A comparison between Thoracic epidural, Intercostal nerve block and Paravertebral nerve block in terms of their limitation, efficacy, side effects etc.
In our institution thoracic epidural analgesia is often used when multiple rib fractures are involved. Patients are monitorized into the critical care unit and bupivacaine 0.1% plus morphine 20-40 microg/ml is administered at 6-8 ml/h. This practice allows the physicians a minor use of mechanical ventilation.
I should have asked in "Diffuse" rib fracture, what is your management of choice?covering like 7-10 levels with TEP may will cause epidural side effects like hypotension etc.
We routinely use an epidural T6-7 catheter with a 10 ml bolus dose of 0.25% plain bupivacaine and a continuous infusion of 0.0625%-0.125% bupivacaine with morphine 20-40 micrg/ml, chosen by the pain physician doctor and prepared in sterile conditions by the pharmacy service into 500 ml of physiologic solution. The patient is always monitored into the PACU for a minimum period of 48 h and he/she is not allowed to walk only to sit from the bed to a chair due to either major (respiratory depression) or minor adverse effects (pruritus, hypotension...) are expected.
This morphine concentration (40 micrg/ml) allows us to easily calculate the daily amount of epidural morphine because is almost the same number like the epidural infusion rate in ml (8 ml/h = 8 mg/day).
Poster ANALGESIA EPIDURAL TORÁCICA PARA TRATAMIENTO DEL DOLOR TRAS ...
I think in this situation we should pay attention to cost &benefit of each option, so I prefer to use regional block (Rib block) and also systemic drugs. Also such patients are at risk for pulmonary contusion that need care about good respiration.
First of all a precise diagnosis should be done. Is there injury to pleura,lungs,etc. ? If there is some pulmonary contusion, pneumothorax, hemothorax, chylothorax, etc. the condition should be subjected to appropriate surgical or non-surgical treatment. Some times suction drainage and/ or rib osteosymthesis is needed. If there is no pleura or pulmonary injury, then taping, bandaging (zingulum type) should be done to restrict pathologic movements between fragments (source of pain). Parallely, analgesia with regional block should be done.
Dear Shahriar Khezri ,
The erector spinae plane (ESP) block was described in 2016 as a novel regional anesthetic technique for acute and chronic thoracic pain.
The site of injection is distant from the pleura, major blood vessels, and spinal cord; hence, performing the ESP block has relatively few contraindications.
The ESP block is less difficult to perform relative to thoracic epidural anesthesia and thoracic paravertebral block. Also, significant cranial-caudal spread occurs from a single injection point, which is an additional advantage in the setting of multiple rib fractures.
In two small scoping studies we have demonstrated a promising analgesic effect for 7+/-3 fractures with both the erector spinae plane and serratus anterior plane blocks.
https://www.researchgate.net/publication/339787415_Erector_spinae_blocks_for_the_management_of_rib_fractures_A_pilot_matched_study
https://www.researchgate.net/publication/338334995_Erector_spinae_and_serratus_anterior_blocks_for_the_management_of_rib_fractures_A_retrospective_exploratory_matched_study
Thoracic epidural is superior among all..
Erector spinae plane block is more safer than Paravertibral block ...
SAP block serratus anterior plane block also a safer option...
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