老年创伤中的肋骨固定术：最脆弱患者的死亡率获益。
Rib fixation in geriatric trauma: Mortality benefits for the most vulnerable patients.
机构信息
From the Department of Surgery, New York Presbyterian/Queens, Weill Cornell Medical College, Flushing, New York.
出版信息
J Trauma Acute Care Surg. 2020 Jul;89(1):103-110. doi: 10.1097/TA.0000000000002666.
BACKGROUND
Rib fractures in the geriatric trauma population are associated with significant morbidity and mortality. The outcomes of surgical stabilization of rib fractures (SSRF) have not been well defined in this population.
METHODS
Data from the 2016 to 2017 Trauma Quality Improvement Program database were analyzed. Patients older than 65 years admitted with isolated chest wall injury and multiple rib fractures were abstracted from the database. Multivariate propensity score matching was utilized to stratify patients that underwent rib fixation versus nonoperative management. In the matched cohort, we assessed outcomes including mortality, intensive care unit (ICU) and hospital lengths of stay (LOS), tracheostomy rates, and ventilator-associated pneumonia (VAP) rates. We performed a secondary analysis of patients receiving early (<72 hours) versus late SSRF.
RESULTS
Of the 44,450 patients included in the study analysis, 758 (1.7%) underwent SSRF. Patients undergoing SSRF were younger, had a higher prevalence of flail chest, higher rates of emergency room intubation, higher Injury Severity Score, and increased ICU admission rates. The 1:1 propensity score match resulted in 758 patients in each group. The in-hospital mortality rate was significantly lower in patients that underwent SSRF (4.2% vs. 7.3%, p = 0.01). However, the fixation group also had higher rates of tracheostomy during admission (11.2% vs. 4.6%, p < 0.001) and VAP (3.0% vs. 1.6%, p = 0.007). In a secondary matched analysis of 326 pairs of patients undergoing SSRF, we found that early fixation was associated with decreased rates of VAP (1.5% vs. 4.6%, p = 0.01), fewer ventilator days (4 days vs. 7 days, p = 0.003), shorter ICU LOS (6 days vs. 9 days, p = 0.001), and shorter hospital LOS (10 days vs. 15 days, p < 0.001).
CONCLUSION
This study demonstrates a mortality benefit in geriatric trauma patients undergoing SSRF. Early SSRF was observed to be associated with decreased rates of VAP, decreased ICU LOS, and decreased hospital LOS. Early SSRF may be associated with improved outcomes in the geriatric trauma population with multiple rib fractures.
LEVEL OF EVIDENCE
Therapeutic/Care management, level III.
背景
老年人创伤患者的肋骨骨折与显著的发病率和死亡率相关。在该人群中，肋骨骨折手术固定（SSRF）的结果尚未得到很好的定义。
方法
对 2016 年至 2017 年创伤质量改进计划数据库的数据进行了分析。从数据库中提取了年龄大于 65 岁、因单纯胸壁损伤和多处肋骨骨折而入院的患者。利用多变量倾向评分匹配将接受肋骨固定与非手术治疗的患者分层。在匹配队列中，我们评估了死亡率、重症监护病房（ICU）和住院时间（LOS）、气管切开术率和呼吸机相关性肺炎（VAP）率等结果。我们对接受早期（<72 小时）与晚期 SSRF 的患者进行了二次分析。
结果
在研究分析中，44450 例患者中，758 例（1.7%）接受了 SSRF。接受 SSRF 的患者年龄较小，有较高的浮动胸发生率，急诊插管率较高，损伤严重程度评分较高，ICU 入院率较高。1:1 的倾向评分匹配使每组各有 758 例患者。接受 SSRF 的患者院内死亡率显著降低（4.2%比 7.3%，p=0.01）。然而，固定组在住院期间气管切开术的发生率也较高（11.2%比 4.6%，p<0.001）和 VAP（3.0%比 1.6%，p=0.007）。在对 326 对接受 SSRF 的患者进行的二次匹配分析中，我们发现早期固定与 VAP 发生率降低有关（1.5%比 4.6%，p=0.01）、呼吸机使用天数减少（4 天比 7 天，p=0.003）、ICU LOS 缩短（6 天比 9 天，p=0.001）和住院 LOS 缩短（10 天比 15 天，p<0.001）。
结论
本研究表明，老年人创伤患者接受 SSRF 可降低死亡率。早期 SSRF 与 VAP 发生率降低、ICU LOS 缩短和住院 LOS 缩短有关。早期 SSRF 可能与多发肋骨骨折的老年创伤患者的改善结局有关。
证据水平
治疗/护理管理，III 级。
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