多根肋骨骨折老年患者使用区域镇痛与谵妄风险：东部创伤外科学会多中心研究。
Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study.
机构信息
From the Department of Surgery (K.M.O'C., B.R.H.R., S.A.), Department of Anesthesiology and Pain Medicine (K.V.P., E.P., M.S.V.), and Department of Pediatrics (F.R.), Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Department of Surgery (K.B.), Medical College of Wisconsin, Milwaukee; Department of Surgery (J.P.), Gundersen Health System, La Crosse, Wisconsin; Department of Family Medicine (E.C.B-S.), Mercy Health, Muskegon, Michigan; Department of Surgery (L.J.), St. Vincent Indianapolis Hospital, Indianapolis, Indiana; School of Medicine (J.L.), Department of Surgery (M.L.M.), University of Utah, Salt Lake City, Utah; Department of Surgery (J.B., K.J.B.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (J.J.), Mission Trauma Services, Asheville, North Carolina; Department of Surgery (S.G., K.M.), Loma Linda University, Loma Linda, California; Harborview Injury Prevention and Research Center (Q.Q.), Seattle, Washington.
出版信息
J Trauma Acute Care Surg. 2021 Aug 1;91(2):265-271. doi: 10.1097/TA.0000000000003258.
BACKGROUND
Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers.
METHODS
Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence.
RESULTS
Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16).
CONCLUSION
In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury.
LEVEL OF EVIDENCE
Therapeutic, level IV; Epidemiologic, level III.
背景
单中心数据表明，区域镇痛（RA）技术可降低多发性肋骨骨折老年患者发生谵妄的风险。我们假设，在来自多个一级创伤中心的更大患者队列中，RA 和谵妄之间也会出现类似的关联。
方法
收集了 2012 年 1 月至 2016 年 12 月期间七个一级创伤中心 ICU 中 65 岁或以上、有≥3 根肋骨骨折的患者的回顾性数据。排除头部和/或脊柱损伤损伤严重程度评分（AIS）≥3 或有痴呆病史的患者。谵妄的定义为 ICU 护理的前 7 天内有一个阳性的 ICU 意识模糊评估法评分。使用具有稳健标准误差的泊松回归来确定 RA（胸硬膜外或椎旁导管）与谵妄发生率的关联。
结果
分析了 574 名中位年龄为 75 岁（四分位距[IQR]，69-83）、损伤严重程度评分 14（IQR，11-18）和 ICU 住院时间 3 天（IQR，2-6 天）的患者的数据。患者中 38.9%为女性，15.3%为非白人，31.4%需要胸腔引流管。19.3%的患者使用了区域镇痛。RA 使用与患者特征无差异；然而，RA 患者的胸部损伤更严重（胸部 AIS、浮动段、血气胸、胸腔引流管）。在单变量分析中，RA 组和无 RA 组发生谵妄的可能性无差异（18.9% vs. 23.8%，p=0.28）。在调整年龄、性别、损伤严重程度评分、最大胸部 AIS、胸腔引流管、ICU 住院时间和创伤中心后，RA 与谵妄风险降低相关（发病率比[IRR]，0.65；95%置信区间[CI]，0.44-0.94），但与院内死亡率（IRR，0.42；95%CI，0.14-1.26）或呼吸并发症（IRR，0.70；95%CI，0.42-1.16）无关。
结论
在这个多中心队列中，患有多发性肋骨骨折的老年受伤患者中，RA 的使用与谵妄风险降低 35%相关。需要进一步的研究来制定标准化方案，以实现老年严重胸部损伤患者的最佳疼痛管理和谵妄预防。
证据水平
治疗，IV 级；流行病学，III 级。
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