Femoral nailing during serum bicarbonate-defined hypo-perfusion predicts pulmonary organ dysfunction in multi-system trauma patients.
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.
Morshed
Saam
S
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
Corrales
Luis A
LA
Lin
Kai
K
Miclau
Theodore
T
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
D027321:Anion Transport Proteins; D017920:Antiporters; C425809:SLC4A11 protein, human; D019344:Lactic Acid