K. M. McKendy1, K. Boulva1, L. Lee1, A. N. Beckett1, D. L. Deckelbaum1, P. Fata1, K. A. Khwaja1, D. S. Mulder2, T. S. Razek1, J. R. Grushka1 1McGill University,General And Trauma Surgery,Montreal, QC, Canada 2McGill University,Cardiothoracic Surgery,Montreal, QC, Canada
Introduction: To determine the effect of epidural anaesthesia on the incidence of respiratory complications and in-hospital mortality in adult patients with rib fractures after blunt trauma.
Methods: All adult patients presenting at a university-affiliated level I trauma center from 2004 to 2013 with at least one rib fracture secondary to blunt trauma were queried from a prospectively entered database. Patients who had a combined blunt-penetrating mechanism of injury, simultaneous intracranial haemorrhage or traumatic brain injury, or underwent a laparotomy or thoracotomy were excluded from the analysis. Epidurals were placed within the initial 24 hours of presentation according to the treating physician’s preferences. Main outcome measures were respiratory complications (pneumonia, DVT/PE, and respiratory failure) and 30-day in-hospital mortality. Coarsened exact matching was used to account for differences in patient-level factors (age, sex, Injury Severity Score [ISS], number of rib fractures, flail segment, bilateral rib fractures, chest tube insertion, pulmonary contusion, and year of injury) between those who received epidural anaesthesia (EPI) and those who did not (NEPI) in a one-to-one fashion. Subgroup analyses were performed based on age (≥65 and < 65 years), number of rib fractures (≥3 and <3 fractures), burden of trauma (ISS ≥16 and ISS < 16), and bilaterality of fractures. Statistical significance was defined as p<0.05.
Results: A total of 1360 (EPI 329, NEPI 1031) patients met the inclusion criteria (mean age 54.2 years (SD19.7), 68% male). Overall, the mean number of rib fractures was 4.8 (SD3.3) ribs (21% bilateral) with a high total burden of injury (mean ISS 19.9 (SD8.9)). The incidence of respiratory complications was 13% (180/1360) and mortality 4% (53/1360) in the unmatched cohort. After matching, 204 EPI patients were compared to 204 NEPI patients with no differences in demographics and traumatic characteristics (. In matched analysis, EPI patients experienced more respiratory complications (19% vs. 10%, p=0.009) but no differences in 30-day mortality (5% vs. 2%, p=0.159) compared to NEPI patients. There were also no differences in duration of mechanical ventilation (EPI 148 h (SD167) vs. NEPI 117 (SD187), p=0.434) and intensive care unit length of stay (EPI 6.5 d (SD7.6) vs. NEPI 5.8 d (SD9.1), p=0.626). Total length of stay was higher in the EPI group (16.6 d (SD19.6) vs. 12.7 d (SD15.2), p=0.026). This relationship remained unchanged in all subgroup analyses.
Conclusion: Epidural anaesthesia is associated with increased respiratory complications and mortality after traumatic rib fractures. Alternate analgesic strategies and rib fracture fixation should be further investigated to treat these severely injured patients.