Beyene Robel T, Wallace Marshall W, Statzer Nicholas, Hamblin Susan E, Woo Edward, Nelson Scott D, Allen Brian F S, McEvoy Matthew D, Riffert Derek A, Wesoloski Amber N, Ye Fei, Irlmeier Rebecca, Fiorentino Michele, Dennis Bradley M
From the Division of Acute Care Surgery (R.T.B., M.F., B.M.D.), Vanderbilt University Medical Center, Nashville, Tennessee; Division of General Surgery (M.W.W.), University of Utah School of Medicine, Salt Lake City, Utah; Department of Anesthesiology (N.S., B.A., A.N.W.), Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pharmacy Practice (S.E.H.), Lipscomb University College of Pharmacy and Health Sciences, Nashville, Tennessee; Department of Biomedical Informatics (E.W., S.D.N.), Vanderbilt University Medical Center, Nashville, Tennessee; Paradigm Health (M.D.M.), PLLC, Franklin, Tennessee; Vanderbilt University School of Medicine (D.R.); and Department of Biostatistics (F.Y., R.I.), and Department of Medicine (F.Y.), Vanderbilt University Medical Center, Nashville, Tennessee.
J Trauma Acute Care Surg. 2024 Dec 1;97(6):849-855. doi: 10.1097/TA.0000000000004445. Epub 2024 Sep 13.
Thoracic epidural catheters (TECs) are useful adjuncts to multimodal pain regimens in traumatic rib fractures. However, TEC placement is limited by contraindications, patient risk profile, and provider availability. Continuous peripheral infusion of ketamine and/or lidocaine is an alternative that has a modest risk profile and few contraindications. We hypothesized that patients with multiple traumatic rib fractures receiving TECs would have better pain control, in terms of daily morphine milligram equivalents (MMEs) and mean pain scores (MPSs) when compared with continuous peripheral infusions of ketamine and/or lidocaine.
We retrospectively analyzed traumatic rib fracture admissions to a level 1 trauma center between January 2018 and December 2020. We evaluated two treatment groups: TEC only and continuous infusion only (drip only). A linear mixed-effects model evaluated the association of MME with treatment group. An interaction term of treatment group by time (days 1-7) was included to allow estimating potential time-dependent treatment effect on MME. A zero-inflated Poisson mixed-effects model evaluated the association of treatment with MPS. Both models adjusted for confounders.
A total of 1,647 patients were included. After multivariable analysis, a significant, time-varying dose-response relationship between treatment group and MME was found, indicating an opioid-sparing effect favoring the TEC-only group. The opioid-sparing benefit for TEC-only therapy was most prominent at day 3 (27.4 vs 36.5 MME) and day 4 (27.3 vs 36.2 MME) ( p < 0.01). The drip-only group had 1.21 times greater MPS than patients with TEC only ( p < 0.001).
Drip-only analgesia is associated with higher daily MME use and MPS, compared with TEC only. The maximal benefit of TEC therapy appears to be on days 3 and 4. Prospective, randomized comparison between groups is necessary to evaluate the magnitude of the treatment effect.
Therapeutic/Care Management; Level III.
胸段硬膜外导管（TECs）是创伤性肋骨骨折多模式镇痛方案的有用辅助手段。然而，TEC的放置受到禁忌症、患者风险状况和医护人员可用性的限制。氯胺酮和/或利多卡因持续外周输注是一种风险较低且禁忌症较少的替代方法。我们假设，与氯胺酮和/或利多卡因持续外周输注相比，接受TECs的多发性创伤性肋骨骨折患者在每日吗啡毫克当量（MMEs）和平均疼痛评分（MPSs）方面将有更好的疼痛控制。
我们回顾性分析了2018年1月至2020年12月期间一家一级创伤中心收治的创伤性肋骨骨折患者。我们评估了两个治疗组：仅使用TEC组和仅持续输注组（仅滴注组）。线性混合效应模型评估了MME与治疗组之间的关联。纳入治疗组与时间（第1 - 7天）的交互项，以估计对MME的潜在时间依赖性治疗效果。零膨胀泊松混合效应模型评估了治疗与MPS之间的关联。两个模型均对混杂因素进行了校正。
共纳入1647例患者。多变量分析后，发现治疗组与MME之间存在显著的、随时间变化的剂量反应关系，表明仅TEC组具有阿片类药物节省效应。仅TEC治疗的阿片类药物节省效益在第3天（27.4对36.5 MME）和第4天（27.3对36.2 MME）最为显著（p < 0.01）。仅滴注组的MPS比仅使用TEC的患者高1.21倍（p < 0.001）。
与仅使用TEC相比，仅滴注镇痛与每日更高的MME使用量和MPS相关。TEC治疗的最大益处似乎出现在第3天和第4天。有必要进行组间前瞻性随机比较以评估治疗效果的大小。
治疗/护理管理；三级。
