Older Adults with Broken Ribs: Testing a Numbing Injection Near the Spine (Erector Spinae Plane Block) and the Impact on Breathing and Pain

erector spinae plane (ESP) catheter plus standard analgesia Within 24 h of enrolment an anaesthetist performs an ultrasound-guided ESP block on the fractured-rib side. A Tuohy needle is placed onto the transverse process and 20 mL of 0.2 % ropivacaine is injected beneath the erector-spinae muscle. A multi-orifice catheter is then threaded 3–4 cm and connected to an ambulatory pump. Total duration of ESP-catheter delivery – The ambulatory pump is pre-programmed to give 20 mL of 0.2 % ropivacaine bolus then every four hours for a maximum of 96 h (4 days). The Acute Pain Service (APS) reviews the site and pump settings each morning and will remove the catheter earlier if (i) local infection, leakage or dislodgement is suspected, (ii) analgesia is no longer required, or (iii) the treating anaesthetist believes continuing infusion offers no further benefit. Every day the participant will have an assessment with a Starkmed (Atarmon, NSW, Australia) Portable spirometer and undergo 3 attempts at the best deep breath and forced expiration. This will be to measure FEV1, PEFR and FVC. This will occur every day the patient is in hospital for a maximum of 5 days. This is different to laboratory measurements as the device is portable. This starkmed data will be compared to the laboratory measurements for equivalence. Strategies to monitor adherence/fidelity – • Daily APS ward-round checklist confirms: correct pump program, reservoir volume consistent with expected delivery, intact dressings, and dermatomal “block-to-ice” spread. • The pump’s electronic event log is downloaded on removal and compared with the infusion schedule. • Research staff audit medication charts, nursing progress notes and REDCap fields for “Analgesic medication class and dose taken”, “Total ropivacaine delivered”, and “Protocol adherence – correct pump settings”. • Feasibility targets (greater than 60 % catheters in situ for equal to 5 days; 100 % correct pump settings) are reported with 95 % CIs in the pilot analysis pla. Status of guideline multimodal analgesia – The oral/IV drug protocol is standard care, not part of the investigational intervention. Standard care for rib-fracture patients at our centre is a predefined multimodal analgesia bundle that is entirely independent of the study intervention. Every participant receives regular paracetamol 1 g orally every six hours and, provided there are no renal or other contraindications, celecoxib 200 mg orally twice daily. Break-through pain is managed with immediate-release oral opioids—oxycodone 2.5–10 mg every three hours, tramadol 50–100 mg every six hours, or sublingual buprenorphine 100–400 µg every four hours—with escalation to an intravenous patient-controlled analgesia pump (fentanyl or oxycodone) if oral therapy is inadequate. Where severe pain continues to compromise ventilation, the treating team may commence a low-dose ketamine infusion at 0.1–0.2 mg per kg per h. All medications are charted in the electronic medical record, reviewed during the daily Acute Pain Service ward round, and the class and dose of every analgesic are captured in the REDCap case-report form, giving the research team an objective audit of protocol adherence. Because this regimen is embedded in routine ward practice and is provided to both study arms, it represents usual care rather than an additional element of the research intervention.