Epidural analgesia vs intravenous analgesia
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Baker et al. 2016 | UK | R, Level I trauma center | ≥ 16 years ≥ 1 thoracic fractures (ribs, sternum, scapular and clavicular fractures) | Patients who died within 24 h of admission to hospital and patients with penetrating injuries | Continuous epidural analgesia, containing bupivacaine and fentanyl | Intravenous analgesia, morphine delivered by PCA | 6 | 159 | 4 (66.7%) | 122(76.7%) | 65.9 ± 18.4 | 46.5 ± 17.8 | 25.3 ± 10.5 | 24.1 ± 10.5 |
Ahmed et al. 2015 | India | RCT, ICU | 18–55 years ≥ 3 rib fractures with flail segment required mechanical ventilation | Acute spine fracture, pre-existing spine deformity, severe traumatic brain or spinal cord injury, unstable pelvic fracture or open abdomen, ongoing cardiac instability or coagulopathy, and active chest wall infection | Thoracic epidural analgesia, 4 mL of 0.125% bupivacaine bolus followed by 4 mL/h of 2 µg/kg fentanyl as adjuvant | Intravenous analgesia, fentanyl 2 µg/kg | 10 | 10 | 7(70%) | 8(80%) | 39.8 ± 8.8 | 36.7 ± 10.6 | 25 ± 7 | 28 ± 7 |
Waqar et al. 2013 | Paki-stan | R, Surgical ICU | > 18 years ≥ 3 rib fractures | Contraindications to epidural catheter, pregnancy, allergy to local anesthetics or opioids, and associated injuries like intracranial hematoma | Thoracic epidural analgesia, bupivacaine | Intravenous opioid analgesia | 47 | 38 | 35 (75%) | 29 (76%) | 54 ± 17 | 45 ± 22 | 23.6 ± 10.3 | 21.0 ± 6.7 |
Yeh et al. 2012 | USA | R, Trauma service | > 18 years ≥ 3 rib fractures | Contraindications to epidural catheter, acute spine fractures or pre-existing spine deformity, traumatic brain injury or altered mental status or spinal cord injury, unstable pelvic fracture or open abdomen, hemodynamic instability and coagulopathies | Epidural analgesia, containing bupivacaine and fentanyl | Oral or intravenous narcotics, delivered by PCA | 34 | 153 | 26(76.5%) | 113(73.9%) | 51.4 ± 15.0 | 48.8 ± 18.4 | 22.5 ± 8.2 | 22.6 ± 9.6 |
Kieninger et al. 2005 | USA | R, Level I trauma center | > 55 years ≥ 1 rib fracture ISS score < 16 | Sternal fracture, required intubation before admission to the trauma service or associated injuries that included intracranial hemorrhage | Epidural analgesia | Intravenous opioids | 53 | 134 | 18(33.9%) | 52(38.8%) | 77.7 ± 10.2 | 77.3 ± 10.5 | 10.3 ± 3.6 | 8.3 ± 3.9 |
Bulger et al. 2004 | USA | RCT, Level I trauma center | > 18 years ≥ 3 rib fractures | Acute spine fracture or pre-existing spine deformity, severe traumatic brain or spinal cord injury, or severe altered mental status, unstable pelvic fracture or open abdomen, active chest wall infection, and acute thoracic aortic transection | Thoracic epidural analgesia, bupivacaine, morphine and fentanyl | Intravenous opioid analgesia, morphine and fentanyl by PCA for alert patients and with nurse assistance for patients who could not participate in self-administration | 22 | 24 | 17(77%) | 16(67%) | 49 ± 18 | 46 ± 16 | 26 ± 8 | 25 ± 8 |
Wu et al. 1999 | USA | R, NR | > 18 years ≥ 3 rib fractures Following motor vehicle crash | NR | Thoracic epidural analgesia, 0.125 to 0.25% bupivacaine and 2.5 µg/kg fentanyl | Intravenous morphine, delivered by PCA | 25 | 39 | 13(52%) | 20(51%) | 56 ± 17 | 45 ± 22 | 21.6 ± 10.3 | 21.9 ± 6.7 |
Moon et al. 1999 | USA | RCT, NR | 18–60 years > 3 consecutive rib fractures or a flail chest segment or pulmonary contusion or sternal fracture | Contraindications to epidural catheter placement (coagulopathy, infection at insertion site, sepsis, or hypovolemic shock), morbid obesity, evidence of spinal cord injury, GCS < 15, adrenal insufficiency, use of steroids, need for vasoactive agents to support blood pressure, immunodeficiency disease, pregnancy, inability to communicate effectively, or history of allergy to local anesthetics or opioids | Thoracic epidural analgesia, initial bolus of fentanyl 50 µg and morphine 3 mg followed by continuous infusion of bupivacaine 0.25% and morphine 0.005%, at a rate of 4 to 6 ml/hr | Intravenous analgesia, intravenous morphine 0.1 mg/kg loading doses followed by morphine 1 mg/ml delivered by PCA in bolus doses of 2 mg | 13 | 11 | 8(61.5%) | 6(54.5%) | 37 ± NR | 40 ± NR | 26.6 ± NR | 23.4 ± NR |
Mackersie et al.1991 | USA | RCT, Level I trauma center | > 18 years ≥ 3 rib fractures and flail chest or flail sternum or ≥ 2 rib fractures and exploratory laparotomy or pulmonary contusion | Pregnancy, history of substance abuse, psychiatric disorder, axial spine injury, chronic pain or chronic us of analgesics, and painful extremity injury | Continuous epidural analgesia, fentanyl bolus 1.0 µg/kg followed by continuous administration at an initial rate of 0.5 mg/kg/hour | Continuous intravenous,fentanyl bolus 5 µg/cc followed by continuous administration at an initial rate of 0.5 mg/kg/hour | 15 | 17 | NR | NR | 49.3 ± 19 | 47.8 ± 14 | 20 ± 7.6 | 16.0 ± 7.2 |
Wisner et al.1990 | USA | R, NR | ≥ 60 Admission diagnosis of either rib fracture or sternal fracture | NR | Epidural analgesia, morphine sulfate bolus or continuous infusions of fentanyl | Intravenous or intramuscular | 52 | 167 | 22(42.3%) | 74(44.3%) | 71.0 ± 1.1 | 69.4 ± 0.6 | 15.7 ± 1.0 | 14.6 ± 0.8 |
Ullman et al.1989 | USA | RCT, Surgical ICU | ≥ 3 unilateral fractured ribs or flail segment with significant contusion of the chest wall with impaired ventilation | NR | Thoracic epidural analgesia, loading dose fentanyl 100 µg with morphine 5 mg, and continuous morphine 70 µg/ml | Continuous intravenous morphine | 15 | 13 | 11(73.3%) | 11(84.6%) | 46.1 ± 4.6 | 53.0 ± 6.0 | 19.5 ± 2.03 | 25.3 ± 2.9 |
Epidural analgesia vs intercostal block
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Britt et al. 2015 | USA | R, Level II trauma center | > 18 years ≥ 2 rib fractures | NR | Epidural analgesia, bupivacaine 0.1% with 5 µg/mL fentanyl | Continuous intercostal nerve block, bupivacaine 0.5% continuous 4 mL/hour | 45 | 64 | 31(68.9%) | 38(58.5%) | 60.9 ± 17.3 | 70.5 ± 6.9 | 13.6 ± 5.2 | 12.5 ± 6.2 |
Hashemzadeh et al. 2011 | Iran | RCT, ICU | > 18 years > 1 rib fracture GCS > 14 | Liver or blunt splenic trauma, decreased consciousness, cerebral injury, mechanical ventilation, coagulopathy, fever and systemic or epidural infection | Thoracic epidural analgesia, bupivacaine 0.125 and 1 mg morphine every 8 h, and pethidine 0.5 ml PRN | Intercostal nerve block, bupivacaine 0.25% every 8 h, and pethidine 0.5 ml PRN | 30 | 30 | 28(95%) | 27(90%) | 45.5 ± 15.4 | 64.5 ± 7.2 | NR | NR |
Truitt et al. 2011 | USA | P, NR | > 18 years ≥ 3 unilateral rib fractures | Intubated before CINB placement, confounding injuries (traumatic brain injury, pelvic fracture, and long bone fracture), and allergy to anesthetics | Continuous intercostal nerve block | Epidural analgesia | 102 | 75 | NR | NR | 69 | 68 | 14 | 15 |
Epidural analgesia vs paravertebral block
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Shapiro et al. 2017 | USA | R, Level II trauma center | ≥ 2 unilateral rib fractures | Bilateral rib fractures | Epidural analgesia | Paravertebral analgesia, bupivacaine 0.5% | 31 | 79 | NR | NR | 61.4 ± 18.1 | 68.7 ± 18.1 | NR | NR |
Malekpour et al. 2017a | USA | R, NR | > 18 years > 1 rib fracture | Patients with sternum, larynx, and trachea fractures | Epidural analgesia | Paravertebral block | 1073 | 1110 | 740 (69%) | 706 (63.9%) | 58 ± 16.3 | 54.5 + 17.8 | 17 (11–22) | 14 (10–22) |
Mohta et al. 2009 | India | RCT, NR | > 18 years ≥ 3 unilateral rib fractures | Unconscious patients, unstable cardiac status or severely altered mental status, liver or kidney disease, contraindications to TEA or TPVB, pre-existing spinal deformity, use of anticoagulants or coagulopathy | Continuous thoracic epidural | Thoracic paravertebral | 15 | 15 | 12 (80%) | 12(80%) | 38.9 ± 14.9 | 40.4 ± 14.8 | 15.9 ± 7.1 | 13.6 ± 5.6 |
Paravertebral block vs intravenous analgesia
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Yeying et al. 2017 | China | RCT, Level I trauma center | ≥ 18 years ≥ 3 unilateral rib fractures | Age < 18 or > 70, severe head injury or unconsciousness, pathological obesity (BMI ≥ 35), thoracic and abdominal visceral injuries, unstable cardiac status, severe liver or kidney disease, coagulopathy, spinal or pelvic fracture, infection at the puncture site and allergy to local anesthetics | Paravertebral block, 250 ml 0.2% ropivacaine 5 mL/h, with a 5 ml bolus dose, and lockout interval of 15 min | Intravenous analgesia, 100 ml 2 µg/kg sufentanil (diluted with saline) 2 ml/h, with a 2 ml bolus dose, and lockout interval of 15 min | 45 | 45 | 29 (64.4%) | 68.9% | 39.1 ± 8.9 | 41.2 ± 9.7 | 14.2 ± 5.1 | 13.7 ± 5.5 |
Intercostal block vs intravenous analgesia
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Hwang et al. 2014 | Korea | R, NR | ≥ 1 rib fracture | NR | Conventional (iv PCA and/or fentanyl patch) + continuous intercostal nerve block (CINB) | Conventional pain control (iv PCA and/or fentanyl patch) | 23 | 31 | 44 (81.4%) | 48.5 ± NR | NR | NR |