EAST Guidelines Review: Issue 1 - Summer 2023
In this issue review of the following EAST Guidelines published in 2022:
(scroll down to see summaries)
Guideline 1 reviewed by George Kasotakis, MD, MPH
Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma
Guideline 2 reviewed by Husayn Ladhani, MD
Management of the open abdomen: A systemic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma
Guideline 3 reviewed by Abid Khan, MD
Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma
Guideline 4 reviewed by Matthew D. Painter, MD, FACS
Nonsurgical Management and Analgesia Strategies for Older Adults with Multiple Rib Fractures: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma
Murphy PB, Kasotakis G, Haut ER, Miller A, Harvey E, Hasenboehler E, Higgins T, Hoegler J, Mir H, Cantrell S, Obremskey WT, Wally M, Attum B, Seymour R, Patel N, Ricci W, Freeman JJ, Haines KL, Yorkgitis BK, Padilla-Jones BB. Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open. 2023 Feb 21;8(1):e001056. doi: 10.1136/tsaco-2022-001056. PMID: 36844371; PMCID: PMC9945020.
Relevant Background:
Opioids have traditionally been the most commonly used analgesic after trauma, however, abuse has reached epidemic proportions, and deaths from opiate-related overdoses have tripled over the last few decades. NSAIDs are increasingly considered as an alternative or adjunct to analgesia as a result. However, controversy exists over their use in traumatic fractures, as they might delay healing due to their anti-inflammatory properties. This guideline, jointly developed by EAST and the Orthopedic Trauma Association, aims to examine the benefit-to-harm ratio of using NSAIDs in orthopedic trauma.
PICOs:
PICO 1: Should NSAIDs be used in analgesic regimens for adult patients with traumatic fractures versus routine analgesic regimens that do not include NSAIDs to improve pain control and reduce oral morphine equivalents (OMEs), without increasing incidence of non-union and acute kidney injury?
PICO 2: Should ketorolac be used in analgesic regimens for adult patients with traumatic fractures versus routine analgesic regimens that do not include ketorolac to improve pain control and reduce OMEs, without increasing incidence of non-union?
PICO 3: Should selective NSAIDs (COX-2 inhibitors) be used in analgesic regimens for adult patients with traumatic fractures versus routine analgesic regimens that include non-selective NSAIDs to improve pain control and reduce OMEs, without increasing incidence of non-union?
Recommendations:
PICO 1: We conditionally recommend NSAIDs to be used in analgesic regiments for adult patients (=18 years old) with traumatic fracture. (The larger, better controlled studies failed to demonstrate increased risk of non-union, while pain control was significantly better).
PICO 2: We conditionally recommend ketorolac be used in analgesic regimens for adult patients (=18 years old) with traumatic fracture. (Ketorolac was associated with reduced opioid use and improved analgesia, without increasing non-union)
PICO 3: We are unable to make a recommendation on whether COX-2 inhibitors versus non-selective NSAIDs should be used in adults with traumatic fractures, due to paucity of data.
Clinical Application:
Based on the available evidence, non-steroidal anti-inflammatories have a clear effect on reducing post-traumatic fracture opioid use and improving pain control, without an. effect on kidney function. These benefits outweigh the small risk of non-union.
Mahoney EJ, Bugaev N, Appelbaum R, et al. Management of the open abdomen: A systemic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2022;93:e110-e118.
Relevant Background:
Many techniques for the management of the open abdomen (OA) have been described, including negative pressure wound therapy (NPWT), fascial traction systems (FTS), visceral edema removal techniques (VERT), and complex abdominal wall reconstructive techniques, but the optimal management strategy has remained elusive. The previous Practice Management Guideline (PMG) on the management of OA in 2011 could not make a recommendation due to the heterogeneity of populations in studies. However, new literature has emerged since that publication, necessitating an updated systemic review and meta-analysis regarding the optimal strategies for the management of OA after damage control laparotomy (DCL).
PICOs:
PICO 1: In hemodynamically normal trauma and EGS patients with OA after DCL in whom intra-abdominal pathology has been addressed and physiology normalized, should VERT versus no interventions be performed to help achieve primary myofascial closure, reduce ventral herniation, reduce fascial dehiscence, reduce incidence of enterocutaneous/atmospheric fistula (ECF), and reduce mortality.
PICO 2: In hemodynamically normal trauma and EGS patients with OA after DCL in whom intra-abdominal pathology has been addressed and physiology normalized, should FTS versus no traction system be used to help achieve primary myofascial closure, reduce ventral herniation, reduce fascial dehiscence, reduce incidence of ECF, and reduce mortality.
Recommendations:
PICO 1: Based on the small number of studies, methodological variations limiting direct comparison between patients, and high heterogeneity among studies, the quality of evidence was considered very low and NO RECOMMENDATION could be make regarding the use of VERT in hemodynamically normal trauma and EGS patients with OA after DCL.
PICO 2: Based on retrospective nature of many studies, small number of studies, and variable heterogeneity among studies, the quality of evidence was considered very low and the authors were able to CONDITIONALLY RECOMMEND the use of FTS in hemodynamically normal patients with OA after DCL.
Clinical Application:
This updated EAST PMG suggests that FTS improves the rate of primary myofascial closure over routine care without increased ECF formation or mortality. In majority of the studies included, FTS in addition to routine care was compared to routine care alone, where routine care was usually NPWT. Therefore, FTS could be considered in addition to NPWT in patients with OA after DCL.
Additional Thoughts or Information:
While this study suggests using FTS, many different systems exist. These include suture traction, the ABRA system, Wittmann Patch, progressive partial fascial closure, and mesh-mediated fascial traction. There is a very small number of studies evaluating each system with significant heterogeneity among studies, and none of the studies compare one system to another. Therefore, no one system could be deemed superior to another system. The choice of FTS to use is likely dependent on local resources and expertise of the surgeons. The authors of this PMG could not make a recommendation regarding the use of VERT. The three techniques evaluated were diuretic therapy, hypertonic saline infusion, and direct peritoneal resuscitation. While there was insufficient evidence to make a recommendation to use VERT in addition to routine care, there could be an adjunctive role for these technique when combined with FTS. Future well-designed studies evaluating different management strategies, alone or in combination, in addition to routine care are needed.
Freeman JJ, Asfaw SH, Vatsaas CJ, et al. Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open. 2022;7:e000886
Relevant Background:
Approximately 60% of trauma patients suffer from thoracic trauma and 1/3 of them will be diagnosed with pneumothorax and/or hemothorax, often requiring tube thoracostomy (TT) placement. Controversy exists as to whether antibiotic prophylaxis is indicated for tube thoracostomy placement to protect against skin flora contamination. Two previous EAST practice management guidelines have addressed this topic with conflicting recommendations. The first, in 2000, gave a level 3 recommendation in favor of the use of prophylactic antibiotics for TT placement. The update in 2012 did not recommend for or against the routine use of prophylactic antibiotics for TT placement.
PICOs:
Population-adult (=18years old) trauma patients who require TT for traumatic hemothorax or pneumothorax. Intervention-antibiotic prophylaxis given at TT insertion. Comparator-no antibiotics. Outcomes-empyema, pneumonia, and mortality.
Recommendations:
This guideline gives a conditional recommendation that antibiotic prophylaxis should be given at the time of insertion of tube thoracostomy to reduce empyema.
Clinical Application:
Tube thoracostomy is one of the most common procedures performed by trauma surgeons. The routine administration of antibiotics at the time of insertion appears to reduce the risk of empyema development. No effect was seen on the rate of pneumonia or mortality with antibiotic prophylaxis.
Additional Thoughts or Information:
The meta analysis performed for this guideline demonstrates a clear benefit to antibiotic prophylaxis to reduce the risk of empyema when placing a tube thoracostomy, showing half the risk of empyema with antibiotic administration. Patients requiring TT for a penetrating mechanism had an even more profound benefit, with only 25% of the rate of empyema when using prophylactic antibiotics. This guideline used studies published from 1977-2019 to perform the meta analysis. It should be noted that the benefit of antibiotic administration seemed to decline in the more recent studies. This suggests that improvements in technique and management may have led to improvements in the risk of empyema outside of antibiotic administration. There is no recommendation made regarding the choice of medication or the duration of administration as this was highly variable among the studies.
Mukherjee K, Schubl SD, Tominaga G, et al. Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2023 Mar 1;94(3):398-407.
Relevant Background:
Rib fractures occur in 10% of trauma patients with multiple associated injuries in the thoracic cavity. Outcomes are worse in adults aged ≥ 65, prompting analysis and creation of a practice management guideline for this population concerning nonoperative management.
PICOs:
PICO 1: In adults aged =65 years old with =3 rib fractures (P), should admission to an ICU setting (I) versus admission to a non-ICU setting (C) take place to reduce pneumonia, need for intubation, ventilator days, or mortality (O)?
PICO 2: In adults aged =65 years old with rib fractures (P), should routine use of IS (I) versus no routine use of IS (C), be performed to reduce pneumonia, need for intubation, or mortality (O)?
PICO 3: In adults aged =65 years old with rib fractures and acute hypoxic respiratory failure refractory to nasal cannula and face mask (P), should NIPPV (high-flow nasal cannula [HFNC], bi-level positive airway pressure [BiPAP], continuous positive airway pressure [CPAP]) (I) versus endotracheal intubation (C) be utilized to reduce pneumonia, need for intubation, ventilator days, or mortality (O)?
PICO 4: In adults aged =65 years old with =3 rib fractures and dyspnea or refractory pain (P), should ketamine infusion plus structured multi-modal pain therapy per institutional protocol (I) versus structured multi-modal pain therapy per institutional protocol alone (C) be performed to reduce pain, pneumonia, need for intubation, ventilator days, or mortality (O)?
PICO 5: In adults aged =65 years old with =3 rib fractures and dyspnea or refractory pain, should a thoracic epidural catheter and structured multi-modal pain therapy per institutional protocol (I) versus structured multi-modal pain therapy per institutional protocol alone (C) be performed to reduce pain, pneumonia, need for intubation, hospital length of stay, or mortality (O)?
PICO 6: In adults aged =65 years old with =3 rib fractures and dyspnea or refractory pain, should nonepidural locoregional anesthetic (subcutaneous infusion pump or local block) and structured multi-modal pain therapy per institutional protocol (I) versus structured multi-modal pain therapy per institutional protocol alone (C) be performed to reduce pain, pneumonia, need for intubation, ventilator days, or mortality(O)?
Recommendations:
PICO 1: ICU admission: The data do not support any quantitative analysis or recommendations due to a high degree of bias and low quality of evidence.PICO 2: Incentive spirometry: Recommendation for incentive spirometry use to reduce overall pulmonary complications. The data quality was low, not allowing for quantitative analysis, but IS is noted to have good therapeutic tolerance, few side effects, and low cost.
PICO 3: Noninvasive Positive Pressure Ventilation: Recommendation for use of NIPPV in patients with persistent acute hypoxic respiratory failure after optimization of analgesia. Improved rates of both mortality and pneumonia on meta-analysis with NIPPV compared to intubation.
PICO 4: Ketamine Infusion: No recommendation for or against the use of ketamine infusion. Low to moderate quality of evidence noted, with lack of standardization of pain management in control groups; no significant treatment effect on pain scores from included studies.
PICO 5: Epidural Analgesia: No recommendation for or against the use of epidural analgesia. Retrospective studies showed an increased risk of intubation, and prolonged hospital stay, without impact on pneumonia rates or mortality. Prospective studies showed a nonsignificant trend towards reduction in pneumonia rates, without impact on mortality, length of hospital stay, or ventilator days. With moderate level evidence, 11/19 authors favored no recommendation.
PICO 6: Nonepidural Locoregional Analgesia: No recommendation for or against the use of nonepidural locoregional analgesia. Meta-analysis was performed exploring rates of pneumonia, without differences noted. 12/19 authors voted for no recommendation.
Clinical Application:
This guideline focuses on incentive spirometry and pain control as the mainstays of care for chest wall injury in the elderly. Unfortunately, the existing data do not allow for definitive recommendations for ICU admission, but do suggest incentive spirometry and NIPPV as options for therapy. Other methods of pain control are not recommended over multimodal pain control, but are included as options for pain control in the appropriate setting.
Additional Thoughts or Information:
These recommendations highlight the challenge of working with a subset of the population for literature, as much of the information is indirect. It also highlights the myriad approaches used in the clinical setting when managing chest wall injury, leading to heterogeneity in much of the literature. Given the lack of randomized trials in this population, high quality research should be a focus in the future for this topic.