Session V - Polytrauma

Secondary Surgery in Blunt Trauma Patients and Perioperative Liberation of Proinflammatory Cytokines: Clinical Relevance of Biochemical Markers

Frank Hildebrand, MD; Martijn van Griensven, PhD; Christian Krettek, MD, FRACS; Hans-Christoph Pape, MD; Department of Trauma Surgery, Hannover Medical School, Hannover, Germany

Purpose: The aim of this study was to assess the associations between the timing of secondary definitive fracture surgery on inflammatory changes and outcome in the polytrauma patient. The study population comprised a series of polytrauma patients who were managed by using a strategy of primary temporary skeletal stabilization followed by delayed definitive fracture fixation.

Methods: In a prospective cohort study performed at a level I trauma center, patients' injury and operative details as well as immune markers and clinical outcome were studied. The patients were divided into an early secondary surgery group (ESS, surgery at days 2 to 4) and a late secondary surgery group (LSS, surgery at days 5 to 8). During the posttraumatic course, inflammatory markers (Interleukin-6 and tumor necrosis factor a) were determined on a daily basis. Perioperatively, these markers were additionally evaluated at 30 minutes, 7 hours, and 24 hours after initiation of surgery.

Results: Secondary surgery on days 2 to 4 was associated with a higher incidence of postoperative organ dysfunction (N = 33, 46.5%) than secondary surgery on days 5 to 8 (N = 9, 15.7%, P = 0.01). A significant association between the combination of initial IL-6 values >500 pg/dL + surgery on days 2 to 4 and the development of multiple organ failure (r = 0.96, P <0.001) occurred. A correlation between the initial IL-6 values >500 pg/dL and surgery on days 5 to 8 (r = 0.57, P <0.07) could not be found. Levels of IL-6 also demonstrated a predictive value for the development of multiple organ failure: IL-6>500 pg/dL in group ESS, r = 0.96, P <0.001; Il-6 >500 pg/dL in group LSS, r = 0.57, P<0.07.

Conclusions: According to our data, no distinct clinical advantage could be determined for carrying out early secondary definitive fracture fixation. In contrast, for patients who demonstrate initial IL-6 values above 500 pg/dL, it may be advantageous to delay the interval between primary temporary fracture stabilization and secondary definitive fracture fixation for more than 4 days. In patients with blunt multiple injuries undergoing primary temporary fixation of major fractures, the timing of secondary definitive surgery should be carefully selected because it may act as a second hit phenomenon and cause a deterioration of clinical status.