American Surgical Association

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Decreased Risk of Delirium with Use of Regional Anesthesia in Geriatric Trauma Patients with Multiple Rib Fractures
Kathleen O'Connell*, Alex Quistberg*, Robert Tessler*, Bryce Robinson*, Joseph Cuschieri*, Ronald Maier, Frederick Rivara*, Monica Vavilala*, Saman Arbabi
University of Washington, Seattle, WA

Objective: Delirium is a modifiable factor associated with increased morbidity and mortality. The goal was to examine the risk of delirium in geriatric trauma patients with rib fractures treated with systemic opioids compared to those treated with regional anesthesia (RA).
Methods: Cohort study of patients 65 years and older admitted to a regional trauma center from 2011-2016. Inclusion factors were ≥ 3 rib fractures, blunt trauma mechanism, and admission to the ICU. Exclusion criteria included head AIS ≥3, spine AIS ≥3, dementia, and death within 24 hours. The primary outcome was delirium positive ICU days. Delirium incident rate ratios (IRR) and 95% confidence intervals (95% CI) were estimated using generalized linear mixed models with Poisson distribution and robust standard errors.
Results: Of the 144 patients included in the study, 27 (19%) received RA and 117 (81%) received opioid-based systemic analgesia. Of the patients with RA, 14 received epidural catheters, and 13 received paravertebral catheters. Patients with RA were more likely to have a flail segment (P = 0.02), hemopneumothorax (P = 0.03), chest tube placement (P = 0.02) and intubation (P < 0.01). The risk of delirium decreased by 24% per day per patient with initiation of RA (IRR 0.76, 95% CI 0.61, 0.96). Individual opioid use as measured in daily morphine equivalents was significantly reduced after initiation of RA (mean difference -7.62, 95% CI -14.4, -0.81).
Conclusions: The use of regional anesthesia in geriatric trauma patients with multiple rib fractures is associated with a significantly decreased risk of delirium.

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