title: Assessment of resuscitation as measured by markers of metabolic acidosis and features of injury.
abstract: OBJECTIVE
  The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery.
  
  
  METHODS
  A cohort of 335 patients with fractures of the pelvis, acetabulum, femur, or spine were included. Patients underwent definitive fixation within 36 hours if one of the following three parameters were met: lactate < 4.0 mmol/L; pH ≥ 7.25; or base excess (BE) ≥ -5.5 mmol/L. If all three parameters were met, resuscitation was designated full protocol resuscitation (FPR). If less than all three parameters were met, it was designated an incomplete protocol resuscitation (IPR). Complications were assessed by an independent adjudication committee and included infection; sepsis; PE/DVT; organ failure; pneumonia, and acute respiratory distress syndrome (ARDS).
  
  
  RESULTS
  In total, 66 patients (19.7%) developed 90 complications. An historical cohort of 1441 patients had a complication rate of 22.1%. The complication rate for patients with only one EAC parameter at the point of protocol was 34.3%, which was higher than other groups (p = 0.041). Patients who had IPR did not have significantly more complications (31.8%) than those who had FPR (22.6%; p = 0.078). Regression analysis showed male gender and injury severity score to be independent predictors of complications.
  
  
  CONCLUSIONS
  This study highlights important trends in the IPR and FPR groups, suggesting that differences in resuscitation parameters may guide care in certain patients; further study is, however, required. We advocate the use of the existing protocol, while research is continued for high-risk subgroups. Cite this article: Bone Joint J 2017;99-B:122-7.
authors.affiliation: MetroHealth Medical Center, Case Western Reserve University, Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, Ohio, 44109, USA.
authors.forename: D S
authors.initials: DS
authors.lastname: Weinberg
authors.affiliation: University of North Carolina, School of Medicine, Department of Orthopaedics, CB# 7055, Chapel Hill, North Carolina 27599, USA.
authors.forename: A S
authors.initials: AS
authors.lastname: Narayanan
authors.affiliation: MetroHealth Medical Center, Case Western Reserve University, Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, Ohio, 44109, USA.
authors.forename: T A
authors.initials: TA
authors.lastname: Moore
authors.affiliation: MetroHealth Medical Center, Case Western Reserve University, Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, Ohio, 44109, USA.
authors.forename: H A
authors.initials: HA
authors.lastname: Vallier
mesh_terms: D000077:Acetabulum / Q000293:injuries; D000138:Acidosis / Q000175:diagnosis / Q000209:etiology*; D002985:Clinical Protocols; D005260:Female; D005264:Femoral Fractures / Q000601:surgery; D005592:Fracture Fixation / Q000379:methods; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D008297:Male; D010384:Pelvic Bones / Q000293:injuries; D011300:Preoperative Care / Q000379:methods; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D016103:Spinal Fractures / Q000601:surgery; D061665:Time-to-Treatment
keywords: Acidosis; Damage control; Early appropriate care; Fixation timing; Lactate; Polytrauma; Resuscitation