Operative management versus nonoperative manageme

Authors: Jaap Schuurmans J C Goslings T Schepers

Publish Date: 2016/08/29

Volume: 43, Issue: 2, Pages: 163-168

PDF Link

Abstract

Flail chest is a lifethreatening complication of severe chest trauma with a mortality rate of up to 15  The standard nonoperative 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 chestRandomizedcontrolled trials comparing operative management versus nonoperative management of flail chest were included in this systematic review and metaanalysis PubMed Trip Database and Google Scholar were used for study identification We compared operativetononoperative 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 resultsThree randomizedcontrolled trials were included in this systematic review In total there were 61 patients receiving operative management compared to 62 patients in the nonoperative management group A positive effect of surgical rib fracture fixation was observed for pneumonia rate ES 05 95  CI 03 07 duration of mechanical ventilation DMV ES −65 days 95  CI −119 −12 duration of ICU stay ES −52 days 95  CI −62 −42 duration of hospital stay DHS ES −114 days 95  CI −124 −104 tracheostomy rate TRCH ES 04 95  CI 02 07 and treatment costs saving 996800–1444300 per patient No significant difference was noted in mortality rate ES 06 95  CI 01 24 between the two treatment strategiesDespite 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 injuriesFlail chest FC is a lifethreatening complication of severe chest trauma and occurs in up to 15  of chest wall injuries 1 “Flail chest occurs when three or more adjacent ribs are fractured in at least two places creating a chest wall segment that moves paradoxically from the chest wall 2” The paradoxical movements make breathing less efficient resulting in poor oxygenation of blood and potential asphyxia 3 The trauma that results in a flail chest can also lead to lung contusion and pneumothorax which worsens blood oxygenation 4 5 6 Among flail chest patients 40 percent get pneumonia making it the most common nonacute complication 7 Consequently flail chest is a dangerous chest trauma complication with a relatively high chance of causing asphyxia or deathThe standard hospitalization practices of FC management currently include non invasive ventilation and pain control Although mechanical ventilation management has improved throughout the years FC is still associated with long Intensive Care Unit ICU stays a high morbidity rate and high treatment costs 8 It is crucial to find the best treatment strategy to optimize FC management to benefit patient care and to continue researching the benefits of operative managementOperative management has gained increasing attention for flail chest settings Even though there are more publications on operative management the number of randomizedcontrolled trials is limited RCT Recently published systematic reviews therefore combine prospective and retrospective publications for metaanalysis Most of these studies and reviews suggest operative fixation of flail chest could be an alternative treatment to reduce duration of ICU stay days on mechanical ventilation DMV mortality rate and treatment costs 6 9 10 11 A systematic review of randomizedcontrolled trials only has not been published to date The aim of this literary study was to assess whether operative management of FC has a positive effect on patient outcomes compared to current treatment methods

Keywords: