钝性创伤后肋骨骨折的手术固定：来自东部创伤外科学会的实践管理指南
Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma.
作者信息
Kasotakis George, Hasenboehler Erik A, Streib Erik W, Patel Nimitt, Patel Mayur B, Alarcon Louis, Bosarge Patrick L, Love Joseph, Haut Elliott R, Como John J
机构信息
From the Section of Trauma, Acute Care Surgery & Surgical Critical Care, Department of Surgery (G.K.), Boston University School of Medicine, Boston, Massachusetts; Department of Orthopedic Surgery Adult and Trauma Service (E.A.H.), Johns Hopkins Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Department of Surgery (E.W.S.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Surgery (N.P., J.J.C.); MetroHealth Medical Center, Cleveland, Ohio; Section of Surgical Sciences, Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences (N.P., J.J.C.), Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt Brain Institute, Center for Health Services Research, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee (M.B.P.); Trauma Surgery (L.A.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (P.L.B.), University of Alabama, Birmingham, Alabama; Department of Surgery (J.L.), University of Texas at Houston, Houston, Texas; and Division of Acute Care Surgery, Department of Surgery (E.R.H.), The Johns Hopkins University School of Medicine, Baltimore, Maryland.
出版信息
J Trauma Acute Care Surg. 2017 Mar;82(3):618-626. doi: 10.1097/TA.0000000000001350.
BACKGROUND
Rib fractures are identified in 10% of all injury victims and are associated with significant morbidity (33%) and mortality (12%). Significant progress has been made in the management of rib fractures over the past few decades, including operative reduction and internal fixation (rib ORIF); however, the subset of patients that would benefit most from this procedure remains ill-defined. The aim of this project was to develop evidence-based recommendations.
METHODS
Population, intervention, comparison, and outcome (PICO) questions were formulated for patients with and without flail chest. Outcomes of interest included mortality, duration of mechanical ventilation (DMV), hospital and intensive care unit (ICU) length of stay (LOS), incidence of pneumonia, need for tracheostomy, and pain control. A systematic review and meta-analysis of currently available evidence was performed per the Grading of Recommendations Assessment, Development, and Evaluation methodology.
RESULTS
Twenty-two studies were identified and analyzed. These included 986 patients with flail chest, of whom 334 underwent rib ORIF. Rib ORIF afforded lower mortality; shorter DMV, hospital LOS, and ICU LOS; and lower incidence of pneumonia and need for tracheostomy. The data quality was deemed very low, with only three prospective randomized trials available. Analyses for pain in patients with flail chest and all outcomes in patients with nonflail chest were not feasible due to inadequate data.
CONCLUSION
In adult patients with flail chest, we conditionally recommend rib ORIF to decrease mortality; shorten DMV, hospital LOS, and ICU LOS; and decrease incidence of pneumonia and need for tracheostomy. We cannot offer a recommendation for pain control, or any of the outcomes in patients with nonflail chest with currently available data.
LEVEL OF EVIDENCE
Systematic review/meta-analysis, level III.
背景
在所有受伤患者中，10%被诊断为肋骨骨折，且其与显著的发病率（33%）和死亡率（12%）相关。在过去几十年中，肋骨骨折的治疗取得了重大进展，包括手术复位和内固定（肋骨切开复位内固定术）；然而，最能从该手术中获益的患者亚组仍不明确。本项目的目的是制定基于证据的建议。
方法
针对有和没有连枷胸的患者制定了人群、干预措施、对照和结局（PICO）问题。感兴趣的结局包括死亡率、机械通气时间（DMV）、住院和重症监护病房（ICU）住院时间（LOS）、肺炎发生率、气管切开需求和疼痛控制。根据推荐分级评估、制定和评价方法对现有证据进行了系统评价和荟萃分析。
结果
共识别并分析了22项研究。其中包括986例连枷胸患者，其中334例接受了肋骨切开复位内固定术。肋骨切开复位内固定术降低了死亡率；缩短了机械通气时间、住院时间和ICU住院时间；降低了肺炎发生率和气管切开需求。数据质量被认为非常低，仅有三项前瞻性随机试验。由于数据不足，对连枷胸患者的疼痛分析以及非连枷胸患者的所有结局分析均不可行。
结论
在成年连枷胸患者中，我们有条件地推荐肋骨切开复位内固定术以降低死亡率；缩短机械通气时间、住院时间和ICU住院时间；降低肺炎发生率和气管切开需求。根据现有数据，我们无法对疼痛控制或非连枷胸患者的任何结局提供建议。
证据级别
系统评价/荟萃分析，三级。
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