title: Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation.
abstract: BACKGROUND
  The presence of persistent occult hypoperfusion (OH) is associated with higher morbidity and mortality rates after trauma. Early femur fracture fixation in trauma patients with multiple injuries is associated with decreased morbidity and mortality. Association of OH and incidence of postoperative complications after intramedullary (IM) fixation in patients with femur fractures was investigated.
  
  
  METHODS
  A retrospective study design was used. All patients with femur fractures admitted to the trauma service of a Level I trauma center between January 1, 1995, and August 1, 1998, who were older than 18 years of age and who had IM fracture fixation within 24 hours of admission and serum lactate determinations on admission and at proscribed intervals, were included in the study. Patients with lactic acid levels > or = 2.5 mmol/L were determined to have OH. No patients had clinical signs of shock (hypotension, tachycardia, decreased urine output) on transfer to the operating room. Complete resuscitation was defined as a lactic acid level < 2.5 mmol/L. Patients were divided into two groups based on presence/absence of OH determined from the lactic acid level immediately before surgery. The incidence of all postoperative organ complications was recorded, and complication rates were compared between groups. Total hospital costs were also compared.
  
  
  RESULTS
  One hundred seventy-seven patients with femur fractures were admitted to the trauma service during this period. Seventy-nine patients met initial criteria for inclusion in the study. Further review excluded 32 patients. Occult hypoperfusion was present in 20 patients before early IM fixation (group 2). Twenty-seven patients were completely resuscitated before early IM fixation (group 1). Injury Severity Scores were similar in both groups. Group 2 had 35 complications in 20 patients, and group 1 had 11 complications in 27 patients. A significant difference was found in incidence of postoperative complications in group 1 (20%) versus group 2 (50%). Group 2 also had a significantly higher proportion of postoperative infections than group 1 (72% vs. 28%, respectively) and higher total hospital costs ($46,469 vs. $23,139).
  
  
  CONCLUSIONS
  The presence of OH in trauma patients undergoing early IM fixation of a femur fracture is associated with a twofold higher incidence of postoperative complications. Clinical judgment, not surgical dogma, should guide the timing of IM fixation in these patients. Identifying and correcting OH through relatively simple resuscitative measures may be advantageous in reducing morbidity in the patient with multiple injuries.
authors.affiliation: Department of Surgery, University of Virginia Health System, Charlottesville 22906-0005, USA.
authors.forename: A C
authors.initials: AC
authors.lastname: Crowl
authors.forename: J S
authors.initials: JS
authors.lastname: Young
authors.forename: D M
authors.initials: DM
authors.lastname: Kahler
authors.forename: J A
authors.initials: JA
authors.lastname: Claridge
authors.forename: D S
authors.initials: DS
authors.lastname: Chrzanowski
authors.forename: M
authors.initials: M
authors.lastname: Pomphrey
mesh_terms: D000328:Adult; D015687:Cell Hypoxia; D002985:Clinical Protocols; D005264:Femoral Fractures / Q000097:blood / Q000601:surgery*; D005594:Fracture Fixation, Intramedullary; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D019344:Lactic Acid / Q000097:blood; D009104:Multiple Trauma / Q000097:blood; D011183:Postoperative Complications / Q000097:blood / Q000453:epidemiology* / Q000209:etiology*; D012039:Regional Blood Flow; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D019344:Lactic Acid