51
|
Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017; 48:307-321. [PMID: 27912931 DOI: 10.1016/j.injury.2016.11.026] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/05/2016] [Accepted: 11/21/2016] [Indexed: 02/02/2023]
|
52
|
Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. Eur J Trauma Emerg Surg 2016; 43:163-168. [PMID: 27572897 PMCID: PMC5378742 DOI: 10.1007/s00068-016-0721-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 08/22/2016] [Indexed: 11/29/2022]
Abstract
Purpose Flail chest is a life-threatening complication of severe chest trauma with a mortality rate of up to 15 %. The standard non-operative management has high comorbidities with pneumonia and often leads to extended Intensive Care Unit (ICU) stay, due to insufficient respiratory function and complications. The aim of this literature study was to investigate how operative management improves patient care for adults with flail chest. Methods Randomized-controlled trials comparing operative management versus non-operative management of flail chest were included in this systematic review and meta-analysis. PubMed, Trip Database, and Google Scholar were used for study identification. We compared operative-to-non-operative management in adult flail chest patients. Mean difference and risk ratio for mortality, pneumonia rate, duration of mechanical ventilation, duration of ICU stay, duration of hospital stay, tracheostomy rate, and treatment costs were calculated by pooling these publication results. Results Three randomized-controlled trials were included in this systematic review. In total, there were 61 patients receiving operative management compared to 62 patients in the non-operative management group. A positive effect of surgical rib fracture fixation was observed for pneumonia rate [ES 0.5, 95 % CI (0.3, 0.7)], duration of mechanical ventilation (DMV) [ES −6.5 days 95 % CI (−11.9, −1.2)], duration of ICU stay [ES −5.2 days 95 % CI (−6.2, −4.2)], duration of hospital stay (DHS) [ES −11.4 days 95 % CI (−12.4, −10.4)], tracheostomy rate (TRCH) [ES 0.4, 95 % CI (0.2, 0.7)], and treatment costs (saving $9.968,00–14.443,00 per patient). No significant difference was noted in mortality rate [ES 0.6, 95 % CI (0.1, 2.4)] between the two treatment strategies. Conclusions Despite the relatively small number of patients included, different methodologies and differences in presentation of outcomes, operative management of flail chest seems to be a promising treatment strategy that improves patients’ outcomes in various ways. However, the effect on mortality rate remains inconclusive. Therefore, research should continue to explore operative management as a viable method for flail chest injuries.
Collapse
Affiliation(s)
- Jaap Schuurmans
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - J C Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - T Schepers
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| |
Collapse
|
53
|
Benyan AS, Korymasov EA, Pushkin SY. [Ribs osteosynthesis in patients with isolated and combined chest trauma]. Khirurgiia (Mosk) 2016:26-33. [PMID: 27239911 DOI: 10.17116/hirurgia2016426-33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Rapid methods of costal fractures fixation using special costal plates are becoming more common. AIM To evaluate the efficacy of ribs osteosynthesis in patients with isolated and combined chest trauma. MATERIAL AND METHODS It is presented an experience of surgical treatment of patients with costal fractures in case of isolated (30) and combined (29) chest injury. System for ribs osteosynthesis was used predominantly in surgical tactics. RESULTS Immediate surgical results were analyzed. Most patients had increase of blood gas parameters, oxygenation in the postoperative period. In case of isolated chest injury mean duration of mechanical ventilation was 1.3±1.1, incidence of complications - 3.3%, mortality rate - 0%. In group of combined injuries those indexes were 4.6±3.05, 13.8% and 13.8% respectively. CONCLUSION The method of ribs osteosynthesis in patients with isolated and combined chest trauma showed high efficiency.
Collapse
Affiliation(s)
- A S Benyan
- Samara State Medical University, Ministry of Health of the Russian Federation, Samara; V.D.Seredavin Samara Regional Clinical Hospital, Samara
| | - E A Korymasov
- Samara State Medical University, Ministry of Health of the Russian Federation, Samara; V.D.Seredavin Samara Regional Clinical Hospital, Samara
| | - S Yu Pushkin
- Samara State Medical University, Ministry of Health of the Russian Federation, Samara; V.D.Seredavin Samara Regional Clinical Hospital, Samara
| |
Collapse
|
54
|
Akahoshi T, Yasuda M, Momii K, Kubota K, Shono Y, Kaku N, Tokuda K, Nagata T, Yoshizumi T, Shirabe K, Hashizume M, Maehara Y. Sarcopenia is a predictive factor for prolonged intensive care unit stays in high-energy blunt trauma patients. Acute Med Surg 2016; 3:326-331. [PMID: 29123807 DOI: 10.1002/ams2.195] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 01/08/2016] [Indexed: 01/07/2023] Open
Abstract
Aim Sarcopenia has been increasingly reported as a prognostic factor for outcome in settings such as cirrhosis, liver transplantation, and emergent surgery. We aimed to elucidate the significance of sarcopenia in severe blunt trauma patients. Methods We retrospectively analyzed 84 patients emergently admitted to the intensive care unit at Kyushu University Hospital (Fukuoka, Japan) from May 2012 to April 2015. We assessed the amount of skeletal muscle present according to computed tomography and its relevance to ventilation-free days, patients' length of stay in the intensive care unit, and 28-day mortality. Results Twenty-five (29.7%) patients were defined as sarcopenic. Sixteen (19.7%) patients required 15 days or more in the intensive care unit. The major reason was a prolonged ventilation requirement due to flail chest (n = 7) or pneumonia (n = 3). Sarcopenic patients' stays in intensive care were significantly longer than those of non-sarcopenic patients (18.7 versus 6.4 days, respectively; P < 0.001). Univariate and multivariate analyses showed sarcopenia to be a significant risk factor for prolonged intensive care unit stay. Conclusion Sarcopenia is a risk factor that predicts prolonged intensive care unit stay in high-energy blunt trauma patients.
Collapse
Affiliation(s)
- Tomohiko Akahoshi
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan.,Disaster and Emergency Medicine Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Mitsuhiro Yasuda
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Kenta Momii
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Kensuke Kubota
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Yuji Shono
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Noriyuki Kaku
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Kentaro Tokuda
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Takashi Nagata
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan.,Disaster and Emergency Medicine Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Tomoharu Yoshizumi
- Surgery and Science Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Ken Shirabe
- Surgery and Science Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Makoto Hashizume
- Disaster and Emergency Medicine Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Yoshihiko Maehara
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan.,Surgery and Science Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| |
Collapse
|
55
|
The role of a video-assisted thoracic approach for rib fixation. Eur J Trauma Emerg Surg 2016; 43:185-190. [PMID: 26850079 DOI: 10.1007/s00068-016-0641-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Rib fixation remains a contentious issue in the current practice of orthopaedic, trauma and thoracic surgeons. Whilst rib fractures are undoubtedly associated with high levels of morbidity and mortality, the optimal surgical approach has not yet been fully elucidated in prospective trials and the volume of procedures performed remains low. METHODS We evaluated 21 consecutive patients who underwent surgical rib fixation either via a standard thoracotomy approach or following the introduction of a video-assisted technique with minimal thoracic incisions. RESULTS The average age of patients undergoing rib fixation was 47 and the median length of post-operative stay was 4 days. More than 70 % of patients were found to have concurrent haemothoraces, and 19 % had significant injuries to underlying intra-thoracic structures requiring repair. One patient returned to theatre for persistent blood loss; however, there were no other immediate complications or mortalities. CONCLUSIONS We discuss the involvement of thoracic surgeons, early assessment of the thoracic cavity with video assistance and optimal peri-operative management with particular reference to cases which demonstrate recent changes in our practice.
Collapse
|
56
|
Sareen A, Jain P, Pagare V. IMMEDIATE EFFECT OF KINESIOLOGY TAPING IN TREATING UNDISPLACED RIB FRACTURE PAIN. ACTA ACUST UNITED AC 2015. [DOI: 10.1142/s0218957715500104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Purpose: To determine the immediate effect of kinesiology taping in treating undisplaced rib fracture pain. Method: The study is a retrospective in which 10 Patients (5 females and 5 males) with 1 or 2 undisplaced middle rib fractured (5th, 6th, 7th) were included. The age group of the patients was 27–57 years. The diagnosis was made by the orthopedic surgeon and referred to Institute of Kinesiology Taping. Numeric pain rating scale readings were obtained and documented before and after the taping session. Results: A significant decrease in pain before and after the kinesiology taping was found both while deep breathing ([Formula: see text]0.001) and during coughing ([Formula: see text]0.001). The Mean[Formula: see text] S.D of NPRS reading in case of pre and post taping for deep breathing was 5.7[Formula: see text]0.95 and 4.4[Formula: see text]0.84, respectively and that for coughing was 7.2[Formula: see text]0.63 and 4.7[Formula: see text]1.16, respectively. Conclusion: Kinesiology taping has immediate effect in treating undisplaced middle rib fracture pain.
Collapse
Affiliation(s)
- Aarti Sareen
- Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune, India
| | - Piyush Jain
- Institute of Kinesiology Taping, Uttarpradesh, India
| | - Venus Pagare
- Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune, India
| |
Collapse
|
57
|
Gheorghe A, Moran G, Duffy H, Roberts T, Pinkney T, Calvert M. Health Utility Values Associated with Surgical Site Infection: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:1126-37. [PMID: 26686800 DOI: 10.1016/j.jval.2015.08.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 06/29/2015] [Accepted: 08/03/2015] [Indexed: 05/26/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a costly postoperative complication whose impact on patients' health-related quality of life is highly uncertain and has not been summarized to date. OBJECTIVE The objective was to summarize the evidence base on SSI health utility values reported in patient-level studies and decision models. METHODS A systematic review of SSI utility values reported in patient-level and decision modeling studies was carried out. Studies in which utility values for SSI were either invoked (e.g., model-based economic evaluations) or elicited (e.g., valuation exercises), or at least one non-preference-based instrument was administered to patients with SSI after open surgery were included. Mapping algorithms were used, where appropriate, to calculate utilities from primary data. Results were summarized narratively, and the quality of the utility values used in the included modeling studies was assessed. RESULTS Of 6552 records identified in the database search, 28 studies were included in the review: 19 model-based economic evaluations and 9 patient-level studies. SSI utility decrements ranged from 0.04 to 0.48, of which 19 ranged from 0.1 to 0.3. SSI utility decrements could be calculated for three patient-level studies, and their values ranged from 0.05 (7 days postoperatively) to 0.124 (1 year postoperatively). In most modeling studies, SSI utilities were informed by authors' assumptions or by secondary sources. CONCLUSIONS SSI may substantially affect patients' health utility and needs to be considered when modeling decision problems in surgery. The evidence base for SSI utilities is of questionable quality and skewed toward orthopedic surgery. Further research must concentrate on producing reliable estimates for patients without orthopedic problems.
Collapse
Affiliation(s)
- Adrian Gheorghe
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
| | - Grace Moran
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Helen Duffy
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Thomas Pinkney
- Academic Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Melanie Calvert
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
58
|
Sarani B, Schulte L, Diaz JJ. Pitfalls associated with open reduction and internal fixation of fractured ribs. Injury 2015; 46:2335-40. [PMID: 26521992 DOI: 10.1016/j.injury.2015.10.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 10/05/2015] [Accepted: 10/13/2015] [Indexed: 02/02/2023]
Abstract
Rib fracture is exceedingly common and remains a leading cause of death in patients with chest injury. Probability of death increases by 19% with each broken rib, and the probability of death increases further with age. Treatment is centered on pain control and early mobilization to provide adequate pulmonary hygiene. Multimodality interventions, such as incentive spirometry, postural changes, and coughing, are pivotal in minimizing the risk of pneumonia and death. Recently, many studies have found mortality benefit to operation fixation (ORIF) of ribs in select patients. However, this procedure remains underutilized partly due to lack of familiarity with its technique and pitfalls by trauma surgeons, in particular. Whereas there are publications on operative technique, there are no studies describing pitfalls associated with this procedure. The purpose of this paper is to describe pitfalls on the technical aspects of ORIF of the ribs based on the medical literature where possible and based on our experience in instances where peer reviewed evidence is lacking. The paper is not meant to serve as a protocol for managing rib fractures.
Collapse
Affiliation(s)
- Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, George Washington University.
| | - Leah Schulte
- Department of Orthopedic Surgery, George Washington University
| | | |
Collapse
|
59
|
Qiu M, Shi Z, Xiao J, Zhang X, Ling S, Ling H. Potential Benefits of Rib Fracture Fixation in Patients with Flail Chest and Multiple Non-flail Rib Fractures. Indian J Surg 2015; 78:458-463. [PMID: 28100942 DOI: 10.1007/s12262-015-1409-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 11/12/2015] [Indexed: 12/17/2022] Open
Abstract
The purpose of this study is to evaluate the potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures versus conventional treatment modalities. A retrospective reviewed study compared 86 cases which received surgical treatment between June 2009 and May 2013 to 76 cases which received conservative treatment between January 2006 and May 2009. The patients were divided into the flail chest (n = 38) and multiple non-flail rib fracture groups (n = 124). In the flail chest group, the mechanical ventilation time, ICU monitoring time, tracheostomies, thoracic deformity, and impaired pulmonary function and return to full-time employment were compared. In the multiple non-flail rib fracture group, fracture healing, visual analog scale (VAS) pain score, inpatient length of stay, atelectatic, pulmonary complications, and normal activity-returning time were compared. Patients in the flail chest operative fixation group had significantly shorter ICU stay, decreased ventilator requirements, fewer tracheostomies, less thoracic deformity and impaired pulmonary function, and more returned to full-time employment. Patients in the multiple non-flail rib fracture operative fixation had shorter hospital stay, less pain, earlier return to normal activity, more fracture healing, less atelectasis, and fewer pulmonary infections. This study demonstrates the potential benefits of surgical stabilization of flail chest and multiple non-flail rib fractures with plate fixation. When compared with conventional conservative management, operatively managed patients demonstrated improved clinical outcomes.
Collapse
Affiliation(s)
- Meiguang Qiu
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Road, Guangzhou, 510515 Guangdong China ; Emergency Center of Surgery, Fujian Provincial Hospital, Provincial Clinical Hospital of Fujian Medical University, Fuzhou, 350001 China
| | - Zhanjun Shi
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Road, Guangzhou, 510515 Guangdong China
| | - Jun Xiao
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Road, Guangzhou, 510515 Guangdong China
| | - Xuming Zhang
- Emergency Center of Surgery, Fujian Provincial Hospital, Provincial Clinical Hospital of Fujian Medical University, Fuzhou, 350001 China
| | - Shishui Ling
- Emergency Center of Surgery, Fujian Provincial Hospital, Provincial Clinical Hospital of Fujian Medical University, Fuzhou, 350001 China
| | - Hao Ling
- Emergency Center of Surgery, Fujian Provincial Hospital, Provincial Clinical Hospital of Fujian Medical University, Fuzhou, 350001 China
| |
Collapse
|
60
|
Zhang X, Guo Z, Zhao C, Xu C, Wang Z. Management of patients with flail chest by surgical fixation using claw-type titanium plate. J Cardiothorac Surg 2015; 10:145. [PMID: 26530190 PMCID: PMC4632363 DOI: 10.1186/s13019-015-0363-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/28/2015] [Indexed: 11/29/2022] Open
Abstract
Background The goal of the study was to compare surgical rib fixation using claw-type titanium plate with conservative treatment in the management of patients with flail chest. Methods The study retrospectively studied 23 patients suffering from flail chest injury, who admitted to our hospital from October, 2010 to February, 2014. The patients received surgical fixation by using claw-type titanium plate (surgical fixation group). A age and sex-matched cohort of 29 patients received conservative treatment and defined as conservative treatment group. Outcome variables included number of cases undergoing mechanical ventilation, ventilation time, time of hospital stay, incidence of respiratory complications, incidence of thoracic deformity and postoperative forced expiratory volume in the first second (FEV1). Results Compared with conservative treatment group, surgical fixation group had fewer cases undergoing mechanical ventilation, shorter ventilation time, shorter hospital stay, lower incidence of respiratory complications and thoracic deformity and improved pulmonary function. Patients undergoing surgery earlier had shorter time of mechanical ventilation. Conclusions Surgical rib fixation with claw-type titanium plate is a reliable and efficient method in the management of patients with flail chest.
Collapse
Affiliation(s)
- Xufeng Zhang
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
| | - Zhiqiang Guo
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
| | - Chuncheng Zhao
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
| | - Chenyuan Xu
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
| | - Zheng Wang
- The Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, NO.164 Lan Xi Road, Shanghai, 200062, China.
| |
Collapse
|
61
|
Xu JQ, Qiu PL, Yu RG, Gong SR, Ye Y, Shang XL. Better short-term efficacy of treating severe flail chest with internal fixation surgery compared with conservative treatments. Eur J Med Res 2015; 20:55. [PMID: 26003405 PMCID: PMC4443506 DOI: 10.1186/s40001-015-0146-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 05/15/2015] [Indexed: 11/13/2022] Open
Abstract
Background The objective of the study is to provide evidence for selecting the best treatment approach for severe flail chest by comparing surgical and conservative treatments. Methods This is a retrospective study in which 32 patients with severe flail chest were treated in the Fujian Provincial Hospital (China) between July 2007 and July 2012 with surgical internal rib fixation (n = 17) or conservative treatments (n = 15). Mechanical ventilation time, intensive care unit (ICU) stay time, pulmonary infection, antibiotic treatment duration, acute physiology and chronic health evaluation II (APACHE II) scores 7 and 14 days after trauma, rate of tracheostomy, and rate of endotracheal re-intubation were compared. Results One patient died in the conservative treatment group. Better short-term outcomes were observed in the surgery group, such as total mechanical ventilation time (10.5 ± 3.7 vs. 13.7 ± 4.4 days, P = 0.03), ICU stay (15.9 ± 5.0 vs. 19.6 ± 5.0 days, P = 0.05), pulmonary infection rate (58.8 % vs. 93.3 %, P = 0.02), and APACHE II scores on the 14th day (6.5 ± 3.8 vs. 10.1 ± 4.7, P = 0.02). No difference was observed in the therapeutic time of antibiotics, rate of tracheostomy, and the rate of endotracheal re-intubation between the two groups. Conclusions Results suggest that internal fixation surgery resulted in better outcomes in the management of severe flail chest compared with conservative treatments.
Collapse
Affiliation(s)
- Jing-Qing Xu
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Pei-Li Qiu
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Rong-Guo Yu
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Shu-Rong Gong
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Yong Ye
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Xiu-Ling Shang
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| |
Collapse
|
62
|
Zhang Y, Tang X, Xie H, Wang RL. Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion. Am J Emerg Med 2015; 33:937-40. [PMID: 25910672 DOI: 10.1016/j.ajem.2015.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 04/05/2015] [Accepted: 04/06/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE The objective of this study is to compare the clinical efficacy of surgical fixation and nonsurgical management of flail chest and pulmonary contusion (FC-PC) and to compare the diverse timings of surgery to discuss case management in FC-PC. METHODS The data of 39 patients diagnosed with FC-PC were obtained from the intensive care unit of Shanghai First People's Hospital and analyzed retrospectively from July 2010 to Dec 2013. The patients required ventilator support and were divided into a surgical group and a nonsurgical group, according to the treatment method. The clinical data, such as mortality, the duration of mechanical ventilation (DMV), intensive care unit length of stay, hospital length of stay (HLOS), days of antibiotic use, transfusion volume, medical expense as well as the incidence of tracheotomy, pleural effusion, and incidence of ventilator associated pneumonia, were collected for all subjects. The surgical group was further divided into 2 groups according to the surgery timing. Surgery within 7 days of admission was defined as early surgery, and all other times were defined as late surgery. The clinical data and incidence of incision infection were collected and compared. RESULTS The patients in the surgical group had a slightly shorter HLOS. No differences were noted in mortality and the other clinical data between the groups. The early surgical group had a shorter DMV and less incidence of tracheotomy. The other parameters had no differences. CONCLUSIONS Surgery for FC-PC could reduce the HLOS, and early surgery could decrease the DMV and the need for tracheotomy.
Collapse
Affiliation(s)
- Yuan Zhang
- Department of Emergency and Intensive Care Unit, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xue Tang
- Department of Emergency and Intensive Care Unit, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hui Xie
- Department of Emergency and Intensive Care Unit, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Rui Lan Wang
- Department of Emergency and Intensive Care Unit, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China.
| |
Collapse
|
63
|
Flail chest in polytraumatized patients: surgical fixation using Stracos reduces ventilator time and hospital stay. BIOMED RESEARCH INTERNATIONAL 2015; 2015:624723. [PMID: 25710011 PMCID: PMC4331314 DOI: 10.1155/2015/624723] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 11/11/2014] [Indexed: 11/18/2022]
Abstract
Objectives. Conservative management of patients with flail chest is the treatment of choice. Rib fracture repair is technically challenging; however, with the advent of specially designed molding titanium clips, surgical management has been simplified. Surgical stabilization has been used with good outcomes. We are reporting on our institutional matched-case-control study. Methods. Between April 2010 and April 2011, ten polytraumatized patients undergoing rib stabilization for flail chest were matched 1 : 1 to 10 control patients by age ±10 years, sex, neurological or vertebral trauma, abdominal injury, and arm and leg fractures. Surgery was realized in the first 48 hours. Results. There were no significant differences between groups for matched data and prognostic scores: injury severity score, revised trauma score, and trauma injury severity score. Ventilator time (142 ± 224 versus 74 ± 125 hours, P = 0.026) and overall hospital stay (142 ± 224 versus 74 ± 125 hours, P = 0.026) were significantly lower for the surgical group after adjustment on prognostic scores. There was a trend towards shorter ICU stay for operative patients (12.3 ± 8.5 versus 9.0 ± 4.3 days, P = 0.076). Conclusions. Rib fixation with Stracos is feasible and decreases the length of ventilation and hospital stay. A multicenter randomized study is warranted so as to confirm these results and to evaluate impact on pulmonary function status, pain, and quality of life.
Collapse
|
64
|
Granhed HP, Pazooki D. A feasibility study of 60 consecutive patients operated for unstable thoracic cage. J Trauma Manag Outcomes 2014; 8:20. [PMID: 25642282 PMCID: PMC4311414 DOI: 10.1186/s13032-014-0020-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 11/21/2014] [Indexed: 11/10/2022]
Abstract
Background About 10% of adult patients in high-energy trauma sustain multiple rib fractures. Some of these patients suffer from flail chest leading to respiratory insufficiency. During last years interest and results for operative treatment has improved. The literature today all show positive results for surgical versus conservative treatment, specifically with regard to time spent in mechanical ventilator, complication rates and length of hospital stay. Methods Between September 2010 and July 2012, 60 patients with flail chest or multiple rib-fractures resulting in unstable thoracic cage were operated. 16 women and 44 men with an age between 19-86 years (mean 57). We used modern fracture techniques with plates and intramedullary splint. Thoracotomy was performed and lung lacerations were debrided (11/60). Time spent in ventilator, complications and other adverse effects was studied. The operated cohort was compared to results from six previous years, when none was operated for that diagnose (153 patients). Results There is a significant correlation between Injury Severity Score (ISS) and time spent in ventilator both for patients operated and not operated (p< 0,01). The mean time in ventilator was 9,01 days for not operated patients compared to 2,7 for the operated (p<0,0001). No clear pneumonias were found. We had two deaths during the acute period. The infection rate was low. Conclusions Open reduction and internal fixation is a safe method to treat the unstable thoracic cage with multiple rib fractures and flail chest. Complication are few. The treatment time in mechanical ventilator is significant decreased. The operative treatment is probably cost effective and can be recommended. Knowledge in thoracic surgery and modern fracture surgery is needed. This is a therapeutic consecutive, level III, cohort study with historical controls.
Collapse
Affiliation(s)
- Hans P Granhed
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Pazooki
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
65
|
Wiese MN, Kawel-Boehm N, Moreno de la Santa P, Al-Shahrabani F, Toffel M, Rosenthal R, Schäfer J, Tamm M, Bremerich J, Lardinois D. Functional results after chest wall stabilization with a new screwless fixation device. Eur J Cardiothorac Surg 2014; 47:868-75. [DOI: 10.1093/ejcts/ezu318] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 07/13/2014] [Indexed: 11/13/2022] Open
|
66
|
|
67
|
Said SM, Goussous N, Zielinski MD, Schiller HJ, Kim BD. Surgical stabilization of flail chest: the impact on postoperative pulmonary function. Eur J Trauma Emerg Surg 2013; 40:501-5. [PMID: 26816247 DOI: 10.1007/s00068-013-0344-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 09/30/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Flail chest results in significant morbidity. Controversies continue regarding the optimal management of flail chest. No clear guidelines exist for surgical stabilization. Our aim was to examine the association of bedside spirometry values with operative stabilization of flail chest. METHODS IRB approval was obtained to identify patients with flail chest who underwent surgical stabilization between August 2009 and May 2011. At our institution, all rib fracture patients underwent routine measurement of their forced vital capacity (FVC) using bedside spirometry. Formal pulmonary function tests were also obtained postoperatively and at three months in patients undergoing stabilization. Both the Synthes and Acute Innovations plating systems were utilized. Data is presented as median (range) or (percentage). RESULTS Twenty patients (13 male: 65 %) with median age of 60 years (30-83) had a median of four ribs (2-9) in the flail segment. The median Injury Severity Score was 17 (9-41) and the median Trauma and Injury Severity Score was 0.96 (0.04-0.99). Preoperative pneumonia was identified in four patients (20 %) and intubation was required in seven (35 %). Median time from injury to stabilization was four days (1-33). The median number of plates inserted was five (3-11). Postoperative median FVC (1.8 L, range 1.3-4 L) improved significantly as compared to preoperative median value (1 L, range 0.5-2.1 L) (p = 0.003). This improvement continued during the follow-up period at three months (0.9 L, range 0.1-3.0) (p = 0.006). There were three deaths (15 %), none of which were related to the procedure. Subsequent tracheostomy was required in three patients (15 %). The mean hospital stay and ventilator days after stabilization were nine days and three days, respectively. Mean follow-up was 5.6 ± 4.6 months. CONCLUSION Operative stabilization of flail chest improved pulmonary function compared with preoperative results. This improvement was sustained at three months follow-up.
Collapse
Affiliation(s)
- S M Said
- Division of Thoracic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
| | - N Goussous
- Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - M D Zielinski
- Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - H J Schiller
- Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - B D Kim
- Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
68
|
Fabricant L, Ham B, Mullins R, Mayberry J. Prolonged pain and disability are common after rib fractures. Am J Surg 2013; 205:511-5; discusssion 515-6. [PMID: 23592156 DOI: 10.1016/j.amjsurg.2012.12.007] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 12/26/2012] [Accepted: 12/31/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND The contribution of rib fractures to prolonged pain and disability may be underappreciated and undertreated. Clinicians are traditionally taught that the pain and disability of rib fractures resolves in 6 to 8 weeks. METHODS This study was a prospective observation of 203 patients with rib fractures at a level 1 trauma center. Chest wall pain was evaluated by the McGill Pain Questionnaire (MPQ) pain rating index (PRI) and present pain intensity (PPI). Prolonged pain was defined as a PRI of 8 or more at 2 months after injury. Prolonged disability was defined as a decrease in 1 or more levels of work or functional status at 2 months after injury. Predictors of prolonged pain and disability were determined by multivariate analysis. RESULTS One hundred forty-five male patients and 58 female patients with a mean injury severity score (ISS) of 20 (range, 1 to 59) had a mean of 5.4 rib fractures (range, 1 to 29). Forty-four (22%) patients had bilateral fractures, 15 (7%) had flail chest, and 92 (45%) had associated injury. One hundred eighty-seven patients were followed 2 months or more. One hundred ten (59%) patients had prolonged chest wall pain and 142 (76%) had prolonged disability. Among 111 patients with isolated rib fractures, 67 (64%) had prolonged chest wall pain and 69 (66%) had prolonged disability. MPQ PPI was predictive of prolonged pain (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.4 to 2.5), and prolonged disability (OR, 2.2; 95% CI, 1.5 to 3.4). The presence of significant associated injuries was predictive of prolonged disability (OR, 5.9; 95% CI, 1.4 to 29). CONCLUSIONS Prolonged chest wall pain is common, and the contribution of rib fractures to disability is greater than traditionally expected. Further investigation into more effective therapies that prevent prolonged pain and disability after rib fractures is needed.
Collapse
Affiliation(s)
- Loic Fabricant
- Division of Trauma, Critical Care, & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, L611, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | | | | | | |
Collapse
|
69
|
Abstract
Blunt chest wall trauma accounts for a large proportion of all trauma presentations to the Emergency Departments in the United Kingdom and has a high reported incidence of morbidity and mortality. The difficulty in the assessment and management of this patient group arises from the possibility that the patient may develop potentially life-threatening complications up to approximately 72 h post-injury, even in patients who have sustained what is initially considered a minor injury. Limited consensus currently exists in the literature regarding optimal assessment or management strategies for this patient group. The aim of this review is to provide an overview of current research investigating the optimal assessment and management strategies for the blunt chest wall trauma patient.
Collapse
Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea, UK
- College of Medicine, Swansea University, Swansea, UK
| | | | | |
Collapse
|
70
|
Abstract
Abstract
Postoperative pulmonary complications are responsible for significant increases in hospital cost as well as patient morbidity and mortality; respiratory muscle dysfunction represents a contributing factor. Upper airway dilator muscles functionally resist the upper airway collapsing forces created by the respiratory pump muscles. Standard perioperative medications (anesthetics, sedatives, opioids, and neuromuscular blocking agents), interventions (patient positioning, mechanical ventilation, and surgical trauma), and diseases (lung hyperinflation, obesity, and obstructive sleep apnea) have differential effects on the respiratory muscle subgroups. These effects on the upper airway dilators and respiratory pump muscles impair their coordination and function and can result in respiratory failure. Perioperative management strategies can help decrease the incidence of postoperative respiratory muscle dysfunction. Such strategies include minimally invasive procedures rather than open surgery, early and optimal mobilizing of respiratory muscles while on mechanical ventilation, judicious use of respiratory depressant anesthetics and neuromuscular blocking agents, and noninvasive ventilation when possible.
Collapse
|
71
|
Paydar S, Mousavi SM, Niakan H, Abbasi HR, Bolandparvaz S. Appropriate management of flail chest needs proper injury classification. J Am Coll Surg 2012; 215:743-4. [PMID: 23084501 DOI: 10.1016/j.jamcollsurg.2012.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 07/20/2012] [Indexed: 12/24/2022]
|