肋骨骨折的镇痛选择：椎旁阻滞还是硬膜外镇痛？
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Analgesic Choice in Management of Rib Fractures: Paravertebral Block or Epidural Analgesia?
背景与目的
肋骨骨折在创伤中较为常见。本研究的目的是通过检索国家创伤数据库（NTDB），评估肋骨骨折的临床结局与硬膜外镇痛（EA）和椎旁阻滞（PVB）的关系。
方 法
检索2011和2012年国家创伤数据库，记录18岁以上所有肋骨骨折患者情况。主要结局指标为住院死亡率。次要结局指标为住院天数、重症监护室（ICU）进入情况、ICU停留时间、机械通气情况、机械通气时间、肺炎以及其他并发症的发生。首先比较倾向得分匹配的EA和PVB患者的临床结局。然后，将EA和PVB患者合并为干预组，并与倾向得分匹配的未干预患者比较临床结局。
结 果
共有194766例患者纳入研究，1073例行EA，1110例行PVB、192583例没有干预。倾向得分匹配后，比较EA患者与PVB患者的主要和次要结局指标，结果无差异。倾向得分匹配干预组与非干预组并比较，采取干预的患者住院时间延长、ICU入住率更高（p＜0001），但未行干预与死亡率明显增加相关（比值比：2.25；95%CI，1.14-3.84；P = 002）。
结 论
通过检索国家创伤数据库，在肋骨骨折的治疗中未发现EA与PVB的明显差异。行神经阻滞干预与临床结局改善相关，但这也有可能是选择了更健康的患者行神经阻滞，对此可作相关前瞻性研究。
原始文献摘要
Malekpour M, Hashmi A, Dove J, Torres D, Wild J.Analgesic Choice in Management of Rib Fractures: Paravertebral Block or Epidural Analgesia? [J].Anesth Analg，2017，124(6):1906-1911. doi: 10.1213/ANE.0000000000002113.
BACKGROUND:
Rib fractures are commonly encountered in the setting of trauma. The aim of this study was to assess the association between the clinical outcome of rib fracture and epidural analgesia (EA) versus paravertebral block (PVB) using the National Trauma Data Bank (NTDB).
METHODS:
Using the 2011 and 2012 versions of the NTDB, we retrieved completed records for all patients above 18 years of age who were admitted with rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes were length of stay (LOS), intensive care unit (ICU) admission, ICU LOS, mechanical ventilation, duration of mechanical ventilation, development of pneumonia, and development of any other complication. Clinical outcomes were first compared between propensity score-matched EA and PVB patients. Then, EA and PVB patients were combined into the procedure group and the outcomes were compared with propensity score-matched patients that received neither intervention (no-procedure group).
RESULTS:
A total of 194,766 patients were included in the study with 1073 patients having EA, 1110 patients having PVB, and 192,583 patients having neither procedure. After propensity score matching, comparison of primary and secondary outcomes between EA and PVB patients showed no difference. Comparison of propensity score-matched procedure and no-procedure patients showed prolonged LOS and more frequent ICU admissions in patients receiving a procedure (both P < .0001), yet having no procedure was associated with a significantly increased odds of mortality (odds ratio: 2.25; 95% confidence interval, 1.14-3.84; P = .002).
CONCLUSIONS:
Using the NTDB, EA and PVB were not found to be significantly different in management of rib fractures. There was an association between use of a block and improved outcome, but this could be explained by selection of healthier patients to receive a block. Prospective study of this association is recommended.
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