Highlights
- •Early SSRF was associated with mildly prolonged length of stay and decreased risk of unplanned intubation compared with epidural analgesia.
- •Epidural analgesia may offer comparable in-hospital outcomes in the absence of SSRF among adults with acute rib fractures.
- •Early referral to a chest wall injury center may facilitate the timely identification of and intervention for appropriate surgical candidates.
Abstract
Introduction
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).
Methods
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.
Results
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(): 1.06, 95%CI: 1.00–1.12, p = 0.047) and ICU LOS (Exp(): 1.17, 95%CI: 1.08–1.27, p<0.001).
Conclusions
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.
Keywords
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Article info
Publication history
Published online: July 25, 2022
Accepted:
July 23,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
