Schaffer Sabina, Bayat Dunya, Biffl Walter L, Smith Jeffrey, Schaffer Kathryn B, Dandan Tala H, Wang Jiayan, Snyder Deb, Nalick Chris, Dandan Imad S, Tominaga Gail T, Castelo Matthew R
Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA.
Orthopedic Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA.
Trauma Surg Acute Care Open. 2022 Mar 24;7(1):e000862. doi: 10.1136/tsaco-2021-000862. eCollection 2022.
The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty caregivers are the norm. We hypothesized that opioid requirements would differ by primary type of injury and by age, and we sought to identify factors affecting opioid prescribing at discharge (DC).
Retrospective analysis of pain management at a level II trauma center for January-November 2018. Consecutive patients with exploratory laparotomy (LAP); 3 or more rib fractures (fxs) (RIB); or pelvic (PEL), femoral (FEM), or tibial (TIB) fxs were included, and assigned to cohorts based on the predominant injury. Patients who died or had head Abbreviated Injury Scale >2 and Glasgow Coma Scale <15 were excluded. All pain medications were recorded daily; doses were converted to oral morphine equivalents (OMEs). The primary outcomes of interest were OMEs administered over the final 72 hours of hospitalization (OME72) and prescribed at DC (OMEDC). Multimodal pain therapy defined as 3 or more drugs used. Categorical variables and continuous variables were analyzed with appropriate statistical analyses.
208 patients were included: 17 LAP, 106 RIB, 31 PEL, 26 FEM, and 28 TIB. 74% were male and 8% were using opiates prior to admission. Injury cohorts varied by age but not Injury Severity Score (ISS) or length of stay (LOS). 64% of patients received multimodal pain therapy. There was an overall difference in OME72 between the five injury groups (p<0.0001) and OME72 was lower for RIB compared with all other cohorts. Compared with younger (age <65) patients, older (≥65 years) patients had similar ISS and LOS, but lower OME72 (45 vs 135*) and OMEDC. Median OME72 differed significantly between older and younger patients with PEL (p=0.02) and RIB (p=0.01) injuries. No relationship existed between OMEDC across injury groups, by sex or injury severity. Patients were discharged almost exclusively by trauma service advanced practice clinicians (APCs). There was no difference among APCs in number of pills or OMEs prescribed. 81% of patients received opioids at DC, of whom 69% were prescribed an opioid/acetaminophen combination drug; and only 13% were prescribed non-steroidal anti-inflammatory drugs, 19% acetaminophen, and 31% gabapentin.
Opioid usage varied among patients with different injury types. Opioid DC prescribing appears rote and does not correlate with actual opioid usage during the 72 hours prior to DC. Paradoxically, OMEDC tends to be higher among females, patients with ISS <16, and those with rib fxs, despite a tendency toward lower OME72 usage among these groups. There was apparent underutilization of non-opioid agents. These findings highlight opportunities for improvement and further study.
IV.
阿片类药物危机促使人们审视阿片类药物的处方和使用模式。普通外科已提出多模式疼痛管理和针对特定手术的有限处方指南，但在创伤领域的研究较少，因为创伤患者通常存在多系统损伤且涉及多个专科护理人员。我们假设阿片类药物的需求量会因主要损伤类型和年龄而有所不同，并试图确定影响出院时阿片类药物处方的因素。
对2018年1月至11月在一家二级创伤中心的疼痛管理进行回顾性分析。纳入连续接受剖腹探查术（LAP）、3处或更多肋骨骨折（RIB）、骨盆骨折（PEL）、股骨骨折（FEM）或胫骨骨折（TIB）的患者，并根据主要损伤将其分为不同队列。排除死亡患者或头部简明损伤量表评分>2且格拉斯哥昏迷量表评分<15的患者。每天记录所有止痛药物；剂量换算为口服吗啡当量（OME）。主要关注的结局指标是住院最后72小时内给予的OME（OME72）以及出院时开具的OME（OMEDC）。多模式疼痛治疗定义为使用3种或更多药物。采用适当的统计分析方法对分类变量和连续变量进行分析。
共纳入208例患者：17例LAP、106例RIB、31例PEL、26例FEM和28例TIB。74%为男性，8%在入院前使用阿片类药物。各损伤队列的年龄有所不同，但损伤严重程度评分（ISS）和住院时间（LOS）无差异。64%的患者接受了多模式疼痛治疗。五个损伤组之间的OME72总体存在差异（p<0.0001），与所有其他队列相比，RIB组的OME72较低。与年轻（年龄<65岁）患者相比，老年（≥65岁）患者的ISS和LOS相似，但OME72（45 vs 135*）和OMEDC较低。老年和年轻的PEL损伤患者（p=0.02）及RIB损伤患者（p=0.01）的OME72中位数存在显著差异。不同损伤组之间、不同性别或损伤严重程度的OMEDC之间均无关联。患者几乎均由创伤服务高级实践临床医生（APC）办理出院。APC开具的药丸数量或OME数量无差异。81%的患者出院时接受了阿片类药物，其中69%开具了阿片类药物/对乙酰氨基酚复方制剂；仅13%开具了非甾体抗炎药，19%开具了对乙酰氨基酚，31%开具了加巴喷丁。
不同损伤类型患者的阿片类药物使用情况各不相同。出院时阿片类药物的处方似乎较为机械，与出院前72小时内的实际阿片类药物使用情况无关。矛盾的是，尽管这些组的OME72使用量有降低趋势，但女性、ISS<16的患者以及肋骨骨折患者的OMEDC往往更高。非阿片类药物存在明显的使用不足。这些发现凸显了改进和进一步研究的机会。
IV级。
