Pulmonary gas exchange during intramedullary fixation of femoral shaft fractures.

Abstract

This study was undertaken to determine if the alveolar dead space fraction (Vd/Vt) or the alveolar-arterial oxygen gradient (A-a DO2) increased during intramedullary fixation of femoral shaft fractures. Fifty hemodynamically stable patients with femur fractures were prospectively enrolled. Three serial measurements of Vd/Vt and A-a DO2 were obtained immediately before femoral nailing (Pre), 30 minutes after nailing (+30), and 120 minutes after nailing (+120). Vd/Vt was determined by simultaneously measuring PaCO2 and the steady-state end-tidal CO2 (PetCO2), where Vd/Vt = (1 - PetCO2/PaCO2). Vd/Vt before nailing was 0.09 +/- 0.09 (mean +/- SD); at +30 and +120, Vd/Vt was 0.10 +/- 0.06 and 0.08 +/- 0.07, respectively (p > 0.2; paired t test, both time points). A-a DO2 before nailing was 84 +/- 85 mm Hg, and it did not change significantly at +30 (89 +/- 69 mm Hg; p = 0.51 vs. Pre; paired t-test) or at +120 (51 +/- 45 mm Hg). No difference in data was found with analysis by fracture classification or number of reamer passes. Vd/Vt and A-a DO2, however, were both significantly increased in patients with lung contusion (n = 6) before nailing, but neither measurement increased after nailing. One patient developed fat embolism (Vd/Vt of 0.35 at Pre and 0.31 at +120), and another patient experienced postoperative pulmonary thromboembolism (Vd/Vt increased from 0.06 at Pre to 0.17 at +120). The process of femoral nailing does not cause enough pulmonary embolization to alter pulmonary gas exchange as measured by Vd/Vt and A-a DO2. If Vd/Vt is increased preoperatively, the likelihood of subsequent pulmonary dysfunction secondary to either preoperative lung injury or fat embolism is increased.