title: Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials.
abstract: OBJECTIVE
  A consensus group recently proposed epidural analgesia as the optimal analgesic modality for patients with multiple traumatic rib fractures. However, its beneficial effects are not consistently recognized in the literature. We performed a systematic review and a meta-analysis of randomized controlled trials (RCT) of epidural analgesia in adult patients with traumatic rib fractures.
  
  
  METHODS
  A systematic search strategy was applied to MEDLINE, EMBASE, the Cochrane Library and to the annual meeting of relevant societies (up to July 2008). All randomized controlled trials comparing epidural analgesia with other analgesic modalities in adult patients with traumatic rib fractures were included. Primary outcomes were mortality, ICU length of stay (LOS), hospital LOS and duration of mechanical ventilation.
  
  
  RESULTS
  Eight studies (232 patients) met eligibility criteria. Epidural analgesia did not significantly affect mortality (odds ratio [OR] 1.6, 95% CI, 0.3, 9.3, 3 studies, n = 89), ICU LOS (weighted mean difference [WMD] -3.7 days, 95% CI, -11.4, 4.0, 4 studies, n = 135), hospital LOS (WMD -6.7, 95% CI, -19.8, 6.4, 4 studies, n = 140) or duration of mechanical ventilation (WMD -7.5, 95% CI, -16.3, 1.2, 3 studies, n = 101). Duration of mechanical ventilation was decreased when only studies using thoracic epidural analgesia with local anesthetics were evaluated (WMD -4.2, 95% CI, -5.5, -2.9, 2 studies, n = 73). However, hypotension was significantly associated with the use of thoracic epidural analgesia with local anesthetics (OR 13.76, 95% CI, 2.89, 65.51, 3 studies, n = 99).
  
  
  CONCLUSIONS
  No significant benefit of epidural analgesia on mortality, ICU and hospital LOS was observed compared to other analgesic modalities in adult patients with traumatic rib fractures. However, there may be a benefit on the duration of mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics. Further research is required to evaluate the benefits and harms of epidural analgesia in this population before being considered as a standard of care therapy.
authors.affiliation: Department of Anesthesiology, Hôpital de l'Enfant-Jésus, Université Laval, 1401, 18ème rue, Quebec, QC G1J 1Z4, Canada.
authors.forename: François M
authors.initials: FM
authors.lastname: Carrier
authors.forename: Alexis F
authors.initials: AF
authors.lastname: Turgeon
authors.forename: Pierre C
authors.initials: PC
authors.lastname: Nicole
authors.forename: Claude A
authors.initials: CA
authors.lastname: Trépanier
authors.forename: Dean A
authors.initials: DA
authors.lastname: Fergusson
authors.forename: Daniel
authors.initials: D
authors.lastname: Thauvette
authors.forename: Martin R
authors.initials: MR
authors.lastname: Lessard
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects; D003627:Data Interpretation, Statistical; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D010146:Pain / Q000188:drug therapy* / Q000209:etiology; D017594:Publication Bias; D016032:Randomized Controlled Trials as Topic; D015203:Reproducibility of Results; D012121:Respiration, Artificial; D015656:Respiratory Mechanics / Q000502:physiology; D012253:Rib Fractures / Q000150:complications* / Q000209:etiology / Q000401:mortality; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000150:complications