title: Prolonged resuscitation of metabolic acidosis after trauma is associated with more complications.
abstract: BACKGROUND
  Optimal patterns for fluid management are controversial in the resuscitation of major trauma. Similarly, appropriate surgical timing is often unclear in orthopedic polytrauma. Early appropriate care (EAC) has recently been introduced as an objective model to determine readiness for surgery based on the resuscitation of metabolic acidosis. EAC is an objective treatment algorithm that recommends fracture fixation within 36 h when either lactate <4.0 mmol/L, pH ≥ 7.25, or base excess (BE) ≥-5.5 mmol/L. The aim of this study is to better characterize the relationship between post-operative complications and the time required for resuscitation of metabolic acidosis using EAC.
  
  
  METHODS
  At an adult level 1 trauma center, 332 patients with major trauma (Injury Severity Score (ISS) ≥16) were prospectively treated with EAC. The time from injury to EAC resuscitation was determined in all patients. Age, race, gender, ISS, American Society of Anesthesiologists score (ASA), body mass index (BMI), outside hospital transfer status, number of fractures, and the specific fractures were also reviewed. Complications in the 6-month post-operative period were adjudicated by an independent multidisciplinary committee of trauma physicians and included infection, sepsis, pulmonary embolism, deep venous thrombosis, renal failure, multiorgan failure, pneumonia, and acute respiratory distress syndrome. Univariate analysis and binomial logistic regression analysis were used to compare complications between groups.
  
  
  RESULTS
  Sixty-six patients developed complications, which was less than a historical cohort of 1,441 patients (19.9% vs. 22.1%). ISS (p < 0.0005) and time to EAC resuscitation (p = 0.041) were independent predictors of complication rate. A 2.7-h increase in time to resuscitation had odds for sustaining a complication equivalent to a 1-unit increase on the ISS.
  
  
  CONCLUSIONS
  EAC guidelines were safe, effective, and practically implemented in a level 1 trauma center. During the resuscitation course, increased exposure to acidosis was associated with a higher complication rate. Identifying the innate differences in the response, regulation, and resolution of acidosis in these critically injured patients is an important area for trauma research.
  
  
  METHODS
  Level 1: prognostic study.
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr., Cleveland, OH, 44109, USA. Dsw56@case.edu.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Weinberg
authors.affiliation: Case Western Reserve University, School of Medicine, 10900 Euclid Avenue, Cleveland, OH, 44106, USA.
authors.forename: Arvind S
authors.initials: AS
authors.lastname: Narayanan
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr., Cleveland, OH, 44109, USA.
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Moore
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr., Cleveland, OH, 44109, USA.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Vallier
mesh_terms: D000138:Acidosis / Q000209:etiology / Q000628:therapy*; D000328:Adult; D000465:Algorithms; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects; D050723:Fractures, Bone / Q000150:complications* / Q000601:surgery; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000150:complications* / Q000601:surgery; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D055502:Secondary Prevention / Q000379:methods / Q000592:standards; D012680:Sensitivity and Specificity; D013997:Time Factors; D014193:Trauma Centers; D055815:Young Adult