Association of Opioid Administration During General Anesthesia and Survival for Severely Injured Trauma Patients: A Preplanned Secondary Analysis of the PROPPR Study.
Journal
Anesthesia and analgesia
ISSN: 1526-7598
Titre abrégé: Anesth Analg
Pays: United States
ID NLM: 1310650
Informations de publication
Date de publication:
01 05 2023
01 05 2023
Historique:
medline:
18
4
2023
entrez:
14
4
2023
pubmed:
15
4
2023
Statut:
ppublish
Résumé
There is a lack of reported clinical outcomes after opioid use in acute trauma patients undergoing anesthesia. Data from the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study were analyzed to examine opioid dose and mortality. We hypothesized that higher dose opioids during anesthesia were associated with lower mortality in severely injured patients. PROPPR examined blood component ratios in 680 bleeding trauma patients at 12 level 1 trauma centers in North America. Subjects undergoing anesthesia for an emergency procedure were identified, and opioid dose was calculated (morphine milligram equivalents [MMEs])/h. After separation of those who received no opioid (group 1), remaining subjects were divided into 4 groups of equal size with low to high opioid dose ranges. A generalized linear mixed model was used to assess impact of opioid dose on mortality (primary outcome, at 6 hours, 24 hours, and 30 days) and secondary morbidity outcomes, controlling for injury type, severity, and shock index as fixed effect factors and site as a random effect factor. Of 680 subjects, 579 had an emergent procedure requiring anesthesia, and 526 had complete anesthesia data. Patients who received any opioid had lower mortality at 6 hours (odds ratios [ORs], 0.02-0.04; [confidence intervals {CIs}, 0.003-0.1]), 24 hours (ORs, 0.01-0.03; [CIs, 0.003-0.09]), and 30 days (ORs, 0.04-0.08; [CIs, 0.01-0.18]) compared to those who received none (all P < .001) after adjusting for fixed effect factors. The lower mortality at 30 days in any opioid dose group persisted after analysis of those patients who survived >24 hours (P < .001). Adjusted analyses demonstrated an association with higher ventilator-associated pneumonia (VAP) incidence in the lowest opioid dose group compared to no opioid (P = .02), and lung complications were lower in the third opioid dose group compared to no opioid in those surviving 24 hours (P = .03). There were no other consistent associations of opioid dose with other morbidity outcomes. These results suggest that opioid administration during general anesthesia for severely injured patients is associated with improved survival, although the no-opioid group was more severely injured and hemodynamically unstable. Since this was a preplanned post hoc analysis and opioid dose not randomized, prospective studies are required. These findings from a large, multi-institutional study may be relevant to clinical practice.
Sections du résumé
BACKGROUND
There is a lack of reported clinical outcomes after opioid use in acute trauma patients undergoing anesthesia. Data from the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study were analyzed to examine opioid dose and mortality. We hypothesized that higher dose opioids during anesthesia were associated with lower mortality in severely injured patients.
METHODS
PROPPR examined blood component ratios in 680 bleeding trauma patients at 12 level 1 trauma centers in North America. Subjects undergoing anesthesia for an emergency procedure were identified, and opioid dose was calculated (morphine milligram equivalents [MMEs])/h. After separation of those who received no opioid (group 1), remaining subjects were divided into 4 groups of equal size with low to high opioid dose ranges. A generalized linear mixed model was used to assess impact of opioid dose on mortality (primary outcome, at 6 hours, 24 hours, and 30 days) and secondary morbidity outcomes, controlling for injury type, severity, and shock index as fixed effect factors and site as a random effect factor.
RESULTS
Of 680 subjects, 579 had an emergent procedure requiring anesthesia, and 526 had complete anesthesia data. Patients who received any opioid had lower mortality at 6 hours (odds ratios [ORs], 0.02-0.04; [confidence intervals {CIs}, 0.003-0.1]), 24 hours (ORs, 0.01-0.03; [CIs, 0.003-0.09]), and 30 days (ORs, 0.04-0.08; [CIs, 0.01-0.18]) compared to those who received none (all P < .001) after adjusting for fixed effect factors. The lower mortality at 30 days in any opioid dose group persisted after analysis of those patients who survived >24 hours (P < .001). Adjusted analyses demonstrated an association with higher ventilator-associated pneumonia (VAP) incidence in the lowest opioid dose group compared to no opioid (P = .02), and lung complications were lower in the third opioid dose group compared to no opioid in those surviving 24 hours (P = .03). There were no other consistent associations of opioid dose with other morbidity outcomes.
CONCLUSIONS
These results suggest that opioid administration during general anesthesia for severely injured patients is associated with improved survival, although the no-opioid group was more severely injured and hemodynamically unstable. Since this was a preplanned post hoc analysis and opioid dose not randomized, prospective studies are required. These findings from a large, multi-institutional study may be relevant to clinical practice.
Identifiants
pubmed: 37058726
doi: 10.1213/ANE.0000000000006456
pii: 00000539-202305000-00011
doi:
Substances chimiques
Analgesics, Opioid
0
Banques de données
ClinicalTrials.gov
['NCT01545232']
Types de publication
Clinical Trial
Journal Article
Research Support, N.I.H., Extramural
Langues
eng
Sous-ensembles de citation
IM
Pagination
905-912Subventions
Organisme : NCATS NIH HHS
ID : UL1 TR003167
Pays : United States
Informations de copyright
Copyright © 2023 International Anesthesia Research Society.
Déclaration de conflit d'intérêts
Conflicts of Interest: See Disclosures at the end of the article.
Références
Tobin JM, Varon AJ. Review article: update in trauma anesthesiology: perioperative resuscitation management. Anesth Analg. 2012;115:1326–1333.
Tobin JM, Barras WP, Bree S, et al. Anesthesia for trauma patients. Mil Med. 2018;183:32–35.
Richards JE, Harris T, Dünser MW, Bouzat P, Gauss T. Vasopressors in trauma: a never event? Anesth Analg. 2021;133:68–79.
Sikorski RA, Koerner AK, Fouche-Weber LY, Galvagno SM. Choice of general anesthetics for trauma patients. Current Anesthesiology Reports. 2014;4:225–232.
Bérubé M, Moore L, Lauzier F, et al. Strategies aimed at preventing chronic opioid use in trauma and acute care surgery: a scoping review protocol. BMJ Open. 2020;10:e035268.
Holcomb JB, Tilley BC, Baraniuk S, et al.; PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313:471–482.
Baraniuk S, Tilley BC, del Junco DJ, et al.; PROPPR Study Group. Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation. Injury. 2014;45:1287–1295.
Robinson BRH, Cohen MJ, Holcomb JB, et al.; PROPPR Study Group. Risk factors for the development of acute respiratory distress syndrome following hemorrhage. Shock. 2018;50:258–264.
Kishner S. MD. Opioid equivalents and conversions: overview. Accessed July 22. https://emedicine.medscape.com/article/2138678-overview 2019 .
Gross JL, Perate AR, Elkassabany NM. Pain management in trauma in the age of the opioid crisis. Anesthesiology Clin. 2019;37:79–91.
Kumar K, Kirksey MA, Duong S, Wu CL. A review of opioid-sparing modalities in perioperative pain management: methods to decrease opioid use postoperatively. Anesth Analg. 2017;125:1749–1760.
Dutton RP. Resuscitative strategies to maintain homeostasis during damage control surgery. Br J Surg. 2012;99:S 21–S 28.
Lin JY, Hung LM, Lai LY, Wei FC. Kappa-opioid receptor agonist protects the microcirculation of skeletal muscle from ischemia reperfusion injury. Ann Plast Surg. 2008;61:330–336.
Puana R, McAllister RK, Hunter FA, Warden J, Childs EW. Morphine attenuates microvascular hyperpermeability via a protein kinase A-dependent pathway. Anesth Analg. 2008;106:480–485.
Colnaric JM, El Sibai RH, Bachir R, El Sayed MJ. Injury severity score as a predictor of mortality in adult trauma patients by injury mechanism types in the United States: a retrospective observational study. Medicine (Baltimore). 2022;101:e29614.