Martin Thomas J, Cao Jessica L, Tindal Elizabeth, Adams Charles A, Lueckel Stephanie N, Kheirbek Tareq
Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
Department of Surgery, University of Chicago, Chicago, IL, USA.
Injury. 2023 Jan;54(1):32-38. doi: 10.1016/j.injury.2022.07.038. Epub 2022 Jul 25.
Surgical stabilization of rib fractures (SSRF) improves functional outcomes compared to controls, partly due to reduction in pain. We investigated the impact of early SSRF on pulmonary complications, mortality, and length of stay compared to non-operative analgesia with epidural analgesia (EA).
Retrospective cohort study of the Trauma Quality Improvement Program (TQIP) 2017 dataset for adults with rib fractures, excluding those with traumatic brain injury or death within twenty-four hours. Early SSRF and EA occurred within 72 h, and we excluded those who received both or neither intervention. Our primary outcome was a composite of pulmonary complications including acute respiratory distress syndrome (ARDS) or ventilator-associated pneumonia (VAP). Additional outcomes included unplanned endotracheal intubation, in-hospital mortality, and hospital and intensive care unit (ICU) length of stay (LOS) for those surviving to discharge. Multiple logistic and linear regressions were controlled for variables including age, sex, flail chest (FC), injury severity, additional procedures, and medical comorbidities.
We included 1,024 and 1,109 patients undergoing early SSRF and EA, respectively. SSRF patients were more severely injured with higher rates of FC (42.8 vs 13.3%, p<0.001), Injury Severity Score (ISS) > 16 (56.9 vs 36.1%, p<0.001), and Abbreviated Injury Scale (AIS) Thorax > 3 (33.3 vs 12.2%, p<0.001). Overall, 49 (2.3%) of patients developed ARDS or VAP, 111 (5.2%) required unplanned intubation, and 58 (2.7%) expired prior to discharge. On multivariable analysis, SSRF was not associated with the primary composite outcome (OR: 1.65, 95%CI: 0.85-3.21). Early SSRF significantly predicted decreased risk of unplanned intubation (OR:0.59, 95%CI: 0.38-0.92) compared with early EA alone, however, was not a significant predictor of in-hospital mortality (OR: 1.27, 95%CI: 0.68-2.39). SSRF was associated with significantly longer hospital (Exp(β): 1.06, 95%CI: 1.00-1.12, p = 0.047) and ICU LOS (Exp(β): 1.17, 95%CI: 1.08-1.27, p<0.001).
Aside from unplanned intubation, we observed no statistically significant difference in the adjusted odds of in-hospital pulmonary morbidity or mortality for patients undergoing early SSRF compared with early EA. Chest wall injury patients may benefit from referral to trauma centers where both interventions are available and appropriate surgical candidates may receive timely intervention.
与对照组相比，肋骨骨折手术固定（SSRF）可改善功能结局，部分原因是疼痛减轻。我们研究了早期SSRF与硬膜外镇痛（EA）这种非手术镇痛方法相比，对肺部并发症、死亡率和住院时间的影响。
对创伤质量改进计划（TQIP）2017年数据集中的成年肋骨骨折患者进行回顾性队列研究，排除创伤性脑损伤患者或24小时内死亡患者。早期SSRF和EA在72小时内进行，我们排除了接受两种干预或未接受任何干预的患者。我们的主要结局是肺部并发症的综合指标，包括急性呼吸窘迫综合征（ARDS）或呼吸机相关性肺炎（VAP）。其他结局包括非计划气管插管、院内死亡率，以及存活至出院患者的住院和重症监护病房（ICU）住院时间（LOS）。多因素逻辑回归和线性回归对年龄、性别、连枷胸（FC）、损伤严重程度、额外手术和内科合并症等变量进行了控制。
我们分别纳入了1024例和1109例接受早期SSRF和EA的患者。SSRF组患者损伤更严重，FC发生率更高（42.8%对13.3%，p<0.001），损伤严重程度评分（ISS）>16（56.9%对36.1%，p<0.001），简略损伤量表（AIS）胸部>3（33.3%对12.2%，p<0.001）。总体而言，49例（2.3%）患者发生ARDS或VAP，111例（5.2%）需要非计划插管，58例（2.7%）在出院前死亡。在多变量分析中，SSRF与主要综合结局无关（比值比：1.65，95%置信区间：0.85 - 3.21）。与单独早期EA相比，早期SSRF显著预测非计划插管风险降低（比值比：0.59，95%置信区间：0.38 - 0.92）；然而，它不是院内死亡率的显著预测因素（比值比：1.27，95%置信区间：0.68 - 2.39）。SSRF与显著更长的住院时间（指数（β）：1.06，95%置信区间：1.00 - 1.12，p = 0.047）和ICU住院时间（指数（β）：1.17，95%置信区间：1.08 - 1.27，p<0.001）相关。
除了非计划插管外，我们观察到与早期EA相比，接受早期SSRF的患者在调整后的院内肺部发病率或死亡率的比值比方面无统计学显著差异。胸壁损伤患者可能受益于转诊至具备两种干预措施且合适的手术候选者可获得及时干预的创伤中心。
