Tag Archives: Practice guideline

Complications

NSAIDs And Fracture Healing Revisited – Yet Again!

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I’ve written so many posts about the use of non-steroidal anti-inflammatory drugs (NSAIDs) it’s practically getting old. To summarize, some old animal studies suggested that using NSAIDs during fracture healing could impair the process. However, human studies were not so convincing.

Over the years, there has been quite a bit of conflicting evidence. This generally means the association between healing and NSAID use is weak. However, after this period of time, we should have become aware of a significant cause/effect relationship.

The Eastern Association for the Surgery of Trauma recently released a practice management guideline regarding the use of NSAIDs for the treatment of acute pain after orthopedic trauma. They used a standard methodology to identify and analyze published research. They focused on human studies specifically relating to this drug class’s use in fractures. The group ultimately identified 19 pertinent research papers for analysis, 10 of which were prospective, randomized studies.

Here are the three questions they asked, with their answers:

  • Should NSAIDs be used in analgesic regimens for adult patients
    (≥18 years old) with traumatic fracture versus routine analgesic
    regimens that do not include NSAIDs to improve analgesia and
    reduce opioid use without increases in non-union and acute kidney
    injury rates? Although the quality of the studies for this question was low, EAST conditionally recommended using NSAIDs in pain control regimens. In the higher-quality studies in this group, there was no increased risk of non-union.
  • Should ketorolac be used in analgesic regimens for adult patients with traumatic fracture versus routine analgesic regimens that do not include ketorolac to improve analgesia and reduce opioid use without increasing non-union
    rates? This is the same question asked above, but with a specific drug rather than the class in general. The answer was basically the same.
  • Should selective NSAIDs (COX-2 inhibitors) be used in analgesic
    regimens for adult patients (≥18 years old) with traumatic fracture versus routine analgesic regimens that include non-selective NSAIDs to improve analgesia and reduce opioid use without increasing non-union rates?     COX-2 inhibitors are a subset of NSAIDs that are more selective in their action, blocking only the COX-2 receptor. Several years ago, there was a scandal regarding the COX-2 inhibitor rofecoxib (Vioxx). These selective drugs tended to have a higher incidence of cardiac complications. The manufacturer covered up this fact for several years, resulting in many unneeded deaths before it was removed from the market. The only COX-2 inhibitor available in the US is celecoxib. Only a few studies were performed using this drug during bone healing. There were not enough to make a recommendation.

Bottom line: EAST made conditional recommendations for using NSAIDs in general and ketorolac specifically in adults with fractures. “Conditional” only means that the authors did not have a consensus. Some voted to strongly recommend, and the remainder to conditionally recommend. There were no votes to recommend against their use.

The use of NSAIDs should complement a well-thought-out opioid regimen, which should also be combined with other non-narcotic medications and appropriate mobilization and therapy.

Reference: 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.

Guidelines

Serial Abdominal Examination: The Practice Guideline

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Last week, I published a preliminary practice guideline for nonoperative management of abdominal stab wounds. Click here to view it. A key part of that guideline is the serial abdominal exam. Surgeons talk about this a lot, but how do you do it? I posted about many of the details here.

The serial exam is nuanced enough so that it deserves its own clinical practice guideline! You won’t find this in any doctor or nursing books. It’s really simple, but the devil is truly in the details.

Click this image or the link below to download the guideline. I’ve also posted a Microsoft publisher version in case you want to modify it to suit your center.

Please feel free to email or post comments and questions in the area below this post!

References:

Abdomen, Guidelines

Nonoperative Management Of Abdominal Stab Wounds: The Practice Guideline!

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In my previous post, I reviewed a new paper that examined the appropriate amount of time that patients should be observed for nonoperative manage of an abdominal stab wound. Many of you know that I am a fanatic of properly crafted clinical practice guidelines (CPG). I decided to make a first pass at converting the LAC+USC group’s paper to something that will be helpful at the bedside.

This CPG incorporates the patient selection and timing information published in the paper. It breaks the process down into easily followed tasks, and fills in the blanks for shift to shift management. The CPG is displayed in an “if this, then do that” format. This firms up decision making and makes it easier for your trauma program to monitor compliance with it.

A note about CPGs: they generally cover about 90% of clinical cases. Obviously, they cannot provide guidance for certain rare combinations of circumstance. In that case, the trauma professional should do what they think is right for that situation. Most importantly, they should document this rationale in a progress note.

Here are answers to some of your questions in advance:

  • Patients should not be kept at bed rest. This is always bad.
  • There is no reason to keep the patient NPO. A very small percentage of patients actually fail. It makes no sense to starve everybody for the one or two patients that need to go to the OR each year. Anesthesiologists at trauma centers are very skilled at providing safe intubation in all patients. As you all know, every trauma activation patient coming into your trauma bay needing intubation has just finished a seven course meal!
  • Give your patient clear discharge instructions! They need to know what they can do, and what to look for if things eventually go awry.

And please leave comments and suggestions for improvements in the reply box below or by email to [email protected]. There are always ways to make CPGs even better! I have also included a Microsoft Publisher file so you can modify this guideline to better suit your trauma center.

In my next post, I’ll publish the serial abdominal observation CPG I mention in this one.

Resources:

  1. Download a pdf file of the guideline
  2. Download a Publisher file of the guideline

 

Complications, Thorax

Retained Hemothorax: The Practice Guideline

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Over the last few days, I’ve reviewed some data on managing hemothorax, as well as the use of lytics. Then I looked at a paper describing one institution’s experience dealing with retained hemothorax, including the use of VATS. But there really isn’t much out there on how to roll all this together.

Until now. The trauma group at Vanderbilt published a paper describing their experience with a home-grown practice guideline for managing retained hemothorax.  Here’s what it looks like:

I know it’s small, so just click it to download a pdf copy. I’ve simplified the flow a little as well.

All stable patients with hemothorax admitted to the trauma service were included over a 2.5 year period. The practice guideline was implemented midway through this study period. Before implementation, patients were treated at the discretion of the surgeon. Afterwards, the practice guideline was followed.

Here are the factoids:

  • There were an equal number of patients pre- and post-guideline implementation (326 vs 316)
  • An equal proportion of each group required an initial intervention, generally a chest tube (69% vs 65%)
  • The number of patients requiring an additional intervention (chest tube, VATS, lytics, etc) decreased significantly from 15% to 9%
  • Empyema rate was unchanged at 2.5%
  • Use of VATS decreased significantly from 8% to 3%
  • Use of catheter guided drainage increased significantly from 0.6% to 3%
  • Hospital length of stay was the same, ranging from 4 to 11 days (much shorter than the lytics studies!)

Bottom line: This is how design of practice guidelines is supposed to work. Identify a problem, typically a clinical issue with a large amount of provider care variability. Look at the literature. In general, find it of little help. Design a practical guideline that covers the major issues. Implement, monitor, and analyze. Tweak as necessary based on lessons learned. If you wait for the definitive study to guide you, you’ll be waiting for a long time.

This study did not significantly change outcomes like hospital stay or complications. But it did decrease the number of more invasive procedures and decreased variability of care, with the attendant benefits from both of these. It also dictates more selective (and intelligent) use of additional tubes, catheters, and lytics. 

I like this so much that I’ve incorporated parts of it into the chest tube guideline at my center!

Download the practice guideline here.

Related posts:

Reference: Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions. J Trauma 82(4):728-732, 2017.

Thorax

Practice Guideline: Chest Tube Management (Part 2)

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In my last post, I went over the rationale for developing a practice guideline for something as simple and lowly as chest tube management. Today, I’m posting the details of the guideline that’t been in use at my hospital for the past 15 years. I’ve updated it to reflect two lessons learned from actually using it.

Here’s an image of the practice guideline. Click to open a full-size copy in a new window:

Here are some key points:

  • Note the decision tree format. This eliminates uncertainty so that the clinician can stick to the script. There are no hedge words like “consider” used. Just real verbs.
  • We found that hospital length of stay improved when we changed the three parameters from daily monitoring to three consecutive shifts. We are prepared to pull the tube on any shift, not just during the day time. And it also allows this part of the guideline to be nursing driven. They remind the surgeons that criteria are met so we can immediately remove the tube.
  • Water seal is only used if there was an air leak at some point. This allows us to detect a slow ongoing leak that may not be present during our brief inspection of the system on rounds.
  • The American College of Surgeons Committee on Trauma expects trauma centers to monitor compliance with at least some of their guidelines. This one makes it easy for a PI nurse or other personnel to do so.
  • The first of the “new” parts of this guideline is: putting a 7 day cap on failure due to tube output greater than 150cc per three shifts. At that point, the infectious risks of keeping a tube in begin to outweigh its efficacy. Typically, a small effusion may appear the day following removal, then resolves shortly.
  • The second “new” part is moving to VATS early if it is clear that there is visible hemothorax that is not being drained by the system. Some centers may want to try irrigation or lytics, but the data for this is not great. I’ll republish my posts on this over the next two days.

Click here to download a copy of this practice guideline for adults.

Click here to download the pediatric chest tube practice guideline.