Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation.

Heather A Vallier,Charles E Smith,John J Como,Timothy A Moore,Karl G Wagner,Patricia A Wilczewski,Michael P Steinmetz,Andrea J Dolenc,Xiao-Feng Wang

doi:10.1186/s13018-015-0298-1

Abstract

BackgroundOur group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time.MethodsThree hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥−5.5 mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort.ResultsAll 335 patients achieved the desired level of resuscitation within 36 h of injury. Two hundred sixty-nine (80 %) were treated within 36 h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71 %. Complications occurred in 16.3 % of patients fixed within 36 h and in 33.3 % of delayed patients (p = 0.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3 days and 4.4 versus 11.6 days, respectively, both p < 0.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1 %, p = 0.017) and shorter length of stay (LOS) (p = 0.018).ConclusionsOur EAC protocol recommends definitive fixation within 36 h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.

Highlights

Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis
We developed a protocol to determine timing of definitive fracture care based on the presence and severity of metabolic acidosis as measured by arterial pH or base excess and/or venous lactate [26]
Two hundred sixty-nine patients (80 %) had 301 fractures treated within 36 h of injury, according to the EAC protocol, and 66 (20 %) patients had 79 fractures fixed on a delayed basis, all patients met the desired EAC resuscitation parameters, with improvement of acidosis, within 36 h of injury

Summary

Introduction

Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. Pelvis, acetabulum, and spine fractures minimizes pulmonary and other complications, while damage control tactics may provide provisional stability in patients too unstable to tolerate definitive surgery [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18]. We developed a protocol to determine timing of definitive fracture care based on the presence and severity of metabolic acidosis as measured by arterial pH or base excess and/or venous lactate [26].

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