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

Weinberg DS, Narayanan AS, Moore TA, Vallier HA - J Orthop Surg Res (2015)

Bottom Line: Univariate analysis and binomial logistic regression analysis were used to compare complications between groups.Sixty-six patients developed complications, which was less than a historical cohort of 1,441 patients (19.9% vs. 22.1%).Level 1: prognostic study.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr., Cleveland, OH, 44109, USA. Dsw56@case.edu.

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.

Level of evidence: Level 1: prognostic study.

No MeSH data available.


Related in: MedlinePlus

Number of complications based on time to EAC resuscitation
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Fig1: Number of complications based on time to EAC resuscitation

Mentions: In the continued design and practical application of EAC, it may be advantageous to categorize timing of resuscitation into cutoff hours. The different cutoff points extrapolated from the receiver operating curves suggested that there was no clear time during EAC resuscitation after which point the risk of having a complication increased markedly (Table 4). This confirmed the linear relationship between timing to EAC resuscitation and complication risk. A cutoff value of 12 h was chosen to plot the values in Fig. 1.Table 4


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

Weinberg DS, Narayanan AS, Moore TA, Vallier HA - J Orthop Surg Res (2015)

Number of complications based on time to EAC resuscitation
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4581441&req=5

Fig1: Number of complications based on time to EAC resuscitation
Mentions: In the continued design and practical application of EAC, it may be advantageous to categorize timing of resuscitation into cutoff hours. The different cutoff points extrapolated from the receiver operating curves suggested that there was no clear time during EAC resuscitation after which point the risk of having a complication increased markedly (Table 4). This confirmed the linear relationship between timing to EAC resuscitation and complication risk. A cutoff value of 12 h was chosen to plot the values in Fig. 1.Table 4

Bottom Line: Univariate analysis and binomial logistic regression analysis were used to compare complications between groups.Sixty-six patients developed complications, which was less than a historical cohort of 1,441 patients (19.9% vs. 22.1%).Level 1: prognostic study.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr., Cleveland, OH, 44109, USA. Dsw56@case.edu.

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.

Level of evidence: Level 1: prognostic study.

No MeSH data available.


Related in: MedlinePlus