Prolonged resuscitation of metabolic acidosis after trauma is associated with more complications

Journal of Orthopaedic Surgery and Research

Heather A. Vallier¹  Timothy A. Moore¹  Arvind S. Narayanan²  Douglas S. Weinberg¹ 

[1] Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr., Cleveland 44109, OH, USA;Case Western Reserve University, School of Medicine, 10900 Euclid Avenue, Cleveland 44106, OH, USA

关键词: Polytrauma;    Resuscitation;    Fixation timing;    Acidosis;    Early appropriate care;   

Others  :  1227802
DOI  :  10.1186/s13018-015-0288-3

 received in 2015-08-19, accepted in 2015-09-05,  发布年份 2015

【 摘 要 】

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.

Level of evidence

Level 1: prognostic study.

【 授权许可】

   
2015 Weinberg et al.

【 图 表 】

Fig. 1.

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