Surgical stabilization of rib fractures during the COVID-19 pandemic.

Abstract

Dear Editor, Following publication of our recent clinical trial of surgical stabilization of rib fractures (SSRFs) in patients without flail chest,1 we wish to offer a consideration during the coronavirus disease 2019 (COVID-19) pandemic. Ventilators have now become the most precious resource, and strategies to both adapt and conserve them are of the utmost urgency. Within trauma intensive care units, severe chest wall injury is one of the most common reasons for respiratory failure,2 and SSRF is increasingly considered as a management tool.3 Outcomes reported as improved following SSRF have ranged from outpatient quality of life4 to mortality.5 However, we believe that a particular focus must be placed on ventilator-related outcomes during the current pandemic. Doing so results in two distinct patients: one with present or impending respiratory failure from rib fractures, and the other who, despite pain and splinting, will not require mechanical ventilation. For the former, SSRF will likely conserve ventilators; for the latter, it will consume them unnecessarily. The original trials of SSRF enrolled patients with clinical flail chest, high overall injury severity, and respiratory failure.6,7 In this patient group, the incidence of tracheostomy and the duration of mechanical ventilation were significantly decreased, as compared with nonoperative management. By contrast, in our recent multicenter clinical trial of SSRF in the setting of displaced, nonflail fracture patterns, the incidence of respiratory failure was very low and not influenced by surgery.1 In this latter group of nonflail patients, SSRF would consume OR resources (including staff, personal protective equipment, and a ventilator) without realizing the aforementioned respiratory benefits. During the COVID-19 pandemic, we suggest stratifying chest wall injury patients into two groups when weighing the decision to perform SSRF. The first group will have either impending or present ventilator-dependent respiratory failure due to their rib fractures (most commonly a flail segment) and should be considered for SSRF. Careful attention should be paid to the primary etiology of the patient's respiratory failure (i.e., pulmonary vs. neurologic). If indicated, SSRF should be performed within 48 hours of injury to maximize the likelihood of ventilator avoidance/liberation.8 The second group, while still demonstrating sequellae of multiple rib fractures, will likely not require intubation from their chest wall injuries. Radiographically, these patients may have displaced fractures without a flail segment. In this situation, the current risk/benefit calculation favors nonoperative management with aggressive, multimodality pain control. In conclusion, during the COVID-19 pandemic, we suggest reserving SSRF for patients with rib fractures causing acute respiratory failure and, in this highly select group of patients, performing the surgery as early as possible so as to minimize the duration of mechanical ventilation. Fredric M. Pieracci, MD, MPH Denver Health Medical Center Denver, Colorado [email protected]Adam Shiroff, MD Department of Surgery University of Pennsylvania School of Medicine Philadelphia, Pennsylvania