From the Departments of Surgery (S.A., A.G.) and Pediatrics (F.R., J.W.), University of Washington, Seattle, Washington; and Department of Surgery (G.J.J.), University of Colorado, Denver, Colorado.
J Trauma Acute Care Surg. 2014 Jan;76(1):39-45; discussion 45-6. doi: 10.1097/TA.0b013e3182ab1b08.
In studies of trauma patients with rib fractures, conclusions on the benefits derived from epidural analgesia are inconsistent. The purpose of this study was to further evaluate placement and efficacy of epidural analgesia nationwide.
This was a retrospective cohort study of prospectively gathered data from the National Study on Cost and Outcomes of Trauma database, a multisite prospective study of injured patients aged 18 years to 84 years. Patients were treated at 69 participating hospitals (18 Level I trauma centers and 51 nontrauma centers) across the United States. Our analysis was limited to patients with a blunt mechanism of injury and a thoracic maximum Abbreviated Injury Scale (MAXAIS) score of 2 or greater. Excluded were patients who were not potential candidates for epidural placement, such as patients with significant head and spine injuries (head MAXAIS score > 2 or spine MAXAIS score > 2), significant neurologic impairment (best motor Glasgow Coma Scale [GCS] score < 4), unstable pelvic fractures, coagulopathy, or those who died within 48 hours.
The National Study on Cost and Outcomes of Trauma database contains 5,043 patients, of whom 836 (16.5%) were identified as potential candidates for epidural placement. Of patients included in the study, 100 patients (12%) had epidural catheters placed. The likelihood of epidural catheter placement was significantly higher in trauma centers as compared with nontrauma centers (adjusted odds ratio, 3.06; 95% confidence interval [CI] 1.80-5.22). In the epidural group compared with those not receiving a catheter, the adjusted (including trauma center status) odds of death in patients with three or more rib fractures at 30, 90, and 365 days was 0.08 (95% CI, 0.01-0.43), 0.09 (95% CI, 0.02-0.42), and 0.12 (95% CI, 0.04-0.42), respectively.
Trauma centers are more likely to place epidural catheter in patients with rib fractures. In this multicenter study, epidural catheter placement was associated with a significantly decreased risk of dying in patients with blunt thoracic injury of three or more rib fractures.
Therapeutic study, level II.
在创伤患者肋骨骨折的研究中，关于硬膜外镇痛获益的结论并不一致。本研究的目的是进一步评估全国范围内硬膜外镇痛的置管和效果。
这是一项来自全国创伤成本和结局研究数据库的前瞻性队列研究的回顾性分析，该数据库是一项针对 18 岁至 84 岁受伤患者的多地点前瞻性研究。患者在全美 69 家参与医院（18 家一级创伤中心和 51 家非创伤中心）接受治疗。我们的分析仅限于钝性损伤机制和胸部简明损伤评分（MAXAIS）≥2 分的患者。排除了不是硬膜外置管潜在候选者的患者，例如头部 MAXAIS 评分>2 或脊柱 MAXAIS 评分>2 的患者、有明显神经功能障碍（最佳运动格拉斯哥昏迷量表[GCS]评分<4）、不稳定骨盆骨折、凝血功能障碍或在 48 小时内死亡的患者。
全国创伤成本和结局研究数据库包含 5043 名患者，其中 836 名（16.5%）被确定为硬膜外置管的潜在候选者。在所研究的患者中，有 100 名患者（12%）置管。与非创伤中心相比，创伤中心硬膜外置管的可能性明显更高（调整后的优势比，3.06；95%置信区间[CI]1.80-5.22）。与未接受导管的患者相比，在 30、90 和 365 天时，有 3 根或更多肋骨骨折的患者中，接受硬膜外导管治疗的患者的调整后（包括创伤中心状态）死亡的几率为 0.08（95%CI0.01-0.43）、0.09（95%CI0.02-0.42）和 0.12（95%CI0.04-0.42）。
创伤中心更有可能在肋骨骨折患者中置管。在这项多中心研究中，硬膜外导管置管与钝性胸部损伤 3 根或更多肋骨骨折患者死亡风险显著降低相关。
治疗研究，II 级。
