Weinberg D S, Narayanan A S, Moore T A, Vallier H A
MetroHealth Medical Center, Case Western Reserve University, Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, Ohio, 44109, USA.
University of North Carolina, School of Medicine, Department of Orthopaedics, CB# 7055, Chapel Hill, North Carolina 27599, USA.
Bone Joint J. 2017 Jan;99-B(1):122-127. doi: 10.1302/0301-620X.99B1.BJJ-2016-0418.R2.
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.
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).
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.
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.
对于多发伤患者，明确的骨科治疗的最佳时机往往并不明确。本研究的目的是对我们的早期适当治疗（EAC）策略的安全性进行前瞻性评估，并评估额外实验室数据对确定手术准备情况的潜在益处。
纳入335例骨盆、髋臼、股骨或脊柱骨折患者。如果满足以下三个参数之一，患者在36小时内接受确定性固定：乳酸<4.0 mmol/L；pH≥7.25；或碱剩余（BE）≥-5.5 mmol/L。如果三个参数全部满足，则将复苏指定为完全方案复苏（FPR）。如果未满足所有三个参数，则将其指定为不完全方案复苏（IPR）。并发症由独立的判定委员会评估，包括感染；脓毒症；肺栓塞/深静脉血栓形成（PE/DVT）；器官衰竭；肺炎和急性呼吸窘迫综合征（ARDS）。
共有66例患者（19.7%）发生了90例并发症。1441例患者的历史队列并发症发生率为22.1%。在方案执行时仅有一个EAC参数的患者并发症发生率为34.3%，高于其他组（p = 0.041）。接受IPR的患者并发症发生率（31.8%）并不显著高于接受FPR的患者（22.6%；p = 0.078）。回归分析显示男性性别和损伤严重程度评分是并发症的独立预测因素。
本研究突出了IPR组和FPR组的重要趋势，表明复苏参数的差异可能指导某些患者的治疗；然而，还需要进一步研究。我们提倡使用现有方案，同时继续对高危亚组进行研究。引用本文：《骨与关节杂志》2017年；99-B：122 - 7。
