Authors: Anuj Aggarwal, M.D.; Einar Ottestad, M.D.Affiliation: Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USABackground: Management of pain secondary to rib fracture is... [ view full abstract ]
Authors: Anuj Aggarwal, M.D.; Einar Ottestad, M.D.
Affiliation: Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
Background: Management of pain secondary to rib fracture is a common consult to the acute pain service at Stanford; nationally, greater than 150,000 patients are admitted annually with rib fractures. Pain control is an important component of management of rib fractures to promote deep breathing and clearance of secretions to prevent complications including pneumonia; 10% of patients admitted with rib fractures to American trauma centers die each year. Many methods have been studied to reduce reliance on narcotic analgesics for pain control and several surgical societies advocate epidurals for pain management. However, even in centers that emphasize epidural pain control, only a minority of patients with rib fractures receive epidurals secondary to technical, logistical and functional considerations that affect clinical utility; as such, opioids remain the cornerstone of pain management of rib fractures. At Stanford, we have utilized peripheral lidocaine infusions with anecdotal success for pain management in patients with rib fractures, and currently, no reports exist in the literature of this approach.
Methods: With IRB approval, we reviewed charts from January 1, 2011 to June 30, 2016 for patients with diagnosis of rib fractures for whom the primary service had consulted the acute pain service. Including patients who were admitted and managed by the acute pain service for management of pain secondary to rib fractures, we reviewed adverse events, opioid usage, care delivery factors, vital signs, and other factors of pain management with a focus on patients managed via epidural versus peripheral lidocaine infusion.
Results: 204 patients were admitted with rib fractures for which the acute pain service was specifically consulted. Of these, 86 received epidurals, 89 received peripheral lidocaine infusions, with an overlap of 15 patients. A variety of factors excluded the use of epidurals and our results in aggregate show successful use of peripheral lidocaine for pain management of rib fractures.
Conclusions: Very little data exists of the use of peripheral lidocaine infusions in the management of nonoperative acute pain, and to our knowledge, this is the first demonstration of the use of peripheral lidocaine infusion for pain management of rib fractures. As a modality, peripheral lidocaine infusions are safe, simple, and have the benefit of not being site/dermatome specific. This study serves as the first set of data currently for acute pain management in the trauma patient with peripheral lidocaine infusions. As a vulnerable population with many risk factors disfavoring both opioid analgesics and invasive pain management strategies, peripheral lidocaine infusions may offer a unique tool as part of a comprehensive pain management strategy.
