Carrier François M, Turgeon Alexis F, Nicole Pierre C, Trépanier Claude A, Fergusson Dean A, Thauvette Daniel, Lessard Martin R
Department of Anesthesiology, Hôpital de l'Enfant-Jésus, Université Laval, 1401, 18ème rue, Quebec, QC G1J 1Z4, Canada.
Can J Anaesth. 2009 Mar;56(3):230-42. doi: 10.1007/s12630-009-9052-7. Epub 2009 Feb 11.
A consensus group recently proposed epidural analgesia as the optimal analgesic modality for patients with multiple traumatic rib fractures. However, its beneficial effects are not consistently recognized in the literature. We performed a systematic review and a meta-analysis of randomized controlled trials (RCT) of epidural analgesia in adult patients with traumatic rib fractures.
A systematic search strategy was applied to MEDLINE, EMBASE, the Cochrane Library and to the annual meeting of relevant societies (up to July 2008). All randomized controlled trials comparing epidural analgesia with other analgesic modalities in adult patients with traumatic rib fractures were included. Primary outcomes were mortality, ICU length of stay (LOS), hospital LOS and duration of mechanical ventilation.
Eight studies (232 patients) met eligibility criteria. Epidural analgesia did not significantly affect mortality (odds ratio [OR] 1.6, 95% CI, 0.3, 9.3, 3 studies, n = 89), ICU LOS (weighted mean difference [WMD] -3.7 days, 95% CI, -11.4, 4.0, 4 studies, n = 135), hospital LOS (WMD -6.7, 95% CI, -19.8, 6.4, 4 studies, n = 140) or duration of mechanical ventilation (WMD -7.5, 95% CI, -16.3, 1.2, 3 studies, n = 101). Duration of mechanical ventilation was decreased when only studies using thoracic epidural analgesia with local anesthetics were evaluated (WMD -4.2, 95% CI, -5.5, -2.9, 2 studies, n = 73). However, hypotension was significantly associated with the use of thoracic epidural analgesia with local anesthetics (OR 13.76, 95% CI, 2.89, 65.51, 3 studies, n = 99).
No significant benefit of epidural analgesia on mortality, ICU and hospital LOS was observed compared to other analgesic modalities in adult patients with traumatic rib fractures. However, there may be a benefit on the duration of mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics. Further research is required to evaluate the benefits and harms of epidural analgesia in this population before being considered as a standard of care therapy.
一个共识小组最近提议硬膜外镇痛作为多发创伤性肋骨骨折患者的最佳镇痛方式。然而，其有益效果在文献中并未得到一致认可。我们对成年创伤性肋骨骨折患者硬膜外镇痛的随机对照试验（RCT）进行了系统评价和荟萃分析。
采用系统检索策略检索MEDLINE、EMBASE、Cochrane图书馆以及相关学会的年会（截至2008年7月）。纳入所有比较成年创伤性肋骨骨折患者硬膜外镇痛与其他镇痛方式的随机对照试验。主要结局指标为死亡率、重症监护病房（ICU）住院时间、医院住院时间和机械通气时间。
八项研究（232例患者）符合纳入标准。硬膜外镇痛对死亡率（比值比[OR]1.6，95%可信区间[CI]，0.3，9.3，3项研究，n = 89）、ICU住院时间（加权均数差[WMD] -3.7天，95%CI，-11.4，4.0，4项研究，n = 135）、医院住院时间（WMD -6.7，95%CI，-19.8，6.4，4项研究，n = 140）或机械通气时间（WMD -7.5，95%CI，-16.3，1.2，3项研究，n = 101）均无显著影响。仅对使用局部麻醉药的胸段硬膜外镇痛的研究进行评估时，机械通气时间缩短（WMD -4.2，95%CI，-5.5，-2.9，2项研究，n = 73）。然而，低血压与使用局部麻醉药的胸段硬膜外镇痛显著相关（OR 13.76，95%CI，2.89，65.51，3项研究，n = 99）。
与其他镇痛方式相比，在成年创伤性肋骨骨折患者中，未观察到硬膜外镇痛对死亡率、ICU和医院住院时间有显著益处。然而，使用局部麻醉药的胸段硬膜外镇痛可能对机械通气时间有益。在被视为标准治疗方法之前，需要进一步研究评估硬膜外镇痛在该人群中的利弊。
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