RIB FRACTURES are a frequent occurrence in trauma vic- tims.1 Patients with a “flail chest” pattern of injury, defined as 2 fractures per rib in 3 (or more) consecutive ribs, often strug- gle with hypoxemic respiratory failure related to inefficient ventilatory mechanics, inability to expectorate, underlying pul- monary contusion, and subsequent pneumonia. The operative indications for rib fracture repair have not been established and are considered to be an issue of debate. When a series of adjacent ribs is fractured in 2 places because of a blunt trauma, that segment of the chest wall (the flail) may lose its mechanical continuity with the rest of the thorax. As a result, the flail segment moves paradoxically inward during spontaneous inspiration, causing a variable degree of derangement of ventilation and gas exchange. Over the last ten years, surgical stabilization of rib frac- tures (SSRF) has emerged as a promising therapy for patients with severe chest wall injuries. Conceptually, SSRF applies the fundamental orthopedic principle of reduction and fixa- tion to rib fractures, restoring chest wall stability and mini- mizing pain with respiration, splinting, and secretion accumulation. Indications for surgical stabilization of ribs in severe blunt chest trauma are as follows: acute respiratory failure attribut- able to fractures and refractory to medical management; acute pain attributable to fractures and refractory to medical man- agement; anticipated chronic pain/impaired pulmonary mechanics (anatomic considerations); flail chest: 3 or more contiguous ribs with 2+ fractures; !3 severely displaced, bicortical fractures; loss !30% of chest wall volume. Tradi- tional contraindications to SSRF have included the presence of a pulmonary contusion and severe traumatic brain injury. Particularly in the case of fail chest stabilization, surgical fixa- tion is of great value, as it can reduce ventilator time, pneumo- nia, mortality, and medical costs while greatly improving functional outcomes and quality of life compared to nonopera- tive management. Pulmonary toilet and ventilation strategies and optimizing pain control are incredibly important in this patient population, regardless of the incorporation of surgical intervention in their treatment. Surgical rib stabilization is usually performed under general anesthesia while epidural anesthesia, thoracic paravertebral (TPV) block, and erector spinae plane (ESP) block,or pain control in patients with rib fractures have been reported. In this case series, the authors discuss the use of regional anesthesia to achieve surgical anesthesia in order to avoid risk of ventilator- induced lung injury (VILI). All patients gave written permission for publication of this report.
Alternative Regional Anesthesia for Surgical Management of Multilevel Unilateral Rib Fractures
Agnoletti V.Ultimo
Writing – Original Draft Preparation
2020
Abstract
RIB FRACTURES are a frequent occurrence in trauma vic- tims.1 Patients with a “flail chest” pattern of injury, defined as 2 fractures per rib in 3 (or more) consecutive ribs, often strug- gle with hypoxemic respiratory failure related to inefficient ventilatory mechanics, inability to expectorate, underlying pul- monary contusion, and subsequent pneumonia. The operative indications for rib fracture repair have not been established and are considered to be an issue of debate. When a series of adjacent ribs is fractured in 2 places because of a blunt trauma, that segment of the chest wall (the flail) may lose its mechanical continuity with the rest of the thorax. As a result, the flail segment moves paradoxically inward during spontaneous inspiration, causing a variable degree of derangement of ventilation and gas exchange. Over the last ten years, surgical stabilization of rib frac- tures (SSRF) has emerged as a promising therapy for patients with severe chest wall injuries. Conceptually, SSRF applies the fundamental orthopedic principle of reduction and fixa- tion to rib fractures, restoring chest wall stability and mini- mizing pain with respiration, splinting, and secretion accumulation. Indications for surgical stabilization of ribs in severe blunt chest trauma are as follows: acute respiratory failure attribut- able to fractures and refractory to medical management; acute pain attributable to fractures and refractory to medical man- agement; anticipated chronic pain/impaired pulmonary mechanics (anatomic considerations); flail chest: 3 or more contiguous ribs with 2+ fractures; !3 severely displaced, bicortical fractures; loss !30% of chest wall volume. Tradi- tional contraindications to SSRF have included the presence of a pulmonary contusion and severe traumatic brain injury. Particularly in the case of fail chest stabilization, surgical fixa- tion is of great value, as it can reduce ventilator time, pneumo- nia, mortality, and medical costs while greatly improving functional outcomes and quality of life compared to nonopera- tive management. Pulmonary toilet and ventilation strategies and optimizing pain control are incredibly important in this patient population, regardless of the incorporation of surgical intervention in their treatment. Surgical rib stabilization is usually performed under general anesthesia while epidural anesthesia, thoracic paravertebral (TPV) block, and erector spinae plane (ESP) block,or pain control in patients with rib fractures have been reported. In this case series, the authors discuss the use of regional anesthesia to achieve surgical anesthesia in order to avoid risk of ventilator- induced lung injury (VILI). All patients gave written permission for publication of this report.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
