Advertisement

Comparison of surgical stabilization of rib fractures vs epidural analgesia on in-hospital outcomes

      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( 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).

      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

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ziegler D.W.
        • Agarwal N.N.
        The morbidity and mortality of rib fractures.
        J Trauma. 1994; 37: 975-979
        • Flagel B.T.
        • Luchette F.A.
        • Reed R.L.
        • Esposito T.J.
        • Davis K.A.
        • Santaniello J.M.
        • et al.
        Half-a-dozen ribs: the breakpoint for mortality.
        Surgery. 2005; 138: 717-725
        • Martin T.J.
        • Eltorai A.S.
        • Dunn R.
        • Varone A.
        • Joyce M.F.
        • Kheirbek T.
        • et al.
        Clinical management of rib fractures and methods for prevention of pulmonary complications: a review.
        Injury. 2019; 50: 1159-1165
        • Bulger E.M.
        • Arneson M.A.
        • Mock C.N.
        • Jurkovich G.J.
        Rib fractures in the elderly.
        J Trauma. 2000; 48 (discussion 1046-7): 1040-1046
        • Bergeron E.
        • Lavoie A.
        • Clas D.
        • Moore L.
        • Ratte S.
        • Tetreault S.
        • et al.
        Elderly trauma patients with rib fractures are at greater risk of death and pneumonia.
        J Trauma. 2003; 54: 478-485
        • Liman S.T.
        • Kuzucu A.
        • Tastepe A.I.
        • Ulasan G.N.
        • Topcu S.
        Chest injury due to blunt trauma.
        Eur J Cardiothorac Surg. 2003; 23: 374-378
        • Tanaka H.
        • Yukioka T.
        • Yamaguti Y.
        • Shimizu S.
        • Goto H.
        • Matsuda H.
        • et al.
        Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients.
        J Trauma. 2002; 52 (discussion 732): 727-732
        • Bottlang M.
        • Long W.B.
        • Phelan D.
        • Fielder D.
        • Madey S.M.
        Surgical stabilization of flail chest injuries with MatrixRIB implants: a prospective observational study.
        Injury. 2013; 44: 232-238
        • Marasco S.F.
        • Davies A.R.
        • Cooper J.
        • Varma D.
        • Bennett V.
        • Nevill R.
        • et al.
        Prospective randomized controlled trial of operative rib fixation in traumatic flail chest.
        J Am Coll Surg. 2013; 216: 924-932
        • Schuurmans J.
        • Goslings J.C.
        • Schepers T.
        Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review.
        Eur J Trauma Emerg Surg. 2017; 43: 163-168
        • Kane E.D.
        • Jeremitsky E.
        • Pieracci F.M.
        • Majercik S.
        • Doben A.R.
        Quantifying and exploring the recent national increase in surgical stabilization of rib fractures.
        J Trauma Acute Care Surg. 2017; 83: 1047-1052
        • Swart E.
        • Laratta J.
        • Slobogean G.
        • Mehta S.
        Operative treatment of Rib fractures in flail chest injuries: a meta-analysis and cost-effectiveness analysis.
        J Orthop Trauma. 2017; 31: 64-70
        • Pieracci F.M.
        • Leasia K.
        • Bauman Z.
        • Eriksson E.A.
        • Lottenberg L.
        • Majercik S.
        • et al.
        A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).
        J Trauma Acute Care Surg. 2020; 88: 249-257
        • Wijffels M.M.E.
        • Prins J.T.H.
        • Perpetua Alvino E.J.
        • Van Lieshout E.M.M
        Operative versus nonoperative treatment of multiple simple rib fractures: a systematic review and meta-analysis.
        Injury. 2020; 51: 2368-2378
        • Granetzny A.
        • Abd El-Aal M.
        • Emam E.
        • Shalaby A.
        • Boseila A
        Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status.
        Interact Cardiovasc Thorac Surg. 2005; 4: 583-587
        • Luchette F.A.
        • Radafshar S.M.
        • Kaiser R.
        • Flynn W.
        • Hassett J.M.
        Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma.
        J Trauma. 1994; 36 (discussion 869-70): 865-869
        • Carrier F.M.
        • Turgeon A.F.
        • Nicole P.C.
        • Trépanier C.A.
        • Fergusson D.A.
        • Thauvette D.
        • et al.
        Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials.
        Can J Anaesth. 2009; 56: 230-242
        • Peek J.
        • Smeeing D.P.J.
        • Hietbrink F.
        • Houwert R.M.
        • Marsman M.
        • de Jong M.B.
        Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis.
        Eur J Trauma Emerg Surg. 2019; 45: 597-622
        • Prins J.T.H.
        • Van Lieshout E.M.M.
        • Ali-Osman F.
        • Bauman Z.M.
        • Caragounis E.-.C.
        • Choi J.
        • et al.
        Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI).
        J Trauma Acute Care Surg. 2021; 90: 492-500
        • Witt C.E.
        • Bulger E.M.
        Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol.
        Trauma Surg Acute Care Open. 2017; 2e000064
        • Ahmed Z.
        • Mohyuddin Z.
        Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation.
        J Thorac Cardiovasc Surg. 1995; 110: 1676-1680
        • Voggenreiter G.
        • Neudeck F.
        • Aufmkolk M.
        • Obertacke U.
        • Schmit-Neuerburg K.-.P.
        Operative chest wall stabilization in flail chest—outcomes of patients with or without pulmonary contusion.
        J Am Coll Surg. 1998; 187: 130-138
        • Khandelwal G.
        • Mathur R.K.
        • Shukla S.
        • Maheshwari A.
        A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture.
        Int J Surg. 2011; 9: 478-481
        • Doben A.R.
        • Eriksson E.A.
        • Denlinger C.E.
        • Leon S.M.
        • Couillard D.J.
        • Fakhry S.M.
        • et al.
        Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation.
        J Crit Care. 2014; 29: 139-143
        • Prins J.T.H.
        • Wijffels M.M.E.
        • Pieracci F.M.
        What is the optimal timing to perform surgical stabilization of rib fractures?.
        J Thorac Dis. 2021; 13: S13-S25
        • Pieracci F.M.
        • Coleman J.
        • Ali-Osman F.
        • Mangram A.
        • Majercik S.
        • White T.W.
        • et al.
        A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures.
        J Trauma Acute Care Surg. 2018; 84: 1-10
        • Marasco S.F.
        • Balogh Z.J.
        • Wullschleger M.E.
        • Hsu J.
        • Patel B.
        • Fitzgerald M.
        • et al.
        Rib fixation in non-ventilator dependent chest wall injuries: a prospective randomized trial.
        J Trauma Acute Care Surg. 2022; (EpubJan 25)
        • Duch P.
        • Møller M.H.
        Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials.
        Acta Anaesthesiol Scand. 2015; 59: 698-709