Effect of regional anesthesia timing on clinical outcomes in isolated flail chest: A nationwide analysis.

BACKGROUND

Flail chest can cause pain and respiratory failure. The impact of early initiation of regional anesthesia (RA) in patients with flail chest remains unclear. We evaluated whether earlier RA (≤24 h) in isolated flail chest improves outcomes.

METHODS

We conducted a retrospective cohort study using data from the ACS-TQIP (2017-2023). Adults (≥18 y) with isolated flail chest receiving treatment were included. We excluded penetrating trauma, extra-thoracic Abbreviated Injury Scale ≥3, discharged within 24 hours, transfers, emergency department deaths, pre-hospital arrest, and pre-hospital or emergency department intubation. Cases were divided into early RA (≤24 h) and late RA (>24 h). The primary outcome was unplanned intubation, and the secondary outcomes included intensive care unit (ICU) admission, discharge disposition, hospital, and ICU length of stay. Multivariable regression adjusted for patient characteristics, thoracic Abbreviated Injury Scale, mechanism of injury, surgical stabilization of rib fractures (SSRF), modified frailty index (mFI-11), pre-injury anticoagulation, and shock index. A subanalysis evaluated the SSRF, nonoperative management cohort, and RA technique.

RESULTS

There were 4,563 isolated flail chest cases with a median age of 59 years. 72.5% were male, and most were motor vehicle collisions (44.6%). 24.2% of patients received early RA. Late RA was associated with increased odds of unplanned intubation [adjusted odds ratio (aOR), 1.52; 95% CI, 1.09-2.12, p=0.015], unplanned ICU admission (aOR, 1.93; 95% CI, 1.34-2.79, p<0.001), longer hospital and ICU stays (p<0.001), and lower odds of routine discharges (aOR, 0.83; 95% CI, 0.70-0.99, p=0.036). In the SSRF cohort, early administration of RA was associated with shorter hospital and ICU stays. In the nonoperative management cohort, early RA was associated with more routine discharges, fewer ICU admissions, and shorter hospital and ICU stays.

CONCLUSIONS

In isolated flail chest, early RA is associated with lower rates of unplanned intubations and ICU admissions, shorter hospital and ICU stays, and higher rates of routine discharge. These findings support prioritizing early RA intervention, which is associated with favorable outcomes. (J Trauma Acute Care Surg 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.).

LEVEL OF EVIDENCE: Retrospective Study, Therapeutic/Care Management; Level III.