Implications of Thoracic Epidural Analgesia on Hospital Charges in Rib Fracture Patients.

Objective: Rib fractures are present in more than 150,000 patients admitted to US trauma centers each year. Those who fracture two or more ribs are typically treated with oral analgesic drugs and are discharged with few complications. The cost of this care generally reflects its brevity. When a patient fractures three or more ribs, there is an elevated risk of complication. In response, treatments are often broadened and their durations prolonged; this affects cost. While health, function, and survival have been widely explored, patient billing has not. Thus, we evaluated the financial implications of one mode of treatment for patients with rib fractures: thoracic epidural analgesia (TEA). Methods: We retrospectively analyzed the registry of a level II trauma center. All patients who fractured one or more ribs (n = 1,344) were considered; 382 of those patients were not candidates for epidural placement and were eliminated from analyses. Epidural placement was determined by individual clinicians. We used multiple linear regressions to determine predictors of cost. Results: After eliminating patients who were not eligible to receive TEA, the average patient bill was $59,123 ($10,631 per day of treatment). The administration of TEA predicted a 25% reduction in total billing (99% CI = -$21,429.55- -$7,794.66) and a 24% reduction in per-day billing (99% CI = -$3,745.99- -$1,276.14). Conclusions: Patients who received TEA were more severely injured and required longer treatments; controlling for these variables, the use of TEA associated with reductions in the cost of receiving care. From an administrative and insurance perspective, more frequent reliance on TEA may be indicated.

Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures.

OBJECTIVE: Each year, more than 150,000 patients with rib fractures are admitted to US trauma centers; as many as 10% die. Effective pain control is critical to survival. One way to manage pain is thoracic epidural analgesia. If this treatment reduces mortality, more frequent use may be indicated. METHODS: We analyzed the patient registry of a level II trauma center. All patients admitted with one or more rib fractures (N = 1,347) were considered. Patients who were not candidates for epidural analgesia (N = 382) were eliminated. Mortality was assessed with binary logistic regressions. RESULTS: Across the total population, mortality was 6.7%; incidence of pneumonia was 11.1%; mechanical ventilation was required in 23.8% of patients, for an average duration of 10.0 days; average stay in the hospital was 7.7 nights; and 49.7% of patients were admitted to the ICU for an average of 7.2 nights. Epidural analgesia was administered to 18.4% of patients. After matching samples for candidacy, patients who received epidurals were 3.7 years older, fractured 2.6 more ribs, had higher injury severity scores, and were more likely to present with bilateral fractures, flail segments, pulmonary contusions, hemothoraces, and pneumothoraces. Despite greater injury severity, mortality among these patients was lower (0.5%) than those who received alternative care (1.9%). Controlling for age, injury severity, and use of mechanical ventilation, epidural analgesia predicted a 97% reduction in mortality. CONCLUSION: Thoracic epidural analgesia associates with reduced mortality in rib fracture patients. Better care of this population is likely to be facilitated by more frequent reliance on this treatment.

Delayed-onset malignant hyperthermia in association with rocuronium use.

PURPOSE: Two cases of malignant hyperthermia suspected to be related to the use of a nondepolarizing neuromuscular blocker are reported. SUMMARY: A pharmacogenetic disorder that may occur in as many as 1 in 3000 anesthesia procedures, malignant hyperthermia has been linked to the use of certain anesthetic gases and depolarizing neuromuscular blocking agents (e.g., succinylcholine). Although nondepolarizing neuromuscular blockers were cited as contributing to the development of malignant hyperthermia in a small number of published reports, the agents are generally considered safe for use in at-risk patients. Here investigators report two cases in which the nondepolarizing agent rocuronium is thought to have triggered malignant hyperthermia in patients with no known history of the disorder. In one case, a critically ill 27-year-old man undergoing an induced-hypothermia protocol developed a fever about 4 days after receiving rocuronium infusions, with temperatures rising over 11 days to a maximum of 105.2 °F. In the other case, a 63-year-old man being treated for serious complications of elective surgery developed extreme fever (maximum temperature of 107.1 °F) about 4 days after receiving two bolus doses and a continuous infusion of rocuronium. In both cases, the discontinuation of rocuronium therapy was followed by the rapid diminution of fever over 12-36 hours. After consultations with medical staff and consideration of other potential causal and contributory factors (e.g., neurologic injury, antimicrobial-induced fever), rocuronium was deemed the most likely trigger of the severe febrile response experienced by these two patients. CONCLUSION: A 27-year-old man and a 63-year-old man received rocuronium and subsequently developed delayed-onset malignant hyperthermia, which resolved after the rocuronium was discontinued.