Hylands Mathieu, Gomez David, Tillmann Bourke, Haas Barbara, Nathens Avery
From the Division of General Surgery Department of Surgery, (M.H.), Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC; Department of Surgery, St. Michael's Hospital-Unity Health and the Temerty Faculty of Medicine (D.G.), Tory Trauma Program, Sunnybrook Health Sciences Center and the Temerty Faculty of Medicine (B.T., B.H., A.N.), University of Toronto; Division of Respirology and Critical Care Medicine, Department of Medicine, University Health Network (B.T.), Toronto, ON, Canada.
J Trauma Acute Care Surg. 2024 Jun 1;96(6):882-892. doi: 10.1097/TA.0000000000004254. Epub 2024 Jan 10.
Given the lack of high-quality data on patient selection for surgical stabilization of rib fractures (SSRF), significant variability in practice likely exists across trauma centers. We aimed to determine whether centers with a more liberal approach to SSRF had improved outcomes.
We performed a retrospective cohort study of adult patients with flail chest admitted to Level I or II trauma centers participating in the American College of Surgeons' Trauma Quality Improvement Program. The primary outcome was hospital mortality; secondary outcomes included discharge status, tracheostomy, duration of mechanical ventilation, and hospital length of stay. Logistic regression was performed to calculate center-level observed/expected rates of SSRF and centers were grouped into quintiles from "most liberal" to "most restrictive." Multivariable regression was used to determine the association between these quintiles and outcomes. We also used an instrumental variable analysis to evaluate the association between SSRF and mortality at the patient level.
Among 23,619 patients with flail chest across 354 centers, 22% underwent SSRF. Center rates of fixation ranged from 0% to 88%. Higher rates of SSRF were not associated with lower mortality overall (highest vs. lowest quintile: odds ratio, 0.86; 95% confidence interval, 0.63-1.17). However, centers with a more liberal approach to SSRF had lower rates of independent status at discharge, higher tracheostomy rates, longer duration of mechanical ventilation, and longer hospital and ICU length of stay. The patient level analysis demonstrated that SSRF as was associated with a 25% lower risk of death.
Overall, centers with a liberal approach to SSRF do not show improved outcomes among patients with a flail chest, but have higher resource utilization. Results at the patient level suggest that there is a population likely to benefit but these patients remain to be identified through further research.
Prognostic and Epidemiological; Level III.
鉴于缺乏关于肋骨骨折手术固定（SSRF）患者选择的高质量数据，各创伤中心的实际操作可能存在显著差异。我们旨在确定对SSRF采取更宽松方法的中心是否能改善预后。
我们对参与美国外科医师学会创伤质量改进项目的一级或二级创伤中心收治的连枷胸成年患者进行了一项回顾性队列研究。主要结局是医院死亡率；次要结局包括出院状态、气管切开术、机械通气时间和住院时间。进行逻辑回归以计算中心层面SSRF的观察/预期率，并将中心分为从“最宽松”到“最严格”的五分位数组。使用多变量回归来确定这些五分位数与结局之间的关联。我们还使用工具变量分析来评估患者层面SSRF与死亡率之间的关联。
在354个中心的23,619例连枷胸患者中，22%接受了SSRF。固定率从0%到88%不等。总体而言，较高的SSRF率与较低的死亡率无关（最高五分位数与最低五分位数：比值比，0.86；95%置信区间，0.63 - 1.17）。然而，对SSRF采取更宽松方法的中心出院时独立状态的发生率较低、气管切开率较高、机械通气时间较长、住院和重症监护病房住院时间较长。患者层面分析表明，SSRF与死亡风险降低25%相关。
总体而言，对SSRF采取宽松方法的中心在连枷胸患者中并未显示出更好的结局，但资源利用率更高。患者层面的结果表明，有一部分人群可能受益，但这些患者仍有待通过进一步研究来确定。
预后和流行病学；三级。
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