Thurs., 10/13/11 Polytrauma, Paper #25, 2:45 pm OTA-2011
Δ Timing of Orthopaedic Surgery in Multiple Trauma Patients: Development of a Protocol for Early Appropriate Care
Heather A. Vallier, MD; Xiaofeng Wang, PhD; Timothy A. Moore, MD; John H. Wilber, MD;
MetroHealth Medical Center, Cleveland, Ohio, USA
Purpose: Early fixation of unstable fractures of the femur, pelvis, acetabulum, and spine reduces some complication rates. However, the practice of “early total care” has been criticized, because hemorrhage from surgery can be associated with a deleterious systemic inflammatory response in an under-resuscitated patient. The alternative of “damage control orthopaedics” could diminish the risk for systemic compromise, but additional complications and costs associated with this strategy are controversial. The purposes of this project were to define which injuries or clinical parameters warrant delay of definitive orthopaedic care, and to determine what time interval for fracture fixation promotes optimal patient outcome. A model was developed to predict complications and to reduce complications and costs.
Methods: A database of 1443 adult patients treated surgically for fractures of the pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 953) was developed. Mean age was 37.8 and mean ISS was 24.7. Low-energy fractures, such as from a fall from standing height, were excluded. Data included fracture characteristics, associated injuries, timing and technique of surgery and any provisional treatment (for spine, pelvis, acetabulum, and femur only), transfusions, length of ventilator assistance, length of ICU and hospital stay, and complications. Vital signs and laboratory parameters including pH, base excess, lactate, and hematocrit were recorded at 8-hour intervals for the first 72 hours. Univariate and multivariate analyses of variance were used to assess associations of parameters over time with the occurrence of complications. Logistic predictive models were developed with the incorporation of multiple fixed and time-dependent covariates. Odds ratios, F tests, and receiver operating characteristic curves were calculated based on the models.
Results: Pulmonary complications were identified in 12.7% of patients, with 8.2% of all patients developing pneumonia. pH and base excess values were significantly lower at all time points (all P <0.0001), and the rate of improvement of these values over time was also significantly slower (all P <0.007), in patients who developed pneumonia or any pulmonary complication. Similarly, lactate values were significantly greater at all time points in patients with pulmonary complications (all P <0.02). Hematocrit and blood pressure values were not associated with complications. Multivariate analysis of variance suggested lactate to be the most specific predictor of complications. Presence of chest injury—mild (abbreviated injury scale [AIS] ≤2) or severe (AIS ≥3)—was the strongest independent predictor of pulmonary complication. Chest injury coupled with initial pH, and the number of fractures treated, generated a predictive model with area under the curve of 0.765 for pneumonia and 0.820 for acute respiratory distress syndrome (ARDS). Initial lactate value was a stronger predictor of pneumonia (P = 0.0006) than initial pH (0=0.04) or the rate of improvement of pH over the first 8 hours (P = 0.0007). When initial pH was >7.25, pulmonary complications occurred in <25% of patients. Other factors predictive of an uncomplicated course included absence of chest injury (P <0.0001), and definitive fixation of fractures within the first 24 hours (P =0.007) or 48 hours (P = 0.005). Additional models are being developed to predict probability of complications in patients with various injury combinations when specific laboratory parameters measuring residual acidosis have been achieved.
Conclusion: Early recognition and control of hemorrhage and aggressive resuscitation to improve acidosis are critical in reducing morbidity and mortality. Acidosis on presentation, as measured by pH, base excess, or lactate is predictive of complications. Correction of pH within the first 8 hours to >7.25 reduces risk of pulmonary complications. Presence and severity of chest injury, number of fractures to be treated, and timing of fixation are other significant variables to include in a predictive model and algorithm development for early appropriate care. The goal is to minimize complications by definitive management of major skeletal injury once the patient has been adequately resuscitated.
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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.