Indications and contraindications for thoracic epidural analgesia in multiply injured patients

SummaryBackground and objectivesRib fractures are associated with significant morbidity and mortality. Previous studies have demonstrated a significant reduction in pneumonia and duration of mechanical ventilation with epidural analgesia (EA) following multiple rib fractures. There remains controversy regarding the appropriate indications and contraindications for EA in multiply injured patients. We sought to determine the factors underlying the decision to use or not to use EA in these patients.MethodsA survey was sent to the directors of pain management services at all American College of Surgeons Committee on Trauma (ACS-COT) designated Level I trauma centers in the U.S. The survey queried their opinion regarding the appropriateness of 33 contraindications and eight indications for EA after rib fractures.ResultsThe response rate was 43% (81/188). Ninety-five percent of responding centers indicated that EA is used after rib fractures, but only 15% had guidelines defining the indications and contraindications. There was general agreement (>80%) regarding the indications for EA but disagreement regarding the contraindications. Contraindications were categorised based on the degree of agreement of respondents. The areas of greatest controversy involved minor spine injuries and minor coagulopathy.ConclusionsThere is wide variability regarding contraindications employed for thoracic epidural analgesia following rib fractures. These data support the need for evidenced based guidelines to define the use of EA in the multiply injured patient.