Comparison of Infectious Complications after Surgical Fixation versus Epidural Analgesia for Acute Rib Fractures

Abstract

Background:

Surgical stabilization of rib fractures (SSRF) is associated with decreased mortality and respiratory complications. Patients who are not offered SSRF are often treated with epidural analgesia (EA) to reduce pain and improve pulmonary mechanics. We sought to compare infectious complications in patients undergoing either SSRF or EA. We hypothesized that infectious complications are equivalent between the two treatment groups.

Patients and Methods:

We performed a retrospective cohort study of adult trauma patients with acute rib fractures within the Trauma Quality Improvement Program (TQIP) 2017 dataset and used International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify patients who underwent SSRF or EA. We excluded patients who received both treatments in the same admission. Our primary outcome was the development of sepsis. Secondary outcomes were specific infections including ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and central line-associated blood stream infections (CLABSI). Multiple logistic regression analyses were used to adjust for age, injury severity score (ISS), chest Abbreviated Injury Scale (AIS), flail chest, traumatic brain injury (TBI), and comorbidities.

Results:

We identified 2,252 and 1,299 patients who underwent SSRF and EA, respectively. Patients with SSRF were younger with higher ISS and longer length of stay (LOS). There was no difference in mortality, however, SSRF had higher rate of sepsis (1.6% vs. 0.5%; p = 0.001), VAP (5.1% vs. 0.9%; p < 0.001), CAUTI (1.7% vs. 0.5%; p = 0.001), and CLABSI (0.2% vs. 0%; p = 0.05). On multiple regression, SSRF was associated with higher odds of sepsis (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.04–6.63), CAUTI (OR, 2.96; 95% CI, 1.11–7.88), and VAP (OR, 3.24; 95% CI, 1.73–6.06). Among those who developed sepsis, there was no significant difference in mortality or LOS between groups.

Conclusions:

Despite no difference in mortality, SSRF was associated with increased risk of septic complications in patients with rib fractures compared to epidural analgesia. Identifying, and addressing, risk factors of sepsis in this patient population is a critical performance improvement process to optimize outcomes without increased adverse events.

Rib fractures are a common source of morbidity and mortality, present in 10% of all trauma patients and 30% of those with substantial chest trauma [1 –3]. In the United States, the annual incidence of both inpatient admissions and emergency department (ED) visits for rib fractures has continued to increase with 77.6 ED visits per 100,000 persons in 2014 [4]. Historically, the mainstay of clinical management of rib fractures has consisted of pain control and pulmonary hygiene [5]. More recently, surgical stabilization of rib fractures (SSRF) re-emerged as an effective modality for the treatment of multiple rib fractures [6,7]. Improvements in morbidity and mortality were reported after SSRF. These are likely attributed to a combination of reduction of acute pain and mechanical stabilization [8].

Adequate early pain management is critical to promoting a return to baseline respiratory and functional status [4]. Prior studies evaluating the benefits of SSRF compared it with non-operative management [9 -11]. However, these studies defined non-operative management broadly and did not stratify non-operative cohorts by different pain management modalities or specific protocols. The management options for acute pain among patients with rib fractures often includes various combinations of oral non-opioid drugs (acetaminophen, non-steroidal anti-inflammatory drugs [NSAIDs], gabapentin, etc.), topical lidocaine, intravenous or oral opioids, intercostal nerve blocks or cryoablation, intravenous ketamine, as well as thoracic epidural analgesia. Epidural analgesia (EA) is probably one of the most aggressive and effective modalities for non-operatively treating acute pain secondary to traumatic rib fractures [12,13]. We were interested in examining the differences in infectious outcomes between SSRF and EA. The potential increase in infectious complications of surgical interventions is possibly countered by the reduction in respiratory complications and morbidity of surgery in acute rib fractures. Therefore, we hypothesized that infectious complications were similar between the patient groups undergoing either treatment modality.

Patients and Methods

This is a retrospective analysis of the 2017 Trauma Quality Improvement Program (TQIP) database. We aimed to evaluate adult trauma patients (≥18 years old) who were treated at the participating trauma centers for acute rib fractures, comparing patients who underwent SSRF versus pain management with EA. After constructing the study concept, we obtained TQIP data from American College of Surgeons. This study was exempt from Institutional Review Board review because of the nature of the analysis of a national de-identified database. We identified patients with rib fractures using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes. Flail anatomy was determined using Abbreviated Injury Scale (AIS) 2005 diagnosis codes. We identified patients who underwent surgical stabilization of rib fractures or epidural analgesia using ICD-10 procedure codes. We also used ICD-10 and TQIP-provided variables codes to define outcomes of sepsis, ventilator associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), central line-associated blood stream infection (CLABSI), and in-hospital mortality.

We excluded patients who died in the first 24 hours after admission (1 patient) and those who underwent both procedures during the same admission (133 patients). We abstracted data on patient demographics, injury pattern and severity, available interventions and hospital stay data (length of stay [LOS], intensive care unit [ICU] admission), as well as medical comorbidities. Our primary outcome was development of septic complications adjusted for age, gender, severe injury (defined as injury severity score [ISS] >16), presence of flail chest, presence of traumatic brain injury (TBI), presence of spinal fractures and spinal cord injury, presence of pelvic fracture, undergoing exploratory laparotomy during hospitalization, chest AIS categories, and medical history of heart failure, chronic obstructive pulmonary disease, dementia, and use of steroids, based on factors that were significantly different between the two groups on the bivariable analysis.

Descriptive data are presented as frequencies for categorical variables, means for parametric continuous variables, and medians for non-parametric continuous variables. We applied Pearson χ² test with Fisher exact test for sparse values to test independence for categorical data. Parametric continuous data were compared using Student t-test. Non-parametric data were analyzed using Mann-Whitney test. Multiple regression analyses were performed to obtain odds ratios and 95% confidence intervals for desired outcomes. Significance was set at p = 0.05. We computed all analyses using a commercial statistical software (STATA/SE 14, StataCorp, College Station, TX).

Results

We identified 3,551 patients meeting inclusion criteria, of whom 2,252 underwent SSRF and 1,299 received EA. Differences in demographics, past medical history, and injury severity are presented in Table 1. Patients who underwent SSRF were younger, more severely injured, and more likely to have flail chest and TBI. Generally, there was a low rate of medical comorbidities in both groups, except for smoking, alcohol use, and chronic obstructive pulmonary disease.

Table 1.

Patient's Characteristics

	All (3,551)	SSRF (2,252)	EA (1,299)	p
Age, y (mean ± SD)	57 ± 15.8	55 ± 15.3	60 ± 16	<0.001
Male	2,523 (71.1%)	1,675 (74.4%)	848 (65.2%)	0.0001
ISS (median)	17 (13–24)	19 (14–27)	14 (10–19)	0.0001
ISS >16	2,016 (56.8%)	1,480 (65.7%)	536 (41.3%)	0.0001
Massive transfusion first 24 h	251 (7.1%)	176 (7.8%)	75 (5.8%)	0.03
AIS chest				0.0001
2	170 (4.8%)	66 (2.9%)	104 (8%)
3	2,398 (67.6%)	1,382 (61.4%)	1,016 (78.4%)
4	762 (21.5%)	622 (27.6%)	140 (10.8%)
5	207 (5.8%)	180 (8%)	27 (2.1%)
Flail chest	1,152 (32.4%)	979 (43.5%)	173 (13.3%)	0.0001
TBI	330 (9.3%)	249 (11.1%)	81 (6.2%)	0.0001
AIS head (n = 330)				NS
1	0	0	0
2	36 (10.9%)	25 (10%)	11 (13.6%)
3	152 (46.1%)	114 (45.8%)	38 (46.9%)
4	109 (33%)	83 (33.3%)	26 (32.1%)
5	33 (10%)	27 (10.8%)	6 (7.4%)
Spinal fracture	557 (15.7%)	415 (18.4%)	142 (10.9%)	0.0001
Spinal cord injury	41 (1.2%)	35 (1.6%)	6 (0.5%)	0.003
Pelvic fracture	478 (13.5%)	344 (15.3%)	134 (10.3%)	0.0001
Past medical history
COPD	320 (9%)	147 (6.5%)	173 (13.3%)	0.0001
Alcoholism	304 (8.6%)	205 (9.1 %)	99 (7.6%)	NS
Heart failure	103 (2.9%)	43 (1.9%)	60 (4.6%)	0.0001
Dependent status	132 (3.7%)	43 (1.9%)	89 (6.9%)	0.0001
Chronic kidney disease	39 (1.1%)	20 (0.9%)	19 (1.5%)	NS
Smoking	892 (25.1%)	560 (24.9%)	332 (25.6%)	NS
Myocardial ischemia	14 (0.4%)	9 (0.4%)	5 (0.4%)	NS
Dementia	61 (1.7%)	14 (0.6%)	47 (3.6%)	0.0001
Steroid use	35 (1%)	16 (0.7%)	19 (1.5%)	0.03

Characteristics of patients who underwent surgical stabilization of rib fractures (SSRF) versus epidural analgesia (EA). Results are presented in percentages, unless otherwise specified.

SSRF = surgical stabilization of rib fractures; EA = epidural analgesia; SD = standard deviation; ISS = injury severity score. AIS = Abbreviated Injury Scale; TBI = traumatic brain injury; COPD = chronic obstructive pulmonary disease.

There was a low rate of complications in all patients (Table 2). However, on bivariable analysis we found that patients who underwent SSRF developed sepsis with increased rates compared with those who received EA alone (1.6% vs. 0.5%; p = 0.001). There was also a higher rate of VAP (5.1% vs. 0.9%; p = 0.0001), CAUTI (1.7% vs. 0.5%; p = 0.002), and CLABSI (0.2% vs. 0%; p = 0.05). There was no difference in mortality, unplanned intubation, or need for admission to ICU between the two groups. More patients in the SSRF group developed venous thromboembolic events compared with the EA group (3.6% vs. 1.9%; p = 0.002). There was a higher rate of acute respiratory distress syndrome in the SSRF group (2.9% vs. 1.2%; p = 0.001); however, when adjusted to injury covariates and comorbidities this difference was not significant (OR, 1.75; 95% CI, 0.96–3.19). Hospital LOS was longer in the SSRF group (median 12 vs. 8 days; p = 0.0001).

Table 2.

Hospital Outcomes

	All	SSRF	EA	p
Hospital LOS	10 (7–16)	12 (8–19)	8 (5–12)	0.0001
Mortality	94 (2.7%)	60 (2.7%)	34 (2.6%)	NS
Unplanned intubation	271 (7.6%)	184 (8.2%)	87 (6.7%)	NS
Ventilator Days	7 (3–12)	7 (3–13)	4 (2–8)	0.0001
ED to ICU admission	2,076 (58.5%)	1,343 (59.6%)	733 (56.4%	NS
ARDS	82 (2.3%)	66 (2.9%)	16 (1.2%)	0.001
Unplanned ICU admission	235 (6.6%)	145 (6.4%)	90 (6.9%)	NS
VAP	127 (3.6%)	115 (5.1%)	12 (0.9%)	0.0001
Sepsis	43 (1.2%)	37 (1.6%)	6 (0.5%)	0.001
CAUTI	46 (1.3%)	39 (1.7%)	7 (0.5%)	0.002
CLABSI	7 (0.2%)	7 (0.2%)	0	0.05
VTE	106 (3%)	82 (3.6%)	24 (1.9%)	0.002

Comparison of outcomes of patients who underwent surgical stabilization of rib fractures (SSRF) versus epidural analgesia (EA). Results are presented in percentages, unless otherwise specified.

LOS = length of stay; ICU = intensive care unit; ED = emergency department; ICU = intensive care unit; ARDS = acute respiratory distress syndrome; VAP = ventilator-associated pneumonia; CAUTI = catheter-associated urinary tract infection; CLABSI = central line-associated blood stream infection; VTE = venous thrombotic events.

Adjusting for age, gender, severe injury, chest AIS, presence of TBI, and other comorbidities and injuries, patients in the SSRF group had higher odds of development of sepsis, VAP, and urinary tract infections (Table 3).

Table 3.

Adjusted OR of Infectious Complications

Outcome	OR	95% CI
Sepsis	2.63	1.04–6.63
VAP	3.24	1.73–6.06
CAUTI	2.96	1.11–7.88

Odds ratios (OR) of development of sepsis, ventilator associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI) in patients who underwent surgical stabilization of rib fractures (SSRF) compared to those managed with epidural analgesia (EA), adjusted for age, gender, injury severity score (ISS) >16, flail chest, traumatic brain injury (TBI), spinal fracture, spinal cord injury, pelvic fracture, undergoing abdominal exploration during hospitalization, chest Abbreviated Injury Scale (AIS) categories, history of heart failure, history of chronic obstructive pulmonary disease (COPD), steroids use, and history of dementia, excluding patients who died in first 24 hours.

CI = confidence interval.

Discussion

In this retrospective analysis of the 2017 TQIP dataset comparing patients with acute rib fractures who were managed by either SSRF or EA, we found no difference in mortality or need for unplanned intubation between the two groups. However, there were higher rates of developing sepsis, VAP, and urinary tract infection in the SSRF group compared with the EA group.

Surgical stabilization of rib fractures has been shown to be an effective modality in the management of acute rib fractures [9 –11,14,15]. Although previously reserved for substantial deformity with flail anatomy, the development of new plating systems and the use of muscle-sparing techniques have provided viable options for patients with displaced rib fractures and uncontrolled pain ([9 –11,14,15]. In the recent NONFLAIL trial, patients with three or more ipsilateral displaced rib fractures who underwent SSRF had reduction in pain score, improved quality-of-life metrics, and decreased pleural space complications compared with non-operative management [8]. Surgical stabilization of rib fractures has become a more accepted option among trauma surgeons who frequently manage patients with chest wall injury with an increase in the rate of its utilization [6,7]. The benefit in outcomes among patients who underwent SSRF seemed to be to some extent the result of early reduction in acute pain [16].

Often, studies that demonstrated the benefits of SSRF compared it to non-operative management broadly [17,18]. Non-operative management protocols include chest physiotherapy, incentive spirometry, physical therapy, as well as achieving pain control using oral or intravenous medications, muscle relaxants, local analgesia by means of intercostal anesthetics injections or ablations, and EA [19]. Of note, two randomized controlled trials showed no additional benefit of gabapentin or ketamine regimens for pain control in acute rib fractures [20,21]. At many centers, EA is considered the most invasive modality of pain control in those who are not undergoing surgical rib fixation. It remains the ultimate pain management option for patients who cannot undergo SSRF, either because of ineligibility or unavailability of the surgical option locally. Although cryoablation of intercostal nerves has emerged as possibly an effective modality with longer duration of pain control [22 –24], its use is not uniformly adopted, and it is often applied in conjunction with surgical stabilization. Therefore, EA remains the last resort for pain management when other modalities fail.

A recent meta-analysis of 19 studies comparing the efficacy of interventions including EA, intravenous analgesia, and intercostal and paravertebral blocks found that administration of EA to patients with multiple rib fractures results in substantial pain reduction compared with the other modalities [12]. However, a multimodal approach to pain management in patients with acute rib fracture is often used [25]. The combination of analgesic, anti-inflammatory, and muscle-relaxing effects of different agents results in adequate pain control and a reduction in opioid use acutely and post-discharge [26].

In this study, we confirmed that there is no difference in mortality between the two groups. However, there were higher rates of infectious complications in patients undergoing SSRF. This is in contrast to other studies that showed lower rates of pneumonia, sepsis, and mortality in surgical patients [10,11,27 –31]. We believe the higher rates of pneumonia and other complications in the non-operative group in prior studies are because of inclusion of patients undergoing different forms of non-operative pain management. It has been suggested that other modalities of pain control for rib fractures are associated with a greater risk of pneumonia and higher number of ventilator days compared with EA [13]. However, this comparison is relatively old considering the new modalities that have been introduced and adopted recently. Other researchers found an increase in respiratory complications when using EA for acute rib fractures compared with other modalities [32]. By comparing SSRF with EA in our study, we aimed to correct this generalization, thus allowing for a more accurate evaluation of the differences in rates of infectious complications and mortality to patients by comparing SSRF with the modality that is considered the most effective form of non-operative pain management for many patients. This comparison was necessary to appropriately communicate differences in infectious complications rates and mortality to patients. These results should not, however, be interpreted as evidence against SSRF. Alternatively, they should allow for further investigation into best practices to minimize the risks associated with surgical approach while maximizing its benefit.

Although there were higher rates of infectious complications among those who underwent SSRF, this does not reflect a failure of surgical options. We speculate that our finding is instead a consequence of diligent clinical protocols that are often introduced in conjunction with new and invasive techniques such as SSRF. It is likely that hospitals that began offering SSRF to patients with acute rib fractures also implemented conservative protocols around the procedure that could have included prolonged intubation, urinary catheterization, and more frequent central venous access. These interventions, rather than SSRF itself, may be responsible for the observed infectious complications. The observed difference in deep vein thrombosis rates between the two groups may similarly be attributed to conservative practices surrounding the introduction of the new surgical technique (SSRF). This causality can be evaluated by comparing infectious complications associated with SSRF between hospitals with higher rates versus lower rates of SSRF utilization. However, the definition of high or low rate of SSRF utilization has not yet been established, although this is an ongoing effort that is led by the Chest Wall Injury Society (CWIS). Furthermore, the TQIP dataset does not readily provide us with granular data on this metric.

Considering these rates of infectious complications in SSRF, we believe that trauma centers should emphasize infection control protocols and ICU care bundles when considering their practices and developing protocols around SSRF. Evaluation of early and timely extubation and initiation of early chest physiotherapy and physical therapy in surgical patients could play a role in reduction in rate of VAP [33,34]. Trauma surgeons who are interested in surgical stabilization of rib fractures should develop quality improvement programs that are specific to optimizing the overall management of acute rib fractures. Through a similar process, our team introduced and evaluated the use of intra-operative ultrasound in SSRF [35]. We demonstrated a substantial reduction in operative time, surgical incision, and pain scores. This was achieved by more accurately localizing fracture sites intraoperatively, allowing for a directed surgical field and efficient operative flow. Although we did not evaluate infectious rates locally, we consider these improvements in surgical outcomes are likely to translate into lower risk of surgical site infection and pulmonary complications.

Other infectious complications are probably of more clinical concerns to practicing surgeons who are interested in surgical stabilization of rib fractures, namely surgical site infection and hardware infection [36,37]. Because TQIP encompasses data from index admissions without indicating long-term outcomes or re-admissions, we were not able to assess these complications. A recent collaboration between Surgical Infectious Society and CWIS resulted in published guidelines of antibiotic use in SSRF to prevent hardware infection [38]. These guidelines should be considered as well in chest wall injury centers.

Our study's limitations are primarily the result of the nature of large national dataset analysis, including information and selection bias. The validity of coding in national databases cannot be assured. The TQIP database does not capture the admissions and operations performed at non-participating centers. Additionally, the observed differences in outcomes could have resulted because of variations among centers that do or do not perform SSRF. Center-specific identifiers were not provided for the 2017 Participant User File (PUF) datasets, therefore, we were not able to control for this factor. The limited data points that are provided by TQIP makes it difficult to control for unknown confounders and risk modifiers. These include the effect modification of other pain management modalities that were used, decision to choose either intervention, and infectious control practices already implemented at different centers. This could explain the relatively wide confidence intervals in our analyses. Therefore, our observed odds ratios of infectious complications could be misrepresented.

Finally, although we controlled for injury severity, the presence of traumatic brain injury, and associated spinal injury, there are likely additional factors that were responsible for development of infectious complications. Additionally, other infectious complications are not fully captured or reported in TQIP, such as delayed hardware infection or surgical site infection. The effects of these complications on patient's recovery and chronic pain could be more substantial than reported infectious rates in our study. However, these results present an adequate preliminary evaluation that requires a multicenter study to obtain more detailed and granular information regarding patients with acute rib fractures.

Conclusions

Despite no difference in mortality, SSRF was associated with increased risk of some infectious complications in patients with acute rib fractures compared to EA. Identifying, and addressing, risk factors of sepsis and nosocomial infection in this patient population, as well as adopting institutional guidelines to prevent surgical site and hardware infections, is a critical performance improvement process, necessary for optimizing outcomes without increased adverse events. Results from TQIP should be considered within the inherent limitations of the dataset. Therefore, a multicenter study to validate our results and further clarify modifiable factors is warranted.

Authors' Contributions

Study conception and design, data analysis and interpretation, manuscript preparation, critical revisions: T.K. Data analysis and interpretation, manuscript preparation, critical revisions: T.J.M, J.C.

Manuscript preparation, critical revisions: H.A.S., A.C.T. Critical revisions: D.S.H., S.N.L.

Footnotes

Funding Information

No funding was received.

Author Disclosure Statement

None of the authors report any conflict of interest or have financial disclosures.

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