Galvagno Jr SM, Smith CE, Varon AJ, Hasenboehler EA, et al. Journal of Trauma and Acute Care Surgery. 2016 Nov 1;81(5):936-51.
| Background | In humans and at the time of the published review (2016), thoracic trauma was considered the second most prevalent nonintentional injury in the United States that was associated with significant morbidity. However, practice management guidelines pertaining to analgesia was last published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma, the authors sought to develop updated guidelines for this topic. |
| Rational and Objective | To evaluate the optimal mode of analgesia and develop a decision-making guideline for patients with blunt thoracic trauma. The guidelines represent a detailed summary and comprehensive overview of the literature regarding analgesia for blunt thoracic trauma intended to inform the decision-making process, but not replace clinical judgment. |
| Trial Design | Systematic review of five major databases: PubMed, EMBASE, CINAHL, MEDLINE (OVID), and The Cochrane Register of Controlled Trials electronic databases. The review was conducted by answering five PICO questions (population [P], intervention [I], comparator[C], and outcome [O]) with the quality of the evidence for each outcome in a PICO format evaluated using the GRADE framework. |
| Patient population and location | The review only included studies pertaining to the treatment of hospitalized patients with blunt thoracic trauma. Blunt thoracic trauma was defined as: Chest wall injuries (rib fracture, flail chest, sternal fracture, and soft tissue contusion);Intrapleural lesions (hemothorax, pneumothorax);Parenchymal lung injuries (pulmonary contusion, lung laceration);Mediastinal lesions (blunt cardiac injury or great vessel injury) Included studies of adult patients (>16 years of age) without restricting gender, ethnicity, or degree of comorbidity. |
| Methods |
Systematic review of five major databases: PubMed, EMBASE, CINAHL, MEDLINE (OVID), and The Cochrane Register of Controlled Trials electronic databases using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework. Inclusion criteria: Randomized controlled trials (RCTs), case control studies, and prospective or retrospective observational cohort studies (with a comparator group). Exclusion: Reviews containing no original data or comments. Intervention Comparison: Studies evaluating Intervention (I) vs. Comparator (C) populations: Intervention studies involved populations receiving: Regional anesthetic techniques Epidural catheters (PICO 1)Paravertebral catheters (PICO 2), Intercostal nerve blocks (PICO 5), Intrapleural infusions of anesthetics (PICO 3), Multimodal approaches (i.e., opioids plus pregabalin/gabapentin, or other nonregional drug combinations), (PICO 4)Comparator population studies included:Nonregional techniques (i.e., intravenous or enteral analgesics such as opioids, acetaminophen, NSAIDs). |
| Endpoints (if applicable) | In a population of adult patients with blunt thoracic trauma (P), five interventions (I), listed below, were compared against nonregional modalities of pain control (C) (i.e., intravenous or enteral analgesics such as opioids, acetaminophen, NSAIDs) to evaluate their effectiveness for the following Outcomes (O): Improve analgesia, Decrease pulmonary complications and need for mechanical ventilation, Shorten length of stay, and/or Decrease mortality (O)? Interventions (I): Epidural catheters (PICO 1)Paravertebral catheters (PICO 2), Intrapleural infusions of anesthetics (PICO 3), Multimodal approaches (i.e., opioids plus pregabalin/gabapentin, or other nonregional drug combinations), (PICO 4)Intercostal nerve blocks (PICO 5). |
| Results |
Search results: 332 pieces of literature identified whereby 70 were deemed appropriate for full text review. 28 studies were included in developing guideline recommendations. All 28 studies were analyzed qualitatively, whereas only 12 of 28 studies were included for quantitative analysis (meta-analysis). All 12 studies analyzed quantitatively pertained to PICO Q.1. PICO Q. 2, 4, and 5: although no articles that met the strict inclusion criteria for evaluation could be found, a qualitative review was performed for articles that were tangentially pertinent to this recommendation. PICO Question Recommendations: PICO 1 Recommendation: In adult patients with blunt thoracic trauma, the authors conditionally recommend epidural analgesia over nonregional modalities of pain control (i.e., intravenous or enteral analgesics such as opioids, acetaminophen, NSAIDs) for the treatment of pain. This recommendation is based on very low-quality evidence. PICO 2 Recommendation: paravertebral block had equivalent pain control compared with epidural analgesia and provided significant pain relief compared with baseline. While desirable consequences probably outweigh undesirable consequences, because of the lack of studies comparing paravertebral block to nonregional pain control modalities, the authors were unable to make a recommendation regarding the use of paravertebral blocks. PICO 3 Recommendation: There is limited available literature regarding intrapleural analgesia for blunt thoracic trauma. The few studies that were identified were of very poor methodological quality. Because of insufficient evidence, the authors were unable to make a recommendation. PICO 4 Recommendation Although the quality and quantity of evidence for the use of multimodal analgesia in adult patients with blunt thoracic trauma is very limited, the authors conditionally recommend this modality. This recommendation is based on very low-quality evidence but places a high value on patient preferences for analgesia. There was some indirect evidence that multiple analgesic modalities (i.e., transdermal fentanyl, NSAIDs), when combined, decrease pain in patients with blunt thoracic trauma. Use of alternative agents for patients with refractory pain is consistent with the clinical experience of the group, as patients often seek alternatives when a standard sole opioid regimen fails.Moreover, standard sole opioid regimens are often associated with adverse effects, especially as doses are escalated, thus requiring consideration for additional nonopioid analgesics. PICO 5 Recommendation:Because of the lack of studies that fulfilled our inclusion criteria, no evidence profile was created. Because of insufficient evidence, the authors were unable to make a recommendation. |
| Limitations | Human study. Overall risk of bias for all studies was high.Low quality of available literature pertaining specifically to patients with blunt thoracic trauma prevented the ability to formulate any strong recommendations. |
| Clinical Relevance Conclusions | Based on the systemic review the authorspropose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma: PICO 1: In patients with blunt thoracic trauma, we conditionally recommend the use of epidural analgesia versus opioids alone to improve analgesia and patient outcomes.PICO 4: In patients with blunt thoracic trauma, we conditionally recommend the use of multimodal analgesia versus opioids alone to improve analgesia and patient outcomes. |