Continuous posterior extrathoracic fascial plane block versus continuous paravertebral block for pain management in patients with multiple rib fractures: a randomised controlled noninferiority trial.

BACKGROUND

Pain control is key to the management of patients with multiple rib fractures. We compared the impact of posterior extrathoracic fascial plane block (PEFB) with paravertebral block (PVB) and systemic analgesia on morphine consumption, pain relief, and improvement in respiratory parameters.

METHODS

Trauma patients with multiple rib fractures who were not mechanically ventilated were randomised into three groups: PEFB, PVB, and systemic analgesia. The primary endpoint was morphine consumption at 24 h. The secondary endpoints (pain at rest and when coughing, morphine consumption in the first 72 h, rescue thoracic epidural analgesia, sniff nasal inspiratory pressure [SNIP], and maximal expiratory pressure [MEP]) were analysed using linear mixed models.

RESULTS

Of the 90 patients included in the study, 77.7% were male; median (interquartile range) Injury Severity Score was 14 (10-19), chest Abbreviated Injury Scale was 3 (3-4), and number of ribs fractured was 4.5 (5-9). Morphine consumption at 24 h in the PEFB group was noninferior to that in the PVB group (17 [11-29] mg and 22 [14-31] mg, respectively; P<0.001). Thirty percent of patients in the control and PEFB groups and 6.7% in the PVB group (P=0.043) had thoracic epidural analgesia during the study. In the per-protocol analysis, morphine consumption at 72 h was higher in the control group but with no significant difference between intervention groups: control, 45 (36-72) mg; PEFB, 30 (16-44) mg; and PVB, 38 (22-62) mg (P=0.051). Pain scores were higher during coughing in all groups (β=3.89, P<0.0001), but scores were lower with a significant interaction in the PVB group (β=-0.58, P=0.010). Over 72 h, SNIP values increased significantly from baseline (β from 7.2 to 14.9; P=0.002) in all groups, and MEP values showed a difference with higher values in the PVB group (β=12.71, 95% confidence interval 2.73-22.77; P=0.012).

CONCLUSIONS

Posterior extrathroacic fascial plane block promoted a noninferior effect on morphine consumption at 24 h compared with paravertebral block in patients with multiple rib fractures. However, although PEFB has merit as a first-line treatment for rib fracture analgesia, it is more likely than PVB to require thoracic epidural anaesthesia rescue. Pain relief during coughing and respiratory parameters improved more in the PVB group.

CLINICAL TRIAL REGISTRATION: NCT03396692.