The effect of epidural placement in patients after blunt thoracic trauma

BACKGROUND In studies of trauma patients with rib fractures, conclusions on the benefits derived from epidural analgesia are inconsistent. The purpose of this study was to further evaluate placement and efficacy of epidural analgesia nationwide. METHODS This was a retrospective cohort study of prospectively gathered data from the National Study on Cost and Outcomes of Trauma database, a multisite prospective study of injured patients aged 18 years to 84 years. Patients were treated at 69 participating hospitals (18 Level I trauma centers and 51 nontrauma centers) across the United States. Our analysis was limited to patients with a blunt mechanism of injury and a thoracic maximum Abbreviated Injury Scale (MAXAIS) score of 2 or greater. Excluded were patients who were not potential candidates for epidural placement, such as patients with significant head and spine injuries (head MAXAIS score > 2 or spine MAXAIS score > 2), significant neurologic impairment (best motor Glasgow Coma Scale [GCS] score < 4), unstable pelvic fractures, coagulopathy, or those who died within 48 hours. RESULTS The National Study on Cost and Outcomes of Trauma database contains 5,043 patients, of whom 836 (16.5%) were identified as potential candidates for epidural placement. Of patients included in the study, 100 patients (12%) had epidural catheters placed. The likelihood of epidural catheter placement was significantly higher in trauma centers as compared with nontrauma centers (adjusted odds ratio, 3.06; 95% confidence interval [CI] 1.80–5.22). In the epidural group compared with those not receiving a catheter, the adjusted (including trauma center status) odds of death in patients with three or more rib fractures at 30, 90, and 365 days was 0.08 (95% CI, 0.01–0.43), 0.09 (95% CI, 0.02–0.42), and 0.12 (95% CI, 0.04–0.42), respectively. CONCLUSION Trauma centers are more likely to place epidural catheter in patients with rib fractures. In this multicenter study, epidural catheter placement was associated with a significantly decreased risk of dying in patients with blunt thoracic injury of three or more rib fractures. LEVEL OF EVIDENCE Therapeutic study, level II.

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