背景:老年人胸壁损伤是发病率和死亡率的重要原因。这些患者的最佳非手术管理策略尚未完全确定护理水平,激励肺活量测定,无创正压通气,和氯胺酮的使用,硬膜外和其他局部镇痛方法。
方法:关于患有严重胸壁损伤的老年患者的相关问题,干预措施,比较(S),并选择适当的选择结果(PICO)。这些重点是ICU入院,激励肺活量测定,无创正压通气,和镇痛包括氯胺酮,硬膜外镇痛,和局部神经阻滞。进行了系统的文献检索和综述,我们的数据进行了定性和定量分析,并根据建议评估等级评估评估了证据质量,发展,和评估(等级)方法。没有使用任何资金。
结果:我们的文献综述(PROSPERO2020-CRD42020201241,MEDLINE,EMBASE,科克伦,WebofScience,2020年1月15日)共进行了151项研究。除临床评估外,任何定义的队列的ICU入院在质量上都不优于其他队列。不良的激励肺活量测定表现与住院时间延长有关,肺部并发症,和计划外的ICU入院。在无气道丢失风险的合适患者中,无创正压通气与肺炎几率降低85%(p<0.0001)和死亡率几率降低81%(p=0.03)相关。氯胺酮的使用显示疼痛评分没有显着降低,但有减少阿片类药物使用的趋势。硬膜外和其他局部镇痛技术对肺炎没有影响,机械通气的长度,住院时间或死亡率。
结论:我们不推荐或反对常规ICU入住。我们建议使用激励肺活量测定法来告知ICU状况,并有条件地建议无气道丢失风险的患者使用无创正压通气。我们不提供支持或反对氯胺酮的建议,硬膜外或其他局部镇痛。
方法:指南;系统综述/荟萃分析,四级。
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.
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.
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.
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.
Systematic Review/Meta-analysis; Level IV.