Regional anaesthesia for early rib fracture associated pain management: Systematic review and network meta-analysis protocol.

IntroductionRib fractures result in significant pain that can impair ventilatory function and result in increased rates of respiratory complication. Early effective analgesia is a crucial treatment goal for these patients however, this is often difficult to achieve. Regional anaesthesia techniques have been used as analgesic adjuncts following thoracic trauma to reduce both pain scores and opioid consumption. More recently, the serratus anterior plane block and erector spinae block have been used in the field of Emergency Medicine as an early analgesic adjunct through either a single depot infiltration of local anaesthetic ( single-shot) or continuous infusion catheter-based blocks in patients with rib fractures. These single-shot blocks are relatively quick and logistically easy to perform. Within the field of Emergency Medicine, the limitations to performing invasive procedures (like catheter-insertion) under strict sterile conditions within an appropriate clinical space makes these single-shot techniques a much more viable option. We will conduct a systematic review of randomised clinical trials (RCTs) with network meta-analysis to test the effectiveness of these single-shot regional anaesthesia techniques on early pain reduction in adult patients with rib fractures. Methods and analysisWe will include RCTs that compare a single-shot regional anaesthesia technique for the purpose of rib fracture management to either placebo, a passive comparison (e.g. standard care management with analgesia), or an active comparison (e.g. one block against another - head-to-head trials). We will perform a search that includes the electronic databases PubMed, MEDLINE, EMBASE, CinAHL and CENTRAL plus clinical trial registries. Two reviewers will independently screen titles and abstracts, perform full article reviews and extract study data, with discrepancies resolved by a third reviewer. We will report study characteristics and quantify risk of bias. We will perform a traditional random-effects meta-analysis for each pairwise comparison and if there is sufficient data, network meta-analysis will be conducted using a Bayesian approach to simultaneously compare multiple treatments via a common comparator (standard care). We will evaluate overall certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation framework. ConclusionThis systematic review and network meta-analysis will provide clinicians with an overview of the effectiveness of the single-shot regional anaesthesia techniques used for early pain reduction in adult patients with rib fractures.