Intramedullary nailing of femoral shaft fractures in polytraumatized patients. a longitudinal, prospective and observational study of the procedure-related impact on cardiopulmonary- and inflammatory responses

Abstract

BackgroundEarly intramedullary nailing (IMN) of long bone fractures in severely injured patients has been evaluated as beneficial, but has also been associated with increased inflammation, multi organ failure (MOF) and morbidity. This study was initiated to evaluate the impact of primary femoral IMN on coagulation-, fibrinolysis-, inflammatory- and cardiopulmonary responses in polytraumatized patients.MethodsTwelve adult polytraumatized patients with femoral shaft fractures were included. Serial blood samples were collected to evaluate coagulation-, fibrinolytic-, and cytokine activation in arterial blood. A flow-directed pulmonary artery (PA) catheter was inserted prior to IMN. Cardiopulmonary function parameters were recorded peri- and postoperatively. The clinical course of the patients and complications were monitored and recorded daily.ResultsMean Injury Severity Score (ISS) was 31 ± 2.6. No procedure-related effect of the primary IMN on coagulation- and fibrinolysis activation was evident. Tumor necrosis factor alpha (TNF-α) increased significantly from 6 hours post procedure to peak levels on the third postoperative day. Interleukin-6 (IL-6) increased from the first to the third postoperative day. Interleukin-10 (IL-10) peaked on the first postoperative day. A procedure-related transient hemodynamic response was observed on indexed pulmonary vascular resistance (PVRI) two hours post procedure. 11/12 patients developed systemic inflammatory response syndrome (SIRS), 7/12 pneumonia, 3/12 acute lung injury (ALI), 3/12 adult respiratory distress syndrome (ARDS), 3/12 sepsis, 0/12 wound infection.ConclusionIn the polytraumatized patients with femoral shaft fractures operated with primary IMN we observed a substantial response related to the initial trauma. We could not demonstrate any major additional IMN-related impact on the inflammatory responses or on the cardiopulmonary function parameters. These results have to be interpreted carefully due to the relatively few patients included.Trial RegistrationClinicalTrials.gov: NCT00981877

Análise da ocorrência e dos fatores predisponentes de infecção de sítio cirúrgico em pacientes sumetidos a cirurgias ortopédicas

“…Moucha et al (2011) Com relação à classificação ASA, neste estudo, os pacientes com ASA acima de III não fizeram parte da amostra (critério de exclusão), uma vez que têm complicações sistêmicas maiores (MANGRAM et al, 1999;APECIH, 2009;CHEN et al, 2010;HUSEBYE et al, 2012), o que poderia confundir na análise dos fatores de risco de ISC.…”

“…A classificação ASA ≥ que III mostra-se como fator de risco importante para ocorrência de ISC (MANGRAM et al,1999;NCCWCH, 2008;APECIH, 2009;NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE -NICE, 2011;HUSEBYE et al, 2012;GREENE et al, 2010GREENE et al, , 2012. A hiperglicemia perioperatória (nível glicêmico ≥200mg/dl) está associada com o aumento do risco de ISC (MANGRAM et al, 1999;DELLINGER, 2001).…”

Advantages and Dangers of Early Osteosynthesis of Femur in Polytrauma With Chest Injur

“…Напротив, интрамедуллярный остеосинтез ввиду малой травматичности и незначительной инт-раоперационной кровопотери рекомендуют выпол-нять в первые сутки после травмы, не дожидаясь окончательной стабилизации состояния пострадав-шего. У пациентов с политравмой, которым выполнен первичный интрамедуллярный остеосинтез бедрен-ной кости, не обнаружено значимого дополнительно-го повышения в крови уровня маркеров активации нейтрофилов (FcγRII -CD32 и MAC-1) [37], TNF-α, IL-6, IL-10, признаков активации коагуляции и фибриноли-за, ухудшения кардиореспираторных параметров [38]. СВР определялась «первым ударом» и не была связана с выполнением операции.…”

Ocorrência e fatores de risco para infecção de sítio cirúrgico em cirurgias ortopédicas

“…In addition, patients may have physical limitations and significant reductions in quality of life. (4) In a multicenter study involving 16,291 patients undergoing orthopedic surgery, with surgical site infection rate of 2.23%, the results indicated that advanced age, length of preoperative hospitalization, duration of surgery, ASA score (≥ III)as main risk factors for the occurrence of this type of infection. (5) In another research, the authors followed-up 1,073 patients in postoperative orthopedic surgery, and of those, 58.7% developed postoperative infectious complications, surgical site infection and dehiscence.…”