Sat., 10/16/10 Polytrauma & Femur, Paper #69, 10:35 am OTA-2010
Is Septicemia a Contraindication to Internal Fixation in the Multiply Traumatized Patient?
Robert F. Ostrum, MD1; Julieanne P. Sees, DO2; Patrick Kane, MD3; Robert Marburger, RN1;
1Cooper University Hospital, Camden, New Jersey, USA;
2UMNDJ- School of Osteopathic Medicine, Newark, New Jersey, USA;
3Brown University Medical School, Providence, Rhode Island, USA
Purpose: This study investigates the incidence of infection and complications associated with internal fixation in multiply injured patients with a prolonged stay in the trauma ICU (TICU).
Methods: A retrospective review of data collected prospectively from our trauma database from January 2004 to June/2009 was performed to identify injured patients with a prolonged TICU stay and a closed fracture requiring internal fixation. Inclusion criteria were patients with an injury severity score (ISS)>4, a combined stay of longer than 5 days in the TICU or trauma step-down unit, temperature spikes of >100°F, and hardware placed for internal fixation of a fracture. Our population sustained a total of 92 fractures that subsequently underwent surgical fixation. Exclusion criteria included patients with an open fracture or fractures that did not require fixation. Identification of deep infection requiring surgical intervention, nonunion, or wound complications was examined. A comparison of the group with positive blood cultures (PBC) to the group with negative blood cultures (NBC) was performed using an independent t test. An analysis of the deep infections in the PBC versus NBC groups was done using a χ2 test. Statistical significance was set at <0.05.
Results: 54 patients met our inclusion criteria, with 28 patients in the PBC group and 26 patients in the NBC group. There was no difference in the ISS between these two groups (P = 0.27). There was a difference in the length of stay in critical care as the NBC group averaged 17.2 days (SD, 8.3), whereas the PBC patients averaged 29.4 (SD, 17.4) (P = 0.002). There were no differences noted in the rate of deep infection after open reduction and internal fixation as there were 5 deep infections in the PBC group (17.9%) versus 3 infections in the NBC group (7.7%) (P = 0.565). In 2 of the 5 deep infections in the PBC group, the blood culture and wound culture organism did not match. The remaining 3 deep infections in the PBC group, blood and wound culture organisms were the same; however, the operative fixation preceded septicemia by 2, 5, and 22 days, respectively. There was no correlation between length of stay in critical care or ISS with deep infection in the PBC group, as 2 patients had an ISS of 4. In the 2 deep infections in the NBC group, 1 patient with an ISS of 22 had a femoral external fixator and fasciotomies performed on presentation. This patient subsequently became infected. One acetabulum fracture had an infected hematoma.
Conclusions: There are currently no guidelines for a safe interval for surgical implantation of orthopaedic hardware in the septic patient. Our results demonstrate that there is not a higher rate of deep infection in patients with hardware and PBC, and that often the infective organism from the orthopaedic surgery does not appear to correlate with the organism of the blood culture. We found that a longer length of stay in the TICU did correlate with a higher incidence of PBC. Three patients had positive blood cultures after their orthopaedic intervention, which demonstrates the systemic complications associated with these critically ill patients. The ISS was a poor predictor of deep infection as many patients with minimal injuries developed respiratory complications leading to a prolonged TICU stay and PBC. Overall, these patients may be under greater stress, negative nitrogen balance, and poor nutrition, making them more susceptible to nosocomial infection. It appears safe to operate on multiply injured patients with PBC when the “window of opportunity” and clinical parameters are optimal. This, however, may not prevent subsequent postoperative sepsis and deep wound infection.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.