Background: The SARS coronavirus-2 (SARS-CoV-2), responsible for COVID-19, with millions of infections that continue to accumulate, as well as the growing concern about chronic respiratory symptoms and changes in pulmonary fibrosis in recovered population. Rib fixation is indicated in patients with a flail chest who do not require mechanical ventilation, since they may develop chronic pain and thoracic deformity with a decrease in quality of life and incapacity for work. Selective mechanical ventilation with double-lumen tubes helps to collapse the lung on the side to be fixed, allowing the surgeon to preserve anatomical structures, making a better dissection.
Case description: A 60-year-old male, diabetic, history of COVID-19, previous 3 months, later depression; cyclist, fell on a retaining wall on 20th October 2020, assessed in a hospital where he was discharged from the emergency room with analgesics, without improvement, for which he went to the social security hospital where they found right rib fractures, monitored in the emergency room for 72 hours with poor analgesic response [Numeric Pain Intensity (NPI) 8–9/10], depending on oxygen at 5 L/min for SatO2 = 90%. He was transferred to our hospital on 23rd October 2020, tomography with bilateral rib fractures (1°–9° right and 2°–5° left), right flail chest, bilateral pulmonary fibrosis (post-COVID-19), and right pleural effusion.
The third, fourth, fifth, sixth, seventh, eight, and ninth right ribs with the StraCos system; it was impossible to perform surgery with right lung exclusion since, due to pulmonary fibrosis, the patient presented desaturations <80% with hemodynamic repercussions. He removed supplemental oxygen at 96 hours postoperatively and endopleural catheter at 7 days.
Conclusion: The SARS-CoV-2 infection has left many lessons, and a great way to discover; it has collapsed health systems and has also had a negative impact on the quality of care for the polytraumatization of the chest in the emergency room. We face real challenges when operating patients with unusual ventilatory parameters for trauma patients, with slow postoperative recovery, and increased costs.
McDonald LT. Healing after COVID-19: are survivors at risk for pulmonary fibrosis? Am J Physiol Lung Cell Mol Physiol 2021;320(2):L257–L265. DOI: 10.1152/ajplung.00238.2020. PMID: 33355522; PMCID: PMC7900916.
Picchi G, Mari A, Ricciardi A, et al. Three cases of COVID-19 pneumonia in female patients in Italy who had pulmonary fibrosis on follow-up lung computed tomography imaging. Am J Case Rep 2020;21:e926921. DOI: 10.12659/AJCR.926921
Wang F, Kream RM, Stefano GB. Long-term respiratory and neurological sequelae of COVID-19. Med Sci Monit 2020;26:e928996. DOI: 10.12659/MSM.928996. PMID: 33177481; PMCID: PMC7643287.
Fang Y, Zhou J, Ding X, et al. Pulmonary fibrosis in critical ill patients recovered from COVID-19 pneumonia: preliminary experience. Am J Emerg Med 2020;38(10):2134–2138. DOI: 10.1016/j.ajem.2020.05.120. PMID: 33071084; PMCID: PMC7368908.
Zhao Y, Wang D, Mei N, et al. Longitudinal radiological findings in patients with COVID-19 with different severities: from onset to long-term follow-up after discharge. Front Med (Lausanne) 2021;8:711435. DOI: 10.3389/fmed.2021.711435
Nirula R, Diaz Jr JJ, Trunkey DD, et al. Rib fracture repair: indications, technical issues, and future directions. World J Surg 2009;33(1):14–22. DOI: 10.1007/s00268-008-9770-y. PMID: 18949513.
de Moya M, Nirula R, Biffl W. Rib fixation: who, what, when? Trauma Surg Acute Care Open 2017;2(1):e000059. DOI: 10.1136/tsaco-2016-000059
de Moya M, Bramos T, Agarwal S, et al. Pain as an indication for rib fixation: a bi-institutional pilot study. J Trauma 2011;71(6):1750–1754. DOI: 10.1097/TA.0b013e31823c85e9. PMID: 22182884.
Perera TB, King KC. Flail chest. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020. PMID:30475563.
Shiroff AM, Keating J, Milanez de Campos JR, et al. Surgical stabilization of rib fractures. J Cardiothorac Trauma 2019;4(1):41–47. DOI: 10.2106/JBJS.ST.19.00032
Chan EG, Stefancin E, Cunha JD. Rib fixation following trauma: a cardiothoracic surgeon's perspective. J Trauma Treat 2016;5:4. DOI: 10.4172/2167-1222.1000339
Hughes JD, Berning MJ, Hunt AL, et al. Rib fractures in geriatric patients: an observational study of surgical management. J Cardiothorac Trauma 2019;4(1):23–27. DOI: 10.4103/jctt.jctt_9_19
Jayle CPM, Allain G, Ingrand P, et al. Flail chest in polytraumatized patients: surgical fixation using Stracos reduces ventilator time and hospital stay. BioMed Res Int 2015;2015:624723. DOI: 10.1155/2015/624723
Winters BA. Older adults with traumatic rib fractures: an evidence-based approach to their care. J Trauma Nurs 2009;16(2):93–97. DOI: 10.1097/JTN.0b013e3181ac9201. PMID: 19543018.
Langiano N, Fiorelli S, Deana C, et al. Airway management in anesthesia for thoracic surgery: a “real life” observational study. J Thorac Dis 2019;11(8):3257–3269. DOI: 10.21037/jtd.2019.08.57. PMID: 31559028; PMCID: PMC6753428.
Meggiolaro KM, Wulf H, Feldmann C, et al. Atemwegsmanagement zur Seitentrennung der Lunge bei thorakalen Eingriffen: Ein Update [Airway management for lung separation in thoracic surgery: an update]. Anaesthesist 2018;67(8):555–567. DOI: 10.1007/s00101-018-0470-1. PMID: 30083992.
Huerta MC, Villazón DO, Acevedo CA, et al. Ventilación mecánica selectiva (a un pulmón) y manejo anestésico en cirugía toracoscópica videoasistida. Rev Mex Cir Endoscop 2002;25(2):87–96.
Peek J, Beks RB, Hietbrink F, et al. Complications and outcome after rib fracture fixation: a systematic review. J Trauma Acute Care Surg 2020;89(2):411–418. DOI: 10.1097/TA.0000000000002716