NAPLES, Fla. – Patients who underwent surgical rib fixation for flail chest spent on average 10 fewer days on mechanical ventilation than did those managed traditionally in a single-center analysis of 21 patients with severe blunt chest trauma.
The total number of ventilator days was significantly lower in patients who underwent rib fixation, at a median of 4.5 days (range 0-30 days), compared with a median of 16 days (range 4-40 days) in those managed with pain control and respiratory therapy (P = .04).
Hospital length of stay was a median of 22 days in the nonsurgical group vs. 13 days in the surgical group, and ICU length of stay was a median of 18 days vs. 9 days, but those differences were not statistically significant. There was one postoperative seroma and no deaths in the surgical group.
Dr. Andrew R. Doben
Surgical rib fixation can be used as a rescue technique when the last resort is prolonged mechanical ventilation, but a large multicenter trial is needed to determine the best approach, Dr. Andrew R. Doben said at the annual meeting of the Eastern Association for the Surgery of Trauma.
"This study provides some of the first data suggesting that surgical fixation may prevent prolonged ventilation in flail chest patients who initially do not require invasive mechanical ventilation," he said in an interview.
Dr. Doben pointed out that major trauma centers see roughly two flail chest injuries per month and that up to 60% of patients do not return to full-time employment. A prospective randomized trial showed benefits with surgical stabilization with Judet struts, compared with internal pneumatic stabilization (J. Trauma 2002;52:727-32), but that trial included only 18 fixation patients and all required invasive mechanical ventilation, he said.
Dr. Doben and his colleagues at the Medical University of South Carolina, Charleston, defined flail chest deformity as three consecutive ribs broken in two or more locations, and they initially focused on patients who failed to wean from the ventilator 5 days post injury, had isolated chest wall trauma, and had good neurologic status. Surgical fixation using a combination of plates and intramedullary nails in three such patients produced positive results similar to those in the literature, but raised the question of whether mechanical ventilation could be avoided in patients who are failing, Dr. Doben said.
"Everybody’s seen these patients – the ‘in-betweeners’ – they’re not really failing, they’re not yet vented, but they’re heading that way," he said.
Dr. Doben highlighted the case of a 60-year-old man with seven total rib fractures including five segmental fractures and paradoxical chest wall motion, who had an epidural in place, was on oxycodone, NSAIDs, acetaminophen, and gabapentin, and was experiencing progressive pulmonary decline on bilevel positive airway pressure therapy for 3 days in the ICU. The patient underwent surgical rib fixation on hospital day 6, was mechanically ventilated overnight, and was extubated the following morning. He was discharged to home on hospital day 11, with no long-acting narcotics needed for pain, he said.
The retrospective chart review included the first 10 patients treated with surgical fixation from September 2008 to May 2010, matched with a previous group of 11 patients managed with standard therapy. Patients were required to have a Chest Abbreviated Injury Scale score of more than 3, a diagnosis of flail chest, and an ICU length of stay greater than 5 days. There were no surgical complications, and the average time on a ventilator after surgery was 1.5 days, said Dr. Doben, now with Baystate Medical Center in Springfield, Mass.
Invited discussant Dr. John C. Mayberry said no strong conclusions supporting flail chest repair can be drawn because of the small study size, but commended the authors for providing new data on its use in patients who do not require ventilation, but clinically worsen.
Dr. Mayberry, with Oregon Health and Science University in Portland, asked whether the study protocol evolved over time, and whether the 10 fixation patients represent the authors’ first experience with the technique. This line of questioning was continued by an audience member who asked what kind of course work prepared the authors to perform rib fixation.
Dr. Doben responded that he had limited experience with chest repairs as a general surgery resident in Maine, but that these were indeed the first 10 rib fixation patients in Charleston. The surgeries in both Maine and Charleston were performed in conjunction with cardiothoracic and orthopedic surgeons who had expertise in hardware insertion, he noted.
With respect to the study protocol, Dr. Doben said initially the authors were very strict and only treated patients on mechanical ventilation, as suggested in the literature, but expanded the scope to include those on nonmechanical ventilation. The analysis excluded patients with a Glasgow Coma Scale score of 8 or less for 5 days, all in-hospital deaths in the control group, and two 80-year-olds with "do not intubate" orders who declined surgery.