Date Published: April 25, 2019
Publisher: Public Library of Science
Author(s): Ying-Hao Su, Shun-Mao Yang, Chun-Hsiung Huang, Huan-Jang Ko, Hyun-Sung Lee.
The timing of surgical stabilization of rib fractures remains controversial. We hypothesized that early surgical stabilization (within 3 days of injury) can improve clinical outcome in patients with severe rib fractures and respiratory failure. The aim of this study was to analyze the impact of early surgical stabilization of rib fractures on the perioperative results, clinical outcomes, and medical costs of patients with severe rib fractures and respiratory failure.
This was a retrospective comparative study based on a prospectively collected database at a single institute. Patients with severe rib fractures and respiratory failure who underwent surgical stabilization were classified into early (within 3 days of injury) and late (more than 3 days after injury) groups. Outcome measures included operation time, duration of mechanical ventilation, intensive care unit stay, hospital stay, complication rate, mortality rate, and medical cost.
A total of 33 patients were enrolled (16 and 17 in the early and late groups, respectively). The demographics, trauma mechanism, associated injuries, and severity of trauma were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (median 36 vs. 90 hours, p = 0.03), intensive care unit stay (median 123 vs. 230 hours, p = 0.004), and hospital stay (median 12 vs. 18 days, p = 0.005); and lower National Health Insurance costs (median 6,617 vs. 10,017 US dollars, p = 0.031). The early group tended to have lower rates of morbidity and mortality, but the difference was not statistically significant.
Early surgical stabilization of rib fractures in selected patients may significantly shorten their duration of mechanical ventilation, and intensive care unit and hospital stays, while incurring less medical costs.
Blunt chest trauma often causes rib fractures, which may be accompanied by hemothorax, pneumothorax, and intrapleural and intrathoracic lesions. The patients suffer from severe chest wall pain, deformity, and subsequent pneumonia and/or respiratory failure (RF). To this date, three randomized controlled trials (RCTs) have shown that surgical stabilization of rib fractures (SSRFs) for flail chest is superior to conservative treatment.[2–4] Reviews and meta-analyses showed that SSRF can reduce the duration of mechanical ventilation (DMV), intensive care unit (ICU) length of stay (LOS), and hospital LOS.[5–7] It also decreases the rate of pneumonia and tracheostomy. The surgical indications for SSRF have been outlined by several studies.[8–10] Patients with flail chest, multiple rib fractures, RF, intractable pain after conservative treatment, loss of lung function, and chest wall deformity are candidates of SSRF.
Between June 2016 and Feb 2018, 74 consecutive patients underwent SSRF at our institute. There were 41 patients who did not meet the criteria of this study: 4 who received SSRF after more than 14 days of injury due to intractable pain and 37 with severe rib fractures but no RF. A total of 33 patients were enrolled and divided into the early (n = 16) and late (n = 17) SSRF groups (Fig 2). The demographics, current smoking status, chronic obstructive pulmonary disease, mechanism of trauma, number of rib fractures, overall number of fractures, associated injuries, RibScore, Rib fracture scoring, blunt pulmonary contusion 18 score, chest abbreviated injury scale, and injury severity score were comparable in both groups (Table 1).
Rib fractures often result from blunt chest trauma and are the main cause of hospital admission. Rib fractures result in pain and disability, and many patients also develop RF, pneumonia, or chest wall deformity. Three previous RCTs showed that SSRF is superior to conservative treatment for patients with flail chest and recognized RF.[2–4] Review articles and meta-analyses also showed that SSRF can reduce ICU and hospital LOS, duration of ventilation, and tracheostomy rate. The indications for SSRF have been well established based on expert consensus.
The timing of SSRF is an important prognostic factor in the management of patients with severe rib fractures and RF. Patients undergoing early SSRF may have significantly shorter DMV, ICU LOS, hospital LOS, and less NHI costs. When patients with severe rib fractures and RF present to the emergency department, early SSRF should be considered whenever feasible.