Thurs., 10/18/07 Polytrauma, Paper #7, 2:15 pm OTA-2007
Intramedullary Nailing of Femoral Shaft Fractures in the Setting of Hypoperfusion Measured by Serum Bicarbonate Predicts Pulmonary Organ Dysfunction in Multisystem Trauma Patients
Saam Morshed, MD, MPH (n); Luis A. Corrales, BS (n); Cindy H. Lin, BS, MPH (n);
Theodore Miclau, MD (n);
Department of Orthopaedic Surgery, San Francisco General Hospital,
University of California, San Francisco School of Medicine, San Francisco, California, USA
Purpose: Femoral shaft fractures often occur in the setting of high-energy, multisystem trauma and appropriate timing of definitive care remains controversial. We hypothesize that intramedullary fixation in the setting of hypoperfusion leads to higher rates of pulmonary and multiorgan failure. This study aims to establish serum bicarbonate (SB) as a viable predictor of hypoperfusion and to compare outcomes of subjects treated in the presence versus absence of hypoperfusion.
Methods: A retrospective cohort study was conducted at an urban Level 1 trauma center using a consecutive series of admissions from 1995 to 2005. Included patients were older than 15 years of age, with an injury severity score (ISS) ≥15, and a femoral shaft fracture (OTA Class 32-A to 32-C). SB and arterial base deficit (BD) were correlated based on all available concordant samples using Spearman rank correlation, and the corresponding cut-off for a BD ≥6 mmol/L was estimated using linear regression. Treatment was defined as intramedullary nailing in the setting of hypoperfusion as defined by SB. Our outcomes were multiorgan failure (MOF) and pulmonary organ dysfunction (POD) occurring after treatment, as defined using the Denver MOF scoring system. Data were analyzed using univariate and multivariate logistic regression.
Results: 72 patients were included in this study. All had admission SB and SB within 24 hours prior to treatment: 68 had SB within 12 hours, and 58 had SB within 6 hours prior to treatment. SB was correlated with BD (Spearman correlation = –0.43, P = 0.001) and BD of ≥6 mmol/L corresponded to SB of ≤24.7 mEq/L. Adjusting for age, ISS, and baseline POD, patients who had measured hypoperfusion within 6 hours of treatment had a 12-fold increase in POD (odds ratio [OR] 12.2, 95% confidence interval [CI] 1.5-98.6, P = 0.019). This association was diminished, but still significant, with hypoperfusion present within 12 hours prior to treatment (OR 5.6, 95% CI 1.0-29.1, P = 0.042) and 24 hours prior to treatment (OR 5.9, 95% CI 1.1-30.7, P = 0.037). Hypoperfusion at admission was associated with an increased risk for POD, although this association was not statistically significant (OR 4.3, 95% CI 0.87-21.4, P = 0.073). Hypoperfusion prior to fracture fixation and on admission also showed consistent but nonstatistically significant increases in estimated risk of MOF.
Conclusions and Significance: The presence of hypoperfusion in polytrauma patients with femoral shaft fractures undergoing definitive fracture repair is highly predictive of POD, especially when measured close to the time of treatment. SB is a simple and readily available clinical test that can identify patients with hypoperfusion without the need for arterial blood sampling. While these results and the predictive value of SB at the time of treatment need to be prospectively validated, they support the notion that patients who are inadequately resuscitated benefit from delayed intramedullary fixation and a damage-control approach.
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