Faculty Collaboration Database

Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 2021 Aug 01;91(2):265-271

Date

05/04/2021

Pubmed ID

33938510

Pubmed Central ID

PMC9704032

DOI

10.1097/TA.0000000000003258

Scopus ID

2-s2.0-85112264472 (requires institutional sign-in at Scopus site)   10 Citations

Abstract

BACKGROUND: Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers.

METHODS: Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence.

RESULTS: Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16).

CONCLUSION: In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury.

LEVEL OF EVIDENCE: Therapeutic, level IV; Epidemiologic, level III.

Author List

O'Connell KM, Patel KV, Powelson E, Robinson BRH, Boyle K, Peschman J, Blocher-Smith EC, Jacobson L, Leavitt J, McCrum ML, Ballou J, Brasel KJ, Judge J, Greenberg S, Mukherjee K, Qiu Q, Vavilala MS, Rivara F, Arbabi S

Author

Jacob R. Peschman MD Assistant Professor in the Surgery department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Abbreviated Injury Scale
Aged
Analgesics, Opioid
Anesthesia, Conduction
Delirium
Female
Humans
Injury Severity Score
Intensive Care Units
Linear Models
Male
Middle Aged
Multiple Trauma
Multivariate Analysis
Pain Management
Pain Measurement
Retrospective Studies
Rib Fractures
Trauma Centers