ImportanceRib fractures secondary to blunt thoracic trauma typically result in severe pain that is notoriously difficult to manage. The serratus anterior plane block (SAPB) is a regional anesthesia technique that provides analgesia to most of the hemithorax; however, SAPB has limited evidence for analgesic benefits in rib fractures.ObjectiveTo determine whether the addition of an SAPB to protocolized care bundles increases the likelihood of early favorable analgesic outcomes and reduces opioid requirements in patients with rib fractures.Design, Setting, and ParticipantsThis multicenter, open-label, pragmatic randomized clinical trial was conducted at 8 emergency departments across metropolitan and regional New South Wales, Australia, between April 12, 2021, and January 22, 2022. Patients aged 16 years or older with clinically suspected or radiologically proven rib fractures were included in the study. Participants were excluded if they were intubated, transferred for urgent surgical intervention, or had a major concomitant nonthoracic injury. Data were analyzed from September 2022 to July 2023.InterventionsPatients were randomly assigned (1:1) to receive an SAPB in addition to usual rib fracture management or standard care alone.Main Outcomes and MeasuresThe primary outcome was a composite pain score measured 4 hours after enrollment. Patients met the primary outcome if they had a pain score reduction of 2 or more points and an absolute pain score of less than 4 out of 10 points.ResultsA total of 588 patients were screened, of whom 210 patients (median [IQR] age, 71 [55-84] years; 131 [62%] male) were enrolled, with 105 patients randomized to receive an SAPB plus standard care and 105 patients randomized to standard care alone. In the complete-case intention-to-treat primary outcome analysis, the composite pain score outcome was reached in 38 of 92 patients (41%) in the SAPB group and 18 of 92 patients (19.6%) in the control group (relative risk [RR], 0.73; 95% CI, 0.60-0.89; P = .001). There was a clinically significant reduction in overall opioid consumption in the SAPB group compared with the control group (eg, median [IQR] total opioid requirement at 24 hours: 45 [19-118] vs 91 [34-155] milligram morphine equivalents). Rates of pneumonia (6 patients [10%] vs 7 patients [11%]), length of stay (eg, median [IQR] hospital stay, 4.2 [2.2-7.7] vs 5 [3-7.3] days), and 30-day mortality (1 patient [1%] vs 3 patients [4%]) were similar between the SAPB and control groups.Conclusions and RelevanceThis randomized clinical trial found that the addition of an SAPB to standard rib fracture care significantly increased the proportion of patients who experienced a meaningful reduction in their pain score while also reducing in-hospital opioid requirements.Trial Registrationhttp://anzctr.org.au Identifier: ACTRN12621000040864

中文翻译：

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前锯肌平面阻滞治疗早期肋骨骨折疼痛

重要性继发于胸部钝挫伤的肋骨骨折通常会导致严重的疼痛，而且众所周知，这种疼痛很难控制。前锯肌平面阻滞 (SAPB) 是一种区域麻醉技术，可为大部分半胸提供镇痛；然而，SAPB 对于肋骨骨折镇痛效果的证据有限。目的确定在方案护理组合中添加 SAPB 是否会增加肋骨骨折患者早期良好镇痛结果的可能性并减少阿片类药物的需求。设计、设置和参与者这个多中心，开放标签、实用性随机临床试验，于 2021 年 4 月 12 日至 2022 年 1 月 22 日在澳大利亚新南威尔士州大都市和地区的 8 个急诊科进行。 16 岁或以上患有临床怀疑或放射学证明肋骨的患者研究中包括骨折。如果参与者被插管、转院进行紧急手术干预或伴有严重的非胸部损伤，则被排除在外。数据分析时间为 2022 年 9 月至 2023 年 7 月。 干预措施 除了常规肋骨骨折治疗或单独标准护理之外，患者还被随机分配 (1:1) 接受 SAPB。 主要结果和措施 主要结果是术后 4 小时测量的综合疼痛评分注册。如果患者的疼痛评分降低 2 分或以上，并且绝对疼痛评分低于 4 分（满分 10 分），则患者符合主要结局。 结果 总共筛选了 588 名患者，其中 210 名患者（中位 [IQR] 年龄， 71 [55-84] 岁；131 [62%] 男性）入组，其中 105 名患者随机接受 SAPB 加标准治疗，105 名患者随机接受单独标准治疗。在完整病例意向治疗主要结局分析中，SAPB 组 92 名患者中有 38 名 (41%) 达到了综合疼痛评分结果，对照组 92 名患者中有 18 名 (19.6%) 达到了综合疼痛评分结果（相对风险[RR]，0.73；95% CI，0.60-0.89；磷= .001)。与对照组相比，SAPB 组的阿片类药物总消耗量出现临床显着减少（例如，24 小时时阿片类药物总需求中位数 [IQR]：45 [19-118] 与 91 [34-155] 毫克吗啡当量） 。肺炎发生率（6 名患者 [10%] vs 7 名患者 [11%]）、住院时间（例如，中位 [IQR] 住院时间，4.2 [2.2-7.7] 天 vs 5 [3-7.3] 天）和 30 SAPB 组和对照组之间的日死亡率（1 名患者 [1%] 与 3 名患者 [4%]）相似。结论和相关性这项随机临床试验发现，在标准肋骨骨折护理中添加 SAPB 显着增加了发生肋骨骨折的比例。患者的疼痛评分显着降低，同时还减少了院内阿片类药物的需求。试验注册http://anzctr.org.au标识符：ACTRN12621000040864