老年多发性肋骨骨折的非手术治疗与镇痛策略：来自东部创伤外科学会和胸壁损伤协会的系统评价、荟萃分析及联合实践管理指南
Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society.
作者信息
Mukherjee Kaushik, Schubl Sebastian D, Tominaga Gail, Cantrell Sarah, Kim Brian, Haines Krista L, Kaups Krista L, Barraco Robert, Staudenmayer Kristan, Knowlton Lisa M, Shiroff Adam M, Bauman Zachary M, Brooks Steven E, Kaafarani Haytham, Crandall Marie, Nirula Raminder, Agarwal Suresh K, Como John J, Haut Elliott R, Kasotakis George
机构信息
From the Division of Acute Care Surgery, Loma Linda University Medical Center (K.M.), Loma Linda; University of California Irvine Medical Center (S.D.S.), Irvine; Scripps Memorial La Jolla (G.T.), San Diego, California; Division of Trauma and Critical Care Surgery, Department of Surgery (S.C., K.L.H., S.K.A., G.K.), Duke University Medical Center, Durham, North Carolina; The Mayo Clinic (B.K.), Rochester, Minnesota; University of California San Francisco-Fresno (K.L.K.), Fresno, California; Lehigh Valley Health Network (R.B.), Allentown, Pennsylvania; Stanford University Medical Center (K.S., L.M.K.), Palo Alto, California; University of Pennsylvania Medical Center (A.M.S.), Philadelphia, Pennsylvania; University of Nebraska Medical Center (Z.M.B.), Omaha, Nevada; Texas Tech University Health Sciences Center (S.E.B.), Lubbock, Texas; Massachusetts General Hospital (H.K.), Boston, Massachusetts; University of Florida College of Medicine (M.C.), Jacksonville, Florida; University of Utah Medical Center (R.N.), Salt Lake City, Utah; MetroHealth Cleveland Medical Center (J.J.C.), Cleveland, Ohio; Johns Hopkins Medical Center (E.R.H.), Baltimore, Maryland.
出版信息
J Trauma Acute Care Surg. 2023 Mar 1;94(3):398-407. doi: 10.1097/TA.0000000000003830. Epub 2022 Nov 15.
BACKGROUND
Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia.
METHODS
Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used.
RESULTS
Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality.
CONCLUSION
We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia.
LEVEL OF EVIDENCE
Systematic Review/Meta-analysis; Level IV.
背景
老年患者胸壁损伤是发病和死亡的重要原因。关于这些患者的最佳非手术管理策略，在护理级别、激励性肺量计（IS）、无创正压通气（NIPPV）以及氯胺酮、硬膜外和其他局部区域镇痛方法的使用方面尚未完全明确。
方法
针对患有严重胸壁损伤的老年患者，选择了与患者群体、干预措施、对照以及适当选定结局相关的问题。这些问题聚焦于重症监护病房（ICU）入院、IS、NIPPV以及包括氯胺酮、硬膜外镇痛和局部区域神经阻滞在内的镇痛。进行了系统的文献检索和综述，对我们的数据进行了定性和定量分析，并根据推荐分级评估、制定和评价方法评估了证据质量。未使用资金。
结果
我们的文献综述（PROSPERO 2020 - CRD42020201241，MEDLINE、EMBASE、Cochrane、科学引文索引，2020年1月15日）共检索到151项研究。除临床评估外，对于任何定义的队列，ICU入院在定性方面并无优势。IS表现不佳与住院时间延长、肺部并发症和非计划入住ICU相关。在没有气道丧失风险的合适患者中，无创正压通气与肺炎发生率降低85%（p < 0.0001）和死亡率降低81%（p = 0.03）相关。使用氯胺酮虽未显著降低疼痛评分，但有减少阿片类药物使用的趋势。硬膜外和其他局部区域镇痛技术并未影响肺炎、机械通气时间、住院时间或死亡率。
结论
我们不推荐或反对常规ICU入院。我们建议使用IS来告知ICU状态，并有条件地建议在没有气道丧失风险的患者中使用NIPPV。对于氯胺酮、硬膜外或其他局部区域镇痛，我们不给出推荐或反对意见。
证据级别
系统评价/荟萃分析；四级。
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