (B) relatively appro- providing primary post trauma priate contraindication but rarely applied (i.e. OK care to place epidural catheter most of the time), (C) Epidural analgesia in multiply injured patients 17 Table 2 Rank list based on % of respondents support- platelet count <50,000, INR > 1.5, or administration ing each contraindication of low molecular weight heparin (LMWH) within the previous 8 h were appropriate contraindications to Contraindication Support (%) placement of a thoracic epidural catheter. Opinions Platelet count <50 k 93 were mixed regarding a platelet count <80,000 or Cellulitis at insertion site 92 administration of LMWH within the previous 12 h. Spinal cord injury 90 The majority of respondents did not believe that Epidural or spinal cord haematoma 90 INR between 1.0 and 1.5 was an appropriate con- INR > 1.5 90 traindication. LMW heparin w/in 8 h 88 Major TBI (GCS < 8) 83 Intracranial haemorrhage 81 3.2. Contraindications related to spinal Penetrating head injury 77 evaluation Haemodynamic instability 74 Unable to obtain consent 69 As many trauma patients admitted to the inten- LMW heparin w/in 12 h 69 sive care unit are still undergoing evaluation for Full spine precautions 68 potential spinal injury, we inquired whether the Platelet count <80 k 65 spine clearance status was an appropriate con- TBI (GCS 8—13) 64 Patient deeply sedated for vent 63 traindication to thoracic epidural placement. We Injury to thoracic aorta 62 included as contraindications an admission sta- Ligament disruption thoracic spine 62 tus of full spine precautions and a series of Ligament disruption cervical spine 57 questions regarding normal imaging at different Ligament disruption lumbar spine 52 spine levels but the inability to evaluate the Unstable pelvic fracture 47 patient clinically for pain that may be associ- Normal thoracic spine films, unable to 43 ated with ligamentous injury. As illustrated in examine Fig. 2, the majority of respondents felt that Transverse process fracture, thoracic 43 full spine precaution status was an appropri- spine ate contraindication, but there was disagreement Spinous process fracture, thoracic spine 40 among the other categories with most report- Normal lumbar spine films, unable to 40 examine ing these as inappropriate or relative but rarely Transverse process fracture, cervical 38 applied contraindications to epidural catheter spine placement. Spinous process fracture, cervical spine 37 Normal cervical spine films, unable to 35 3.3. Contraindications related to spine examine Respiratory failure w/o impaired 35 injury mechanics Spinous process fracture, lumbar spine 30 As
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