Evolution of a Novel Business Leadership Course for General Surgery Chief Residents

Background

General surgery chief residents are typically well equipped for board examinations but poorly trained to deal with the business challenges of surgical practice. We began a business leadership course to better prepare them for their careers.

Methods

Chief residents were given one-hour lectures with topics that included: Differences between private/academic practice, personal finances, contracts, practice management, legal issues and health law, and time management.

Results

Initial evaluations revealed that the topics covered and the presentations were well received. Subsequently, the course was moved to earlier in the academic year to prepare them for contract negotiations and then to Sunday nights to decrease interruptions and allow spouse participation.

Conclusions

The course evolved into a program that the chief residents feel is an important addition to their education. Moving the meetings to a weekend evening improved attendance, decreased interruptions, and allowed participation by spouses and significant others.

Survey of Preoperative Patients' Use of Herbal Products and Other Selected Dietary Supplements

Purpose

This study was designed to determine the prevalence of herbal and selected dietary product use among preoperative patients.

Methods

A questionnaire listing 26 herbal/dietary supplements was given to 979 preoperative patients in the anesthesia assessment unit. Subjects were asked to indicate the amounts and durations of products taken. Demographic data and proposed surgical procedures were noted.

Results

One hundred and seventy surgical patients (17.4%) reported taking herbal or dietary supplements. Neurosurgical, gynecological, and orthopedic surgical patients reported the highest incidences of use at 21%, 21%, and 20%, respectively. Of patients taking these agents, 34.7% took only one product, 23.5% took two products, 11.2% took three products, and 10.6% took four or more products. The most commonly used herbals, in descending order of frequency, were ginkgo, garlic, ginseng, St. John's wort, and echinacea. Glucosamine, chondroitin, and chromium were the surveyed dietary supplements most widely used. More than 40 herbs were taken occasionally. The median age of users and nonusers was 62 years. Orthopedic patients took glucosamine and chondroitin most commonly, ophthalmic patients took ginkgo most commonly, and urology patients took saw palmetto most commonly.

Conclusion

The adverse effects of herbals and dietary products during surgical procedures and the interactions between these products and anesthetic drugs warrant further research. The use of herbal or dietary supplements may indicate alteration of patients' perioperative regimens.

Effect of inhaled tacrolimus on ischemia reperfusion injury in rat lung transplant model

OBJECTIVE

Systemic tacrolimus therapy has been shown to protect against lung ischemia-reperfusion injury in animal models. We sought to investigate on a functional and cellular level if inhaled nanoparticle tacrolimus administered to the donor lung before procurement could similarly attenuate ischemia-reperfusion injury after lung transplant.

METHODS

An isogenic orthotopic rat model of single left lung transplant was used. Donor animals were pretreated with inhaled tacrolimus (treatment group) or inhaled lactose (controls) before lung procurement. Lung grafts were subjected to 3 hours of cold ischemia followed by 4 hours of reperfusion after graft implantation. Recipient animal arterial blood gas measurement and isograft wet to dry weight ratios were obtained. Macrophage, neutrophil, and T-cell accumulation and activation in lung isografts, including γδ T-cell, T-helper, and cytotoxic T-cell subtypes were analyzed by flow cytometry. Tacrolimus levels were measured in the lung isograft using liquid chromatography/mass spectrometry. Isograft cytokine levels were measured with commercial enzyme-linked immunosorbent assay and microbead array kits.

RESULTS

Oxygenation in treatment group animals was significantly higher than in controls. The presence of macrophages, neutrophils, and all T-cell subtypes in the isografts as well as isograft levels of inflammatory cytokines were all less in the treatment group versus controls, although no single variable achieved statistical significance.

CONCLUSIONS

Inhaled nanoparticle tacrolimus treatment of lung donors is associated with an attenuation of ischemia-reperfusion injury on a functional and cellular level in lung transplant.

Saphenous vein graft failure after coronary artery bypass surgery: pathophysiology, management, and future directions

OBJECTIVE

To review our current understanding of the epidemiology and pathogenesis of vein graft failure (VGF), give an overview of current preventive and interventional measures, and explore strategies that may improve vein graft patency.

BACKGROUND

VGF and progression of native coronary artery disease limit the long-term efficacy of coronary artery bypass graft surgery.

METHODS

We reviewed the published literature on the pathophysiology, prevention, and/or treatment of VGF by searching the MEDLINE (January 1, 1966-January 1, 2012), EMBASE (January 1, 1980-January 1, 2012), and Cochrane (January 1, 1995-January 1, 2012) databases. In addition, we reviewed references from the selected articles for studies not identified in the initial search. Basic science and clinical studies were included; non-English language publications were excluded.

RESULTS

Acute thrombosis, neointimal hyperplasia, and accelerated atherosclerosis are the 3 mechanisms that lead to VGF. Preventive measures include matching and quality assessment of conduit and target vessel, lipid-lowering drugs, antithrombotic therapy, and cessation of smoking. Treatment of VGF includes medical therapy, percutaneous intervention, and redo coronary artery bypass graft surgery. In patients undergoing graft intervention, the use of drug-eluting stents, antiplatelet agents, and embolic protection devices may improve clinical outcomes.

CONCLUSIONS

Despite advances in management, VGF remains one of the leading causes of poor in-hospital and long-term outcomes after coronary artery bypass graft surgery. New developments in VGF prevention such as gene therapy, external graft support, fully tissue-engineered grafts, hybrid grafts, and synthetic conduits are promising but unproven. Future efforts to reduce VGF require a multidisciplinary approach with a primary focus on prevention.

A bovine hemoglobin-based oxygen carrier as pump prime for cardiopulmonary bypass: reduced systemic lactic acidosis and improved cerebral oxygen metabolism during low flow in a porcine model

OBJECTIVES

Cerebral ischemia can occur during cardiopulmonary bypass, especially during low flow. HBOC-201 (OPK Biotech, Cambridge, Mass) is a hemoglobin-based oxygen-carrying solution that enhances oxygen delivery. This project evaluated the benefits on total body and cerebral oxygen delivery and consumption using HBOC-201 during cardiopulmonary bypass.

METHODS

Twelve immature swine were assigned to one of 2 groups. One group used HBOC-201 in pump prime, and the other used donor porcine blood. Cardiopulmonary bypass was initiated and then flow was serially decreased from 100% to 75%, to 50%, and then back to full flow. At each interval, (15)O positron emission tomographic analysis was performed, and blood was collected. Total body and cerebral oxygen delivery and consumption were calculated. Statistical analysis was performed with a Tukey-Kramer adjusted P value based on a repeated measures linear model on log-transformed data.

RESULTS

Total and plasma hemoglobin levels were higher in the HBOC-201 group. Oxygen delivery and consumption were not statistically different but did tend to be higher in the HBOC-201 group. Mixed venous saturation was lower in the HBOC-201 group but not significant. Mild metabolic acidosis with increased lactate levels developed in the blood group. Mean cerebral blood flow decreased in both groups when total flow was 50%. In the HBOC-201 group cerebral oxygen metabolism was maintained.

CONCLUSIONS

The addition of HBOC-201 for cardiopulmonary bypass appears to improve oxygen use and minimize anaerobic metabolism. Cerebral oxygen use was preserved in the HBOC-201 group, even during decrease in blood flow. These findings support the reported improved oxygen-unloading properties of HBOC-201 and might provide a benefit during cardiopulmonary bypass.

Interactive financial decision support for clinical research trials

The purpose of this article is to describe a decision support approach useful for evaluating proposals to conduct clinical research trials. Physicians often do not have the time or background to account for all the expenses of a clinical trial. Their evaluation process may be limited and driven by factors that do not indicate the potential for financial losses that a trial may impose. We analyzed clinical trial budget templates used by hospitals, health science centers, research universities, departments of medicine, and medical schools. We compiled a databank of costs and reviewed recent research trials conducted by the Department of Cardiothoracic Surgery in a major academic health science center. We then developed an interactive spreadsheet-based budgetary decision support approach that accounts for clinical trial income and costs. It can be tailored to provide quick and understandable data entry, accurate cost rates per subject, and clear go/no-go signals for the physician.

Flail chest and pulmonary contusion

Flail chest is most often accompanied by a significant underlying pulmonary parenchymal injury and can be a life-threatening thoracic injury. Its management is often complicated by the other injuries it is frequently associated with. Similarly, mortality and morbidity are dictated most often by the associated injuries and findings. Its treatment is complex and should first be one of pain management, judicious fluid resuscitation, and excellent pulmonary toilet. In those patients requiring mechanical ventilatory support, or who require ipsilateral thoracocotomy, rib stabilization may be considered depending on a host of potentially conflicting indications and contraindications. At the end of this section are listed the current major recommendations and their levels of evidence.

Cardiac procedures in lung transplant recipients do not increase mortality in selected patients

BACKGROUND

Associated comorbidities in potential lung transplant recipients may significantly impact operative morbidity and mortality. We undertook this review to specifically study whether patients who underwent associated cardiac procedures either before (as a prerequisite) or during their lung transplantation had different outcomes when compared with the overall cohort of lung transplant recipients.

METHODS

A retrospective chart review was performed of all patients who underwent lung transplantation at the University of Texas Health Science Center at San Antonio from January 1994 to June 2004. The records of these patients were analyzed for patient-days on the ventilator, hospital length of stay, operative morbidity and mortality, and long-term survival. The patients were then divided into two groups and compared: patients who had a cardiac intervention either prerequisite to or concurrent with their transplant (group C, n = 13) and patients who did not (group NC [no cardiac intervention], n = 120).

RESULTS

Although the median length of stay was longer in group C when compared with group NC, the number of patient-days on the ventilator and the operative morbidity and mortality were similar for both groups. Likewise, overall long-term survival was not significantly different (Kaplan-Meier method, p = 0.70).

CONCLUSIONS

Patients who are otherwise deemed to be good candidates for lung transplantation but are found to have an associated cardiac condition that could adversely affect their candidacy may still be considered for transplantation in selected cases if the cardiac abnormality can be addressed either before or during transplantation.

Novel truncated isoforms of constitutive serum amyloid A detected by MALDI mass spectrometry

The main focus of the serum amyloid A (SAA) family has been on the acute phase isoforms. However, the constitutive isoform (SAA4) may have a strong effect on the metabolism of human serum lipoproteins. In this study, the SAA4 protein was examined in the high-density lipoprotein fraction of both healthy and diseased individuals. Novel isoforms of SAA4 were detected using ultracentrifugation combined with solid-phase extraction and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). Three truncated isoforms were identified as well as two glycosylated isoforms. Patterns of isoform distribution may be significant for assessment of cardiovascular risk as well as direction of patient treatment.

Comparison of lipid and non-lipid markers of atherosclerosis in arterial versus venous blood

BACKGROUND

Early studies have suggested that there may be differences in the concentration of lipoprotein particles and their associated apolipoproteins in arterial and venous blood and that this gradient might explain a proclivity to develop atherosclerotic lesions. The aim of this study was to use current methods of analysis to determine levels of these components, including particle densities and several common inflammatory markers in arterial and venous blood.

METHODS

Samples of arterial and venous blood were obtained nearly simultaneously in 26 patients undergoing right and left heart catheterization. Analyses were performed using enzymatic, immunoturbidimetric and ultracentrifugation assays.

RESULTS

Data obtained for total cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol, HDL and LDL particle density, high sensitivity C-reactive protein, serum amyloid-A and apoprotein B-100 concentrations in arterial and venous blood did not demonstrate any significant difference in the means.

CONCLUSION

Arterial and venous blood can be used interchangeably to study the effect of blood concentrations of common soluble surrogate markers of atherosclerosis.

Readmission and mortality in patients discharged the day after off-pump coronary bypass surgery

BACKGROUND

The fate of patients discharged the day following off-pump coronary bypass (OPCAB) has not previously been reported. We studied the mortality and readmissions of a consecutive series of patients discharged after OPCAB, and compared the outcomes of those discharged the day following surgery to the rest of the group.

METHODS

All patients having OPCAB through median sternotomy during the calendar year 2000 by a single surgeon were retrospectively reviewed. Demograghics, intraoperative variables and postoperative complications, readmissions and mortality were recorded. Factors were analyzed to determine associations with time of discharge and readmission.

RESULTS

One hundred fifteen patients had isolated OPCAB averaging 3.1 grafts. Two patients (1.8%) died before discharge. Sixty-three of 113 patients (55.8%) were discharged on day 1 and 8 (12.7%) required readmission compared to 13 of 50 (26%) discharged later. Diabetes (p = 0.04) and renal failure (p = 0.01) exhibited univariate association with day 1 discharge while multivariate analysis added infarction. The combination of previous bypass, obesity, acute myocardial infarction, and hypertension was associated with readmission in the entire OPCAB group but not in day 1 discharged patients.

CONCLUSIONS

The readmission rate for the entire group (18.6%) was high but lower in day 1 discharge patients (12.7%). Day 1 discharge (55.8%) was unusual in patients with diabetes, renal failure, or recent infarction. Previous bypass, obesity, acute myocardial infarction, and hypertension were associated with readmission for the entire group only. Day 1 discharged patients had no deaths or serious consequences, and there were no readmissions in more than 87%.

Three years of experience with prospective randomized effectiveness studies

We developed methodology for prospective randomized effectiveness studies using a demonstration project at a multispecialty practice, health maintenance organization, and hospital in academic medical center. An operational unit called the effectiveness registry was developed to design and support comparisons of potential practice improvements with standard care. The studies differ from observational effectiveness studies in that they provide long-term follow-up of randomized comparison groups. Physician involvement in data collection is limited. No tests or observations are made other than those required for clinical care. Follow-up and data collection are modeled after tumor registry procedures. Patients who refuse randomization enter the study in whichever treatment arm they choose. The protocol for each study is approved by the institutional review board (IRB) before recruitment begins, and all patients, randomized and nonrandomized, sign an informed consent document. Between its beginning on October 7, 1993 and April 7, 1997, the IRB approved 14 trials. Four were terminated after entering at most a few patients. Recruitment is complete in four trials and continues in six. Randomization was accepted by 74% (596/804) of the patients. Over 800 patients in 10 studies are being followed at least annually. Major peer-reviewed journals have accepted reports of initial findings for two studies. Prospective randomized effectiveness studies are feasible in the multipractice setting and have potential to provide useful and reliable assessment of treatment outcomes. Collaborative arrangements between several institutions are needed to provide larger sample sizes.

A multicenter, randomized, blind comparison of amrinone with milrinone after elective cardiac surgery

Amrinone and milrinone are phosphodiesterase inhibitors with positive inotropic effects useful for the treatment of ventricular dysfunction after cardiac surgery. Forty-four patients undergoing elective cardiac surgery at four centers received either amrinone (n = 22) or milrinone (n = 22) in a randomized, blind fashion. Immediately after separation from cardiopulmonary bypass (CPB), two bolus doses of either amrinone 0.75 mg/kg or milrinone 25 microg/kg were administered over 30 s, separated by 5 min. Hemodynamic measurements were recorded before each dose and at the end of the 10-min study. Both amrinone and milrinone increased the cardiac index (48% vs 52%, P = not significant [NS] for amrinone and milrinone, respectively). There was a small increase in mean arterial pressure (MAP) after amrinone administration (from 68 +/- 3 to 72 +/- 3 mm Hg at 10 min, P < 0.05) with no significant change in MAP after milrinone administration. Central venous pressure was significantly higher in the amrinone group at baseline and 5 min (12 vs 10 mm Hg and 11 vs 10 mm Hg, respectively; P < 0.05). Systemic and pulmonary vascular resistances decreased significantly and to a similar extent after either amrinone or milrinone administration. Phenylephrine was required in 11 of 22 patients receiving amrinone and in 11 of 22 patients receiving milrinone to maintain arterial blood pressure. The proportion of patients requiring an intravascular volume infusion (15 of 22 vs 17 of 22, P = NS) and the total fluid volume infused were similar (402 +/- 57 vs 350 +/- 49 mL, P = NS for amrinone and milrinone, respectively). Amrinone and milrinone seem to have similar hemodynamic effects after CPB, with the exception of blood pressure, although the need for vasopressor support of blood pressure did not differ. Selection between these two drugs may include nonhemodynamic considerations such as cost.

IMPLICATIONS

Amrinone and milrinone are drugs that improve cardiac contraction. Their effects have never been directly compared in patients. We found that amrinone and milrinone produced similar hemodynamic effects in adult patients undergoing cardiac surgery. Choice between the two drugs can be based on nonhemodynamic considerations such as cost.

Forced-air warming is no more effective than conventional methods for raising postoperative core temperature after cardiac surgery

OBJECTIVE

To determine whether postoperative forced-air warming of cardiac bypass patients in the intensive care unit (ICU) results in faster rate of warming and improved outcomes compared with more conventional ICU warming methods.

DESIGN

Prospective randomized effectiveness study.

SETTING

Three hundred fifty-bed university-affiliated hospital.

PARTICIPANTS

Sixty consenting randomized patients from a consecutive series of 84 patients undergoing routine adult cardiac surgery.

INTERVENTIONS

One group of patients received usual patient care, which includes warm blankets and overhead heat lamps. Patients in the other group were placed under forced-air warming devices on arrival in the ICU. Sixty consenting patients (30 in each group) were randomly assigned to one or the other method of warming. The remaining 24 patients refused randomization and self-selected a treatment group.

MEASUREMENTS AND MAIN RESULTS

Results are presented for the randomized groups. Core temperature, measured by pulmonary artery catheter thermistor, increased in both groups at the rate of 0.25 degree C per hour. No statistically or clinically significant differences were found between the group for whom the warming device was used and the standard care group in the incidence of postoperative cardiac arrhythmia, duration of time in the ICU, or any other clinical variable.

CONCLUSIONS

There is no evidence from this study to warrant use of forced-air warming devices for the care of postoperative cardiac surgical patients in the ICU.

Minimally invasive axillary-coronary artery bypass

Axillary artery-to-coronary artery bypass using reversed saphenous vein provides a simple method of applying the minimally invasive coronary bypass grafting procedure when the internal thoracic artery is not an adequate conduit. Although this may allow extended use of the minimally invasive coronary bypass procedure, the long-term patency of this technique is unknown.

Access to the thorax by incision

BACKGROUND

For years the standard access to the thorax has been by posterolateral or other muscle cutting thoracotomy incisions. These are accompanied by significant discomfort and often limitation of shoulder girdle movement. To obviate these distressing features, the less traumatic median sternotomy was recommended. In the last ten years, several types of mini or axillary thoracotomies have been described. We believe that the vertical axillary thoracotomy is the best of these incisions as no major muscles are divided, it can be created rapidly, and exposure is excellent.

STUDY DESIGN

We compared the operative approaches from the point of view of the duration of postoperative hospitalization, the length of the operating time, the incidence of postoperative atelectasis, and persistence of incisional pain.

RESULTS

The vertical axillary thoracotomy showed a definite advantage in all these categories.

CONCLUSIONS

These findings suggest that the vertical axillary thoracotomy is the incision of choice for most thoracic procedures as the incision is small and quickly made. Because there is limited division of muscles, the convalescence is smooth and uncomplicated.

Left ventricular-coronary sinus fistula after mitral valve replacement: case report and ultrafast CT findings

Postoperative fistula from left ventricle to right atrium is a rare complication of mitral valve surgery. We describe a case identified by ultrafast computed tomography (CT) and we review the literature regarding this entity.

Paranasal sinusitis: cryptic sepsis after coronary artery bypass operations

Infections occurred in 52 of 400 patients (13%) undergoing coronary artery bypass operations from January 1987 to December 1990. The hospital courses of 5 patients (1.3%) in whom occult infections of the paranasal sinuses developed were reviewed. Only 1 patient had specific clinical findings of acute sinusitis (purulent nasal discharge). Computed tomography showed wall thickening, opacification, or air-fluid levels in one or more paranasal sinuses in each patient. All patients were successfully treated with surgical drainage and antibiotics. Risk factors for development of postoperative acute sinusitis include: prolonged tracheal intubation, airway colonization with nosocomial bacteria, inability to clear nasal secretions, sinus ostial obstruction, and critical organ system dysfunction. Physical examination and roentgenographic evaluation of the paranasal sinuses should be considered when postoperative sepsis of obscure etiology occurs.

Role of autogenous tissue factors in hemolysis during cardiopulmonary bypass operations

Pericardial fluid has been implicated as a causative factor in hemolysis during cardiopulmonary bypass operations. Preoperative blood samples were obtained from 10 patients undergoing coronary artery bypass grafting for ischemic myocardial disease. Whole blood samples were separately incubated with autogenous pericardial fluid, pericardium, pleura, vein, skeletal muscle, and fat harvested during the operative intervention. The plasma fraction was separated by centrifugation and assayed for serum free hemoglobin. Statistical analysis was accomplished by the Bonferroni technique to adjust for multiple comparisons. Pericardial fluid-induced hemolysis was least (20.7 mg/dL). Pleura and muscle contributed significantly to the serum free hemoglobin level (56.3 and 112.3 mg/dL, respectively; p < 0.05). Pericardium, vein, and fat did not cause significant elevations of the serum free hemoglobin level. Postbypass hemolysis is an important management consideration that may be minimized by delicate tissue manipulation and attention to minimizing tissue trauma. Avoidance of aspiration of pericardial fluid into the autotransfusion system is not supported.

Sepsis after coronary bypass grafting: evidence for loss of the gut mucosal barrier

Postoperative infections may originate from a patient's gastrointestinal tract. We studied infections after coronary artery revascularization. Three hundred twenty-nine patients underwent coronary artery revascularization from January 1987 to March 1990. Eight of the 329 (2.4%) died; none of the deaths were infection related. Fifty-five culture-proven infections were identified in 22 of 321 survivors (6.8%); 9 infections (16%) were gram-positive, 5 (9%) were fungal, and 41 (75%) were gram-negative. Site of infections were respiratory tract, 58%; urinary tract, 18%; blood, 13%; and mediastinum, 11%. Ninety-six percent of respiratory tract and all urinary tract infections were gram-negative or fungal. There was no significant difference between infected and noninfected groups in sex, age, smoking history, preoperative hematocrit or leukocyte count, serum albumin level, or time on extracorporeal bypass. The infected group required intubation and nasogastric suction for a significantly longer time than the noninfected group (p less than 0.001). Time to enteral alimentation was significantly longer in the infected group (p less than 0.02). We were unable to correlate the number of infections with the lengths of intubation, nasogastric suction, or time to enteral alimentation. This study supports the concept of postoperative infections arising from bacterial translocation across the patient's gastrointestinal tract. The most significant risk factor is the length of the gastrointestinal tract disuse.

Ductus diverticulum aneurysm and coronary stenosis: repair using circulatory arrest

The case of a 68-year-old man with advanced symptomatic coronary artery disease and large aneurysm of the diverticulum of the ductus arteriosus is presented. Both the coronary artery disease and the aneurysm were successfully repaired at the same time via median sternotomy using cardiopulmonary bypass and a brief period of profound hypothermic circulatory arrest. To our knowledge, this is the 27th reported case of such an aneurysm in an adult.

Pseudosepsis after myocardial infarction. Unusual presentation of anterior wall rupture and left ventricular pseudoaneurysm

Left ventricular pseudoaneurysm complicating myocardial infarction is extremely rare. A case of left ventricular anterolateral pseudoaneurysm with its initial presentation mimicking septic shock is reported. The need for urgent resection is stressed due to the high incidence of spontaneous rupture and death regardless of the age or the size of the pseudoaneurysm.

Scintigraphic documentation of hemorrhage from coronary artery bypass graft

Tc-99m labeled RBC imaging was used to conclusively demonstrate continuing intrathoracic hemorrhage from the anastomotic site of a coronary artery bypass graft. Demonstration of continuing hemorrhage and localization of the most likely site of bleeding resulted in timely and appropriate surgical intervention, which resulted in hemostasis and eventual patient recovery. Tc-99m RBC imaging may be an ideal noninvasive technique to investigate the site and activity of intrathoracic hemorrhage after coronary bypass surgery and other thoracic procedures.

Occult rib fractures and brachial plexus injury following median sternotomy for open-heart operations

The incidence and the sites of rib fractures during open-heart operations through a median sternotomy incision were studied in 36 consecutive patients divided into two groups. In Group 1 (24 patients), a conventional Ankeney retractor was used to expose the heart, and in Group 2 (12 patients), a similar retractor was used but with its uppermost pair of blades removed. Thorough physical examinations and preoperative and postoperative chest roentgenograms were obtained, and postoperative bone scans were done in all patients. No rib fractures were detected on the routine chest roentgenograms in patients in either group. Bone scans, however, showed 44 rib fractures (15 of the first rib, 13 of the second rib, 4 of the third rib, 6 of the fourth rib, 3 of the fifth rib, and 3 of the sixth rib) in 16 patients in Group 1. Six patients in Group 2 had 9 rib fractures (2 of the first rib, 4 of the second rib, and 1 each of the third, fifth, and sixth ribs). None of the patients in Group 2 had brachial plexus injury and neither of the first rib fractures in this group were located posteriorly, whereas 3 patients in Group 1 had both brachial plexus injury and posterior first rib fractures.

Rib fractures in coronary bypass patients: radionuclide detection

Sternal retraction can cause the first rib to be fractured posteriorly, injuring the brachial plexus. The authors conducted bone scans of 24 consecutive open-heart surgery patients and found an unexpectedly high number of rib fractures which in all but one case had not been seen on the chest radiograph. Bone scans are recommended whenever there is unexplained non-incisional pain in a patient who has undergone sternal retraction.