硬膜外置管并不会增加战伤患者静脉血栓栓塞的发生率。

Epidural placement does not result in an increased incidence of venous thromboembolism in combat-wounded patients.

机构信息

From the Department of Surgery (J.D.C., E.A.E., C.J.R.), Walter Reed National Military Medical Center; and Department of Surgery (E.A.E., C.J.R.), Uniformed Services University of the Health Sciences, Bethesda; and Department of Regenerative Medicine (J.D.C., E.A.E.), Naval Medical Research Center, Silver Spring, Maryland.

出版信息

J Trauma Acute Care Surg. 2014 Jul;77(1):61-6; discussion 66. doi: 10.1097/TA.0000000000000273.

DOI:10.1097/TA.0000000000000273

PMID:24977756

Abstract

BACKGROUND

Patient-controlled epidural analgesia (PCEA) decreases the amount of systemic opioid required for adequate analgesia and decreases the rate of opioid-induced adverse effects. Given the location of catheters required to deliver analgesics and the potential for epidural hematoma, the American Society of Regional Anesthesia and Pain Medicine recommends modification of the standard trauma venous thromboembolism (VTE) prophylaxis regimen of enoxaparin 30 mg twice daily to 40 mg daily. The objective of this retrospective study was to determine if 40-mg daily dosing would increase the incidence of VTE.

METHODS

With institutional review board approval, records of all combat casualties admitted to our institution between November 2010 and November 2012 were reviewed for demographics, VTE prophylaxis regimen, PCEA days, and incidence of VTE. Patients who arrived without VTE were the study cohort. Rates of VTE were compared between PCEA and no-PCEA groups. Variables were analyzed with Mann-Whitney U-test, Pearson's χ test, and Fisher's exact test. A p ≤ 0.05 was considered significant. Data are expressed as median (interquartile range).

RESULTS

A total of 565 records were reviewed; 484 met inclusion criteria; and 181 patients (37.4%) had PCEA for 13 days (6-25 days). Age and sex were similar between the groups. PCEA patients were more often injured by dismounted improvised explosive devices (75.1% vs. 39.3%, p < 0.001), had longer hospital stays (38 days vs. 17 days, p < 0.001), had higher Injury Severity Score (ISS) (14 vs. 12, p = 0.033), and were more likely to have an amputation (66.1% vs. 20.4%, p < 0.001). Twenty-three PCEA patients (12.7%) developed VTE versus 32 no-PCEA patients (10.6%) (p = 0.464). Eleven VTE events (47.8%) occurred with the catheter in place, while 12 VTE events (52.2%) occurred 6 days (2-15 days) after removal.

CONCLUSION

Although PCEA catheters were more often placed in patients prone to VTE, there was no difference in incidence of VTE with their use. These data suggest that enoxaparin 40 mg daily in patients with PCEA is not inferior to 30 mg twice daily for VTE prophylaxis in combat-wounded patients.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

摘要

背景

患者自控硬膜外镇痛（PCEA）可减少充分镇痛所需的全身阿片类药物用量，并降低阿片类药物引起的不良反应发生率。鉴于输送镇痛药物所需的导管位置以及硬膜外血肿的潜在风险，美国区域麻醉和疼痛医学学会建议将依诺肝素每日两次 30 毫克的标准创伤静脉血栓栓塞（VTE）预防方案修改为每日 40 毫克。本回顾性研究的目的是确定每日 40 毫克剂量是否会增加 VTE 的发生率。

方法

在获得机构审查委员会批准后，回顾了 2010 年 11 月至 2012 年 11 月期间我院收治的所有战斗伤员的记录，以了解人口统计学特征、VTE 预防方案、PCEA 天数以及 VTE 的发生率。无 VTE 到达的患者为研究队列。比较了 PCEA 组和无 PCEA 组的 VTE 发生率。使用 Mann-Whitney U 检验、Pearson χ检验和 Fisher 确切检验分析变量。p≤0.05 被认为具有统计学意义。数据表示为中位数（四分位距）。

结果

共审查了 565 份记录；符合纳入标准的有 484 份；181 名患者（37.4%）接受了 13 天（6-25 天）的 PCEA。两组的年龄和性别相似。PCEA 患者更常因非机动简易爆炸装置受伤（75.1%比 39.3%，p<0.001），住院时间更长（38 天比 17 天，p<0.001），损伤严重程度评分（ISS）更高（14 比 12，p=0.033），更有可能截肢（66.1%比 20.4%，p<0.001）。23 名 PCEA 患者（12.7%）发生 VTE，32 名无 PCEA 患者（10.6%）发生 VTE（p=0.464）。11 例 VTE 事件（47.8%）发生在导管放置时，而 12 例 VTE 事件（52.2%）发生在导管取出后 6 天（2-15 天）。