title: Femoral nailing during serum bicarbonate-defined hypo-perfusion predicts pulmonary organ dysfunction in multi-system trauma patients.
abstract: OBJECTIVE
  To assess the value of venous serum bicarbonate as an endpoint of resuscitation and guide to timing of femoral nailing in multi-system trauma patients.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Academic Level 1 Trauma Centre.
  
  
  METHODS
  Seventy-two consecutive adult multi-system trauma patients (Injury Severity Score≥15) with femoral shaft fracture (Orthopaedic Trauma Association Class 32-A to 32-C) treated with reamed medullary nail fixation.
  
  
  METHODS
  Femoral nailing in the setting of hypo-perfusion defined by venous serum bicarbonate (SB). Threshold values of SB were determined first by correlating SB and simultaneously drawn arterial base deficit (BD). Then, corresponding values of SB to previously defined thresholds of hypo-perfusion based on BD were identified using regression analysis.
  
  
  METHODS
  Pulmonary organ dysfunction (POD) component of the Denver Multiple Organ Failure scoring system.
  
  
  RESULTS
  Simultaneous admission SB and BD values were correlated (r=-0.43, p=0.001). Adjusting for age, ISS and baseline POD, patients with SB<24.7 mequiv./L within 6 h of treatment had a 12-fold increase in POD (OR 12.2, 95% CI 1.5-98.6, p=0.019). This association was diminished, but still significant with hypo-perfusion present within 12 h prior to treatment (OR 5.6, 95% CI 1.0-29.1, p=0.042) and 24 h prior to treatment (OR 5.9, 95% CI 1.1-30.7, p=0.037).
  
  
  CONCLUSIONS
  Medullary fixation of femoral shaft fracture in the setting of serum bicarbonate-defined hypo-perfusion is associated with increased morbidity. Appropriate damage-control measures and aggressive resuscitation prior to definitive fracture care are advised and physiologic markers such as serum bicarbonate should guide clinical decision making rather than temporal distinctions.
authors.affiliation: Department of Orthopaedic Surgery, University of California-San Francisco, UCSF/SFGH Orthopaedic Trauma Institute, 2550 23rd Str., Bldg. 9, 2nd Floor, San Francisco, CA 94110, United States. morsheds@orthosurg.ucsf.edu
authors.forename: Saam
authors.initials: S
authors.lastname: Morshed
authors.forename: Luis A
authors.initials: LA
authors.lastname: Corrales
authors.forename: Kai
authors.initials: K
authors.lastname: Lin
authors.forename: Theodore
authors.initials: T
authors.lastname: Miclau
mesh_terms: D000328:Adult; D027321:Anion Transport Proteins / Q000097:blood*; D017920:Antiporters / Q000097:blood*; D015331:Cohort Studies; D005260:Female; D005264:Femoral Fractures / Q000503:physiopathology* / Q000601:surgery; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects*; D006801:Humans; D019344:Lactic Acid / Q000378:metabolism; D055370:Lung Injury / Q000503:physiopathology*; D008297:Male; D009104:Multiple Trauma / Q000378:metabolism / Q000503:physiopathology*; D011652:Pulmonary Circulation / Q000502:physiology*; D012189:Retrospective Studies
chemical_list: D027321:Anion Transport Proteins; D017920:Antiporters; C425809:SLC4A11 protein, human; D019344:Lactic Acid