低剂量氯胺酮输注对多发性肋骨骨折患者的标准循证治疗无获益。
No benefit from the addition of low-dose ketamine infusion to standard evidence-based care of patients with multiple rib fractures.
机构信息
From the Division of Trauma, Critical Care, and Emergency Surgery (C.M., J.F., J.G., P.L., M.A.W.), North Memorial Health; and Department of Surgery (M.A.W.), University of Minnesota, Minneapolis, Minnesota.
出版信息
J Trauma Acute Care Surg. 2024 Nov 1;97(5):770-775. doi: 10.1097/TA.0000000000004398. Epub 2024 May 27.
BACKGROUND
Multiple rib fractures from blunt thoracic trauma cause significant morbidity. Optimal current management includes multimodal analgesia, pulmonary hygiene, and early mobilization. Low-dose ketamine infusion (LDKI) has been proposed as an adjunctive analgesic in this setting. A prior study reported decreased pain scores with LDKI in patients with multiple rib fractures. We hypothesized that LDKI would decrease morphine milligram equivalents (MMEs) in patients with multiple rib fractures.
METHODS
A prospective randomized placebo-controlled trial was performed in adult (18 years or older) patients with three or more rib fractures. A prestudy power analysis calculated an 80% chance of identifying a 15% decrease in MMEs with 50 subjects. The study was approved by the institutional review board and informed consent obtained in all subjects. Demographic (age, sex) and injury specific information (Injury Severity Score, number of rib fractures) were obtained. Subjects were randomized 1:1 to receive continuous LDKI (0.1 mg/kg/h) or placebo infusion (0.9% NaCl) for ≤48 hours. All patients received a standard evidence-based multidisciplinary protocol for rib fractures management. Primary outcome measure was MME use or pulmonary complications. Statistical comparison of LDKI versus placebo was performed using the Mann-Whitney U test.
RESULTS
All 50 enrolled subjects (placebo, 25; LDKI, 25) received study drug infusion. The two groups were well matched for age, Injury Severity Score, and number of rib fractures. We observed no differences in the Day 1 (p = 0.961), Day 2 (p = 0.373), or total MMEs (p = 0.946) between groups. Similar total MME use was observed when subjects who received ≥40 hours of study drug and were compared (p = 0.924). Use of LDKI did not alter subsequent need for opiate analgesics postinfusion, hospital length of stay, pulmonary complications, or need for readmission.
CONCLUSION
The addition of LDKI to an established multimodal, evidence-based protocol for management of multiple rib fractures did not decrease opiate usage or impact pulmonary complications.
LEVEL OF EVIDENCE
Therapeutic/Care Managaement; Level I.
背景
钝性胸部创伤导致的多发性肋骨骨折会引起明显的发病率。目前的最佳治疗方法包括多模式镇痛、肺保健和早期活动。小剂量氯胺酮输注（LDKI）已被提议作为该情况下的辅助镇痛剂。先前的一项研究报告称，LDKI 可降低多发性肋骨骨折患者的疼痛评分。我们假设 LDKI 会降低多发性肋骨骨折患者的吗啡毫克当量（MME）。
方法
对 3 根或 3 根以上肋骨骨折的成年（18 岁或以上）患者进行前瞻性随机安慰剂对照试验。一项预研究的功效分析计算出，在 50 名患者中，有 80%的机会确定 MME 降低 15%。该研究获得了机构审查委员会的批准，并在所有患者中获得了知情同意。收集了人口统计学（年龄、性别）和损伤特异性信息（损伤严重程度评分、肋骨骨折数量）。将患者随机分为 1:1 接受连续 LDKI（0.1mg/kg/h）或安慰剂输注（0.9%生理盐水）≤48 小时。所有患者均接受了基于证据的多学科肋骨骨折管理标准方案。主要结局指标是 MME 使用或肺部并发症。使用 Mann-Whitney U 检验比较 LDKI 与安慰剂。
结果
所有纳入的 50 名患者（安慰剂组 25 名；LDKI 组 25 名）均接受了研究药物输注。两组在年龄、损伤严重程度评分和肋骨骨折数量方面匹配良好。我们观察到第 1 天（p=0.961）、第 2 天（p=0.373）或总 MME 之间无差异（p=0.946）。当比较接受≥40 小时研究药物的患者时，观察到相似的总 MME 使用（p=0.924）。使用 LDKI 并不会改变输注后阿片类药物镇痛剂的后续需求、住院时间、肺部并发症或再次入院的需求。
结论
在既定的多模式、基于证据的多发性肋骨骨折管理方案中添加 LDKI 并未减少阿片类药物的使用或影响肺部并发症。
证据水平
治疗/护理管理；1 级。
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