Early Regional Analgesia Better for Blunt Chest Wall Trauma In Elderly Patients

Originally published by our sister publication General Surgery News

ORLANDO, Fla.—Elderly patients with blunt chest wall injury who receive regional analgesia within the first 24 hours have better outcomes compared with regional analgesia after the 24-hour time point, according to a new study.

With this finding, the investigators recommended early initiation of regional analgesia, which they said boasts the potential to decrease complication rates and subsequent resource utilization in this patient population.

“Rib and chest injuries are very common in patients presenting to any trauma center, and the injuries are associated with significant pain,” said Jefferson ProaÑo-Zamudio, MD, a surgical research fellow at Massachusetts General Hospital, in Boston. “While regional analgesia—both in the form of epidural analgesia and peripheral nerve blocks—has become very common in the management of these patients, it has not been studied in terms of the timing of administration and its effects on respiratory morbidity and mortality.”

To help determine the optimal timing for initiation of regional analgesia in elderly patients, Dr. ProaÑo-Zamudio and his colleagues turned to 2017-2019 data from the Trauma Quality Improvement Program (TQIP) database. They reviewed the records of 2,292 individuals 65 years of age and older (mean, 75.3 years; 52.8% male) admitted with blunt chest wall trauma who subsequently received regional analgesia. The median injury severity score of the cohort was 13 (IQR, 9-17).

Patients were categorized according to the time of regional analgesia administration: early (=24 hours of admission) or late (=24 hours). Those who were inpatients for less than 24 hours were excluded from the analysis, as were those who had severe thoracic visceral injuries. The study’s end points included ventilator-associated pneumonia, unplanned ICU admission, unplanned intubation, survival with discharge to home and hospital length of stay.

“Since this was not a clinical trial and patients were not randomized, we performed a multivariable adjustment,” Dr. ProaÑo-Zamudio said in an interview. Multivariable logistic regression adjusted for patient and injury characteristics, trauma center level, and respiratory interventions.

Presenting the study at the 2023 Eastern Association for the Surgery of Trauma Annual Scientific Assembly (paper 18), Dr. ProaÑo-Zamudio reported that elderly patients who were given early regional analgesia gained several benefits relative to their counterparts who received regional analgesia more than 24 hours after admission. They included a decreased incidence of unplanned intubation (2.9% vs. 5.4%; P=0.002), fewer unplanned ICU admissions (4.8% vs. 8.3%; P<0.001) and a shorter mean hospital length of stay (5.6 vs. 6.5 days; P=0.003).

“We consider the combination of hospital length of stay and unplanned ICU admission to be a proxy for consumption of healthcare resources,” Dr. ProaÑo-Zamudio said.

In contrast, no significant differences were found between groups for the development of ventilator-associated pneumonia or mortality.

There are several reasons that early administration of regional analgesia might lead to better outcomes in elderly patients with blunt chest wall injury, the researchers noted. One is that early administration may reduce pain levels, thereby improving patients’ respiratory mechanics. Reduced pain may also improve patient compliance with inpatient physical therapy.

These findings, the researchers said, point to the inherent value of an acute pain service, which may help with the early implementation of regional analgesia.

“Of course, they are the ones who are trained in these procedures and could implement them as necessary,” Dr. ProaÑo-Zamudio said. “So, our recommendation based on this study is that if the pain service or regional analgesia specialists at your institution can be involved earlier in the care of these trauma patients, they should do it.

“Of course, these are not randomized data and the results have yet to be replicated in other centers,” he added. “But the findings tend to show that early initiation of regional analgesia within 24 hours could prevent complications and decrease resource use in elderly patients with blunt chest-wall fractures.”

Sabrina Sanchez, MD, an assistant professor of surgery at Boston Medical Center, agreed that early administration of regional analgesia seemed to have the greatest benefit in these patients, but she questioned whether such a step might depend on the availability of an acute pain service.

“We already know that providing adequate analgesia to patients with rib fractures helps lead to better outcomes, but what’s important about this paper is that it really emphasizes that the sooner you do it, the better off the patient is going to be,” she said. “So if a patient comes in on a Friday evening, we need to do our best to get that person the epidural or nerve block right away.

“Obviously there may be difficulties inherent in implementing this, particularly at institutions that don’t have an acute pain service available 24/7,” Dr. Sanchez said. “In those cases, you may need to engage anesthesiologists who aren’t in the acute pain service to do these procedures. It may even be something that the surgeon needs to learn how to do, especially because we already do a lot of regional blocks in the operating room.”