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Open Access

Use of continuous intercostal nerve blockade is associated with improved outcomes in patients with multiple rib fractures

Rindi Uhlich, Jeffrey David Kerby, Patrick Bosarge, Parker Hu
DOI: 10.1136/tsaco-2020-000600 Published 26 April 2021
Rindi Uhlich
1Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Jeffrey David Kerby
1Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Patrick Bosarge
2Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, USA
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Parker Hu
1Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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  • Figure 1
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    Figure 1

    CONSORT diagram for patient selection. CONSORT, Consolidated Standards of Reporting Trials.

Tables

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  • Table 1

    Characteristics of ON-Q analgesia catheter use

    Mean±SD
    Length of use (days)4.5±4.10
    Number of ribs anesthetized8.0±3.26
    Initial rate of 0.2% ropivacaine infusion (cc/hour)11.1±3.62
    Length of ICU admission prior to catheter insertion (days)2.3±2.03
    Length of ICU stay after catheter insertion (days)6.6±5.50
    Length of mechanical ventilation prior to catheter insertion (days)1.5±2.09
    Length of mechanical ventilation after catheter insertion (days)1.5±2.44
    • ICU, intensive care unit.

  • Table 2

    Comparison of demographic and injury characteristics in patients with multiple rib fractures based on use of ON-Q catheter for continuous intercostal nerve blockade

    ON-Q catheter (CATH)
    (n=48)
    No ON-Q catheter (STD)
    (n=96)
    P value
    Demographics
     Mean age (years)56.8±18.3056.4±18.720.91
     Gender (%)
      Male31 (64.6)69 (71.9)0.37
      Female17 (35.4)27 (28.1)
     Mechanism of injury (%)
      Blunt46 (95.8)93 (96.9)0.75
      Penetrating2 (4.2)3 (3.1)
    Injury characteristics
     Injury Severity Score24.9±9.8124.7±9.730.93
     Abbreviated Injury Scale score area
      Head1.2±1.341.8±1.610.02
      Head >3 (%)4 (8.3)16 (16.7)0.14
      Neck2.9±0.882.8±0.830.72
      Thorax1.5±1.731.6±1.760.62
      Abdomen1.5±1.111.4±1.330.82
     Number of rib fractures9.3±3.736.60±4.110.001
      Anterior3.6±4.422.9±3.950.32
      Lateral3.2±4.161.3±2.200.004
      Posterior3.9±3.442.9±3.440.06
     Six or more rib fractures (%)39 (81.3)44 (48.9)<0.001
     Number of flail segments2.0±2.940.8±1.760.02
     Three or more flail segments (%)15 (31.3)16 (19.8)0.14
     Bilateral rib fractures (%)15 (31.3)46 (47.9)0.06
     Tube thoracostomy (%)34 (70.8)37 (38.5)<0.001
     Thoracotomy (%)3 (6.3)5 (5.2)0.80
     Video Assisted Thorascopic Surgery (VATS) (%)2 (4.2)5 (5.2)0.78
     Rib fixation (%)10 (20.8)3 (3.1)<0.001
     Laparotomy (%)5 (10.4)15 (15.6)0.39
    • Results shown as mean±SD unless otherwise noted.

    • Estimates from Pearson’s χ2 and independent t-test for categorical and continuous variables, respectively.

    • CATH, patients with multiple rib fractures managed with continuous intercostal nerve blockade; STD, patients with multiple rib fractures managed without continuous intercostal nerve blockade.

  • Table 3

    Comparison of outcomes in patients with multiple rib fractures based on use of ON-Q catheter for continuous intercostal nerve blockade

    ON-Q catheter (CATH)
    (n=48)
    No ON-Q catheter (STD)
    (n=96)
    P value
    Outcomes
     30-day hospital-free days15.9±6.4313.2±9.940.048
     90-day hospital-free days74.7±12.5363.3±28.120.001
     ICU-free days4.9±3.716.0±5.650.18
     Ventilator-free days9.4±4.579.8±8.150.68
     Unplanned intubation (%)2 (4.2)6 (6.3)0.61
     Failed extubation (%)4 (8.3)10 (10.4)0.69
     Required tracheostomy (%)4 (8.3)17 (17.7)0.13
     Pneumonia (%)2 (4.2)16 (16.7)0.03
     Hospital mortality (%)1 (2.1)13 (13.5)0.03
      Cardiopulmonary (%)1 (2.1)7 (7.3)0.11
     Rib fracture complication* (%)8 (16.7)33 (34.4)0.03
    • Results shown as mean±SD unless otherwise noted.

    • Estimates from Pearson’s χ2 and independent t-test for categorical and continuous variables, respectively.

    • *Either unplanned intubation, failed extubation, pneumonia, tracheostomy requirement, or hospital mortality.

    • CATH, patients with multiple rib fractures managed with continuous intercostal nerve blockade; ICU, intensive care unit; STD, patients with multiple rib fractures managed without continuous intercostal nerve blockade.

  • Table 4

    Comparison of patients with multiple rib fractures based on management with standard medical management, rib fixation, or ON-Q catheter for continuous intercostal nerve blockade

    ON-Q catheter without rib fixation
    (n=38)
    Rib fixation
    (n=13)
    Standard medical management
    (n=93)
    P value
    Age56.0±18.9454.9±17.2456.9±18.690.92
    Number of rib fractures9.0±3.7811.2±3.146.4±4.00*<0.001
    Number of flail segments1.2±2.254.5±3.28*0.8±1.69<0.001
    30-day hospital-free days16.7±6.5111.5±7.1513.4±9.890.09
    90-day hospital-free days75.1±13.8370.2±9.9463.4±28.460.04
    ICU-free days4.7±3.835.6±3.626.0±5.690.44
    Ventilator-free days8.9±4.3411.5±5.139.7±8.220.51
    Unplanned intubation (%)2 (5.3)06 (6.5)0.63
    Failed extubation (%)3 (7.9)3 (23.1)8 (8.6)0.23
    Required tracheostomy (%)2 (5.3)3 (23.1)16 (17.2)0.14
    Pneumonia (%)2 (5.3)1 (7.7)15 (16.1)0.20
    Hospital mortality (%)1 (2.6)013 (14.0)0.06
    Rib fracture complication† (%)6 (15.8)5 (38.5)30 (32.3)0.12
    • Results shown as mean±SD unless otherwise noted.

    • Estimates from Pearson’s χ2 and analysis of variance for categorical and continuous variables, respectively.

    • *P≤0.05.

    • †Either unplanned intubation, failed extubation, pneumonia, tracheostomy requirement, or hospital mortality.

    • ICU, intensive care unit.

  • Table 5

    Comparison of outcomes in patients with multiple rib fractures based on use of ON-Q catheter for continuous intercostal nerve blockade, excluding patients with rib fixation

    ON-Q catheter (CATH)
    (n=38)
    No ON-Q catheter (STD)
    (n=76)
    P value
    Outcomes
     30-day hospital-free days16.7±6.5112.2±10.050.005
     90-day hospital-free days75.1±13.8360.8±29.470.001
     ICU-free days4.7±3.836.3±6.090.09
     Ventilator-free days8.9±4.3310.2±8.790.29
     Unplanned intubation (%)2 (5.3)6 (7.9)0.72
     Failed extubation (%)3 (7.9)8 (10.5)0.75
     Required tracheostomy (%)2 (5.3)15 (19.7)0.04
     Pneumonia (%)2 (5.3)14 (18.4)0.06
     Hospital mortality (%)1 (2.6)12 (15.8)0.04
     Rib fracture complication* (%)6 (15.8)28 (36.8)0.02
    • Results shown as mean±SD unless otherwise noted.

    • Estimates from Pearson’s χ2 and independent t-test for categorical and continuous variables, respectively.

    • *Either unplanned intubation, failed extubation, pneumonia, tracheostomy requirement, or hospital mortality.

    • CATH, patients with multiple rib fractures managed with continuous intercostal nerve blockade; ICU, intensive care unit; STD, patients with multiple rib fractures managed without continuous intercostal nerve blockade.

  • Table 6

    Comparison of opioid analgesic requirements in patients with multiple rib fractures based on use of ON-Q catheter for continuous intercostal nerve blockade

    Analgesic requirements (oral morphine equivalents)ON-Q catheter (CATH)No ON-Q catheter (STD)P value
    All patientsCATH (n=48)STD (n=96)
     Total for hospitalization2741±19603429±42510.19
      Prior to ON-Q placement1265±1284–
      After ON-Q placement1477±1247–
    Six or more rib fracturesCATH (n=39)STD (n=44)
     Total for hospitalization2641±19904900±54430.01
    Bilateral rib fracturesCATH (n=15)STD (n=46)
     Total for hospitalization3292±23174660±52590.17
    Three or more flail segmentsCATH (n=15)STD (n=16)
     Total for hospitalization3569±26715678±58340.21
    • Results shown as mean±SD unless otherwise noted.

    • Estimates from independent t-test.

    • CATH, patients with multiple rib fractures managed with continuous intercostal nerve blockade; STD, patients with multiple rib fractures managed without continuous intercostal nerve blockade.

  • Table 7

    OR and associated 95% CI for the association of use of continuous intercostal blockade and outcomes

    ORP value95% CI
    Unplanned intubation1.080.930.18 to 6.49
    Failed extubation0.650.510.18 to 2.34
    Pneumonia0.150.020.03 to 0.76
    Require tracheostomy0.230.030.06 to 0.83
    Hospital mortality0.100.040.01 to 0.91
    Rib fracture complication*0.260.0060.10 to 0.67
    • Multivariate logistic regression adjusted for number of rib fractures and number of flail segments.

    • *Either unplanned intubation, failed extubation, pneumonia, tracheostomy requirement, or hospital mortality.

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Use of continuous intercostal nerve blockade is associated with improved outcomes in patients with multiple rib fractures
Rindi Uhlich, Jeffrey David Kerby, Patrick Bosarge, Parker Hu
Trauma Surg Acute Care Open Apr 2021, 6 (1) e000600; DOI: 10.1136/tsaco-2020-000600

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Use of continuous intercostal nerve blockade is associated with improved outcomes in patients with multiple rib fractures
Rindi Uhlich, Jeffrey David Kerby, Patrick Bosarge, Parker Hu
Trauma Surg Acute Care Open Apr 2021, 6 (1) e000600; DOI: 10.1136/tsaco-2020-000600
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Use of continuous intercostal nerve blockade is associated with improved outcomes in patients with multiple rib fractures
Rindi Uhlich, Jeffrey David Kerby, Patrick Bosarge, Parker Hu
Trauma Surgery & Acute Care Open Apr 2021, 6 (1) e000600; DOI: 10.1136/tsaco-2020-000600
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