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2023 EAST/OTA实践管理指南：非甾体抗炎药(NSAIDs)治疗骨科创伤

作者：中华医学网发布时间：2026-01-12 08:37浏览：次

2023 EAST/OTA Practice Management Guideline: Efficacy and Safety of NSAIDs for Acute Pain After Orthopedic TraumaEAST

Core Title: 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 (EAST) and the Orthopedic Trauma Association (OTA)EAST

Publication Date: 2023-02-21; Journal: Trauma Surgery & Acute Care Open, 8(1)EAST

Core Objective: Standardize evidence-based NSAID use for acute pain after traumatic fractures in adults, balancing efficacy (pain control, opioid sparing) and safety (non-union, renal, GI risks) using GRADE methodology.

I. Core Recommendations (Conditional, Low-Quality Evidence)

1. NSAIDs for Adult Traumatic Fracture Pain (≥18 Years)

Recommendation: Conditionally recommend NSAIDs (oral/parenteral) as part of multimodal analgesia for acute pain after traumatic fractures.
Efficacy: Reduces pain scores and opioid consumption (consistent across studies).
Safety: Small non-union risk (NSAIDs 2.99% vs. non-NSAIDs 2.19%, p=0.04); most studies show no significant association with non-union. Acute kidney injury (AKI) not linked to short-term NSAID use in analyzed studies.
Vote: 8 for strong, 11 for conditional recommendation.

2. Ketorolac for Acute Trauma Analgesia

Recommendation: Conditionally recommend ketorolac (parenteral NSAID) for acute pain in adult traumatic fracture patients.
Rationale: Reduces opioid use and improves postoperative analgesia; no confirmed association with non-union.
Vote: 5 for strong, 14 for conditional recommendation.

II. Efficacy & Safety Evidence Summary

(1) Efficacy Outcomes

Outcome	Key Findings	Evidence Quality
Pain Control	NSAIDs reduce pain vs. placebo/standard care; heterogenous data precluded meta-analysis	Low
Opioid Sparing	Consistent reduction in opioid dose/duration vs. opioids alone	Moderate
Functional Recovery	Improved early mobility with better pain control	Low

(2) Safety Outcomes (Critical Concerns)

Risk	Association with NSAIDs	Evidence Quality	Clinical Action
Fracture Non-union	Small absolute risk increase (0.8%); no causal link confirmed	Low	Avoid prolonged use (>2 weeks) in high-risk fractures (e.g., tibial shaft, scaphoid)
Renal Injury	No AKI association in short-term use (≤5 days); higher risk with hypovolemia/CKD	Low	Hydrate; avoid in eGFR <30mL/min/1.73m²
Gastrointestinal Toxicity	Increased risk with older age, history of ulcers, or concurrent steroids	Moderate	Use PPI prophylaxis in high-risk patients; prefer COX-2 inhibitors
Cardiovascular Risk	Increased MI/stroke in long-term use; minimal acute risk	Low	Avoid in uncontrolled hypertension/heart failure

III. Clinical Implementation Framework

(1) Patient Selection (Indications & Contraindications)

Population	Eligibility	Contraindications
Indicated	Adults (≥18) with traumatic fractures; acute pain requiring multimodal analgesia	Severe CKD (eGFR <30); active peptic ulcer; severe heart failure; hypersensitivity to NSAIDs
Caution	Elderly (≥65); CKD (eGFR 30–60); diabetes; hypertension; history of GI ulcers	—
Avoid	Pregnancy (third trimester); breastfeeding; coagulopathy; concurrent anticoagulants	—

(2) Multimodal Analgesia Protocol (Strong Practice Tip)

Initiation: Start NSAIDs within 24 hours post-trauma (oral: ibuprofen 400–600mg q6h; ketorolac 30mg IV/IM q6h, max 5 days).
Opioid Sparing: Combine with acetaminophen (1g q6h) and opioids (rescue only, e.g., oxycodone 5–10mg q4h prn).
Duration: Limit NSAIDs to 5–7 days acutely; reassess after 2 weeks for high-risk fractures.

(3) Monitoring & Risk Mitigation

Renal: Check serum creatinine at baseline and 48–72 hours post-initiation; stop if AKI develops.
GI: Monitor for dyspepsia/bleeding; use PPI if ≥65 years or history of ulcers.
Fracture Healing: Clinical/radiographic follow-up at 4–6 weeks; discontinue NSAIDs if delayed union suspected.

IV. Special Populations & Fracture Types

Population/Fracture	Modification	Evidence Basis
Elderly (≥75)	Lower NSAID dose (e.g., ibuprofen 400mg q8h); avoid ketorolac	Increased GI/renal risk
High-Risk Fractures (tibial shaft, scaphoid, spine)	Limit NSAIDs to ≤5 days; switch to acetaminophen/opioids	Small non-union risk signal
Polytrauma with Hypovolemia	Avoid NSAIDs until hemodynamically stable	AKI risk in hypoperfusion
Postoperative Fracture Fixation	NSAIDs safe for 5–7 days; no implant failure link	Low-quality evidence

V. Key Limitations & Research Gaps

Evidence Quality: Most studies are observational or small RCTs; low-to-moderate quality overall.
Non-union Data: Heterogeneous definitions and follow-up periods; no large RCTs confirming causality.
Long-Term Outcomes: Limited data on chronic pain or functional recovery beyond 3 months.
Pediatric/ Geriatric Subgroups: Insufficient data for <18 or ≥80 years; extrapolation from adult studies.

VI. Clinical Takeaways

NSAIDs are conditionally recommended for acute pain after traumatic fractures, with clear opioid-sparing benefits outweighing small non-union risks.
Ketorolac is a viable parenteral option for severe acute pain, with opioid-sparing effects.
Use short-term (≤7 days), multimodal analgesia, and monitor renal/GI function in high-risk patients.
Avoid prolonged NSAID use in high-risk fractures; prioritize acetaminophen and opioids for long-term pain control.