Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation

Background: The presence of persistent occult hypoperfusion (OH) is associa ted with higher morbidity and mortality rates after trauma. Early femur fra cture fixation in trauma patients,vith multiple injuries is associated with decreased morbidity and mortality. Association of OH and incidence of post operative complications after intramedullary (IM) fixation in patients with femur fractures was investigated. Methods: A retrospective study design was used. All patients with femur fra ctures admitted to the trauma service of a Level I trauma center between Ja nuary 1, 1995, and August 1, 1998, who were older than 18 years of age and who had IM fracture fixation within 24 hours of admission and serum lactate determinations on admission and at proscribed intervals, were included in the study. Patients with lactic acid levels greater than or equal to 2.5 mm ol/L were determined to have OH. No patients had clinical signs of shock (h ypotension, tachycardia, decreased urine output) on transfer to the operati ng roam. Complete resuscitation was defined as a lactic acid level < 2.5 mm ol/L. Patients were divided into two groups based on presence/absence of OH determined from the lactic acid level immediately before surgery. The inci dence of all postoperative organ complications was recorded, and complicati on rates were compared between groups, Total hospital costs were also compa red. Results: One hundred seventy-seven patients with femur fractures were admit ted to the trauma service during this period, Seventy-nine patients met ini tial criteria for inclusion in the study. Further review excluded 32 patien ts. Occult hypoperfusion was present in 20 patients before early IM fixatio n (group 2). Twenty-seven patients were completely resuscitated before earl y IM fixation (group 1). Injury Severity Scores were similar in both groups . Group 2 had 35 complications in 20 patients, and group 1 had 11 complicat ions in 27 patients, A significant difference was found in incidence of pos toperative complications in group 1 (20%) versus group 2 (50%). Group 2 als o had a significantly higher proportion of postoperative infections than gr oup 1 (72% vs. 28%, respectively) and higher total hospital costs ($46,469 vs, $23,139). Conclusion: The presence of OH in trauma patients undergoing early IM fixat ion of a femur fracture is associated with a twofold higher incidence of po stoperative complications. Clinical judgment, not surgical dogma, should gu ide the timing of IM fixation in these patients, Identifying and correcting OH through relatively simple resuscitative measures may be advantageous in reducing morbidity in the patient with multiple injuries.