Schulte Katharina, Whitaker Donald, Attia Rizwan
Department of Cardiothoracic Surgery, King's College Hospital, London, UK Department of General, Visceral and Vascular Surgery, Minimally Invasive Surgery, St. Hedwig Hospital, Berlin, Germany.
Department of Cardiothoracic Surgery, King's College Hospital, London, UK.
Interact Cardiovasc Thorac Surg. 2016 Aug;23(2):314-9. doi: 10.1093/icvts/ivw092. Epub 2016 Apr 12.
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was: In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality? Using the reported search criteria, 137 papers were found. Of these, 11 papers (N = 1712) represent the best evidence to answer the clinical question, and include one meta-analysis, two randomized, controlled trials (RCTs), five retrospective cohort studies and two case-control series. In-hospital mortality was lower for the surgical group in the meta-analysis [n = 582, odds ratio (OR) 0.31 (0.20-0.48), risk difference (RD) 0.19 (0.13-0.26), number needed to treat (NNT) 5] as well as significant decreases in ventilator days [mean 8 days, 95% confidence interval (CI) 5-10 days] and intensive care unit stay (mean 5 days, 95% CI 2-8 days). A reduction was found for septicaemia [n = 345, OR 0.36 (0.19-0.71), RD 0.14 (0.56-0.23), NNT 7], pneumonia [n = 616, OR 0.18 (0.11-0.32), RD 0.31 (0.21-0.41), NNT 3, P = 0.001], tracheostomy (OR 0.06, 95% CI 0.02-0.20) and chest wall deformity [n = 228, OR 0.11 (0.02-0.60), RD 0.30 (0.00-0.60), NNT 3]. Eight studies (n = 1015) had a shorter duration of mechanical ventilation following surgery. A reduction in intensive care unit stay was demonstrated in four papers (n = 389, 3.1-9.0 days), whereas a further three papers described a reduction in the duration of hospitalization (n = 489, 4-10.6 days). Three studies (n = 166) showed a lower risk for tracheostomy. One retrospective cohort study estimated lower total treatment costs in surgically treated patients ($32 300 vs $37 100) although not statistically significant. One retrospective case-control study described a lower risk for reintubation (n = 50, P = 0.034) and home oxygen requirements (n = 50, P = 0.034). One cohort study showed a better APACHE II score 14 days after trauma in the surgical group (P = 0.02). Surgical stabilization of flail chest in thoracic trauma patients has beneficial effects with respect to reduced ventilatory support, shorter intensive care and hospital stay, reduced incidence of pneumonia and septicaemia, decreased risk of chest deformity and an overall reduced mortality when compared with patients who received non-operative management.
一篇心胸外科的最佳证据主题文章是根据结构化方案撰写的。所探讨的问题是：在急性连枷胸患者中，手术肋骨固定在发病率和死亡率方面是否能改善预后？按照报告的检索标准，共找到137篇论文。其中，11篇论文（N = 1712）代表了回答该临床问题的最佳证据，包括1篇荟萃分析、2项随机对照试验（RCT）、5项回顾性队列研究和2个病例对照系列。荟萃分析中手术组的院内死亡率较低[n = 582，比值比（OR）0.31（0.20 - 0.48），风险差（RD）0.19（0.13 - 0.26），需治疗人数（NNT）5]，同时机械通气天数显著减少[平均8天，95%置信区间（CI）5 - 10天]以及重症监护病房住院时间（平均5天，95% CI 2 - 8天）。败血症发生率降低[n = 345，OR 0.36（0.19 - 0.71），RD 0.14（0.56 - 0.23），NNT 7]，肺炎发生率降低[n = 616，OR 0.18（0.11 - 0.32），RD 0.31（0.21 - 0.41），NNT 3，P = 0.001]，气管切开率降低（OR 0.06，95% CI 0.02 - 0.20）以及胸壁畸形发生率降低[n = 228，OR 0.11（0.02 - 0.60），RD 0.30（0.00 - 0.60），NNT 3]。8项研究（n = 1015）显示术后机械通气时间缩短。4篇论文（n = 389，3.1 - 9.0天）表明重症监护病房住院时间缩短，另外3篇论文描述住院时间缩短（n = 489，4 - 10.6天）。3项研究（n = 166）显示气管切开风险较低。一项回顾性队列研究估计手术治疗患者的总治疗费用较低（32300美元对37100美元），尽管无统计学意义。一项回顾性病例对照研究描述再次插管风险较低（n = 50，P = 0.034）以及家庭氧疗需求较低（n = 50，P = 0.034）。一项队列研究显示手术组创伤后14天的急性生理与慢性健康状况评分系统（APACHE II）得分更好（P = 0.02）。与接受非手术治疗的患者相比，胸部创伤患者连枷胸的手术固定在减少通气支持、缩短重症监护和住院时间、降低肺炎和败血症发生率、降低胸壁畸形风险以及总体降低死亡率方面具有有益效果。
