Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: Determination of the clinical relevance of biochemical markers

Background: The aim of this study is to assess the associations between the timing of secondary definitive fracture surgery on inflammatory changes an d outcome in the patient with multiple injuries. The study population consi sts of a series of patients with multiple injuries who were managed using a strategy of primary temporary skeletal stabilization followed by delayed d efinitive fracture fixation, Methods: In a prospective cohort study performed at a Level I trauma center , the patients' injuries and operative details as well as immune markers an d clinical outcomes were studied, The patients were split into an early sec ondary surgery group (group ESS, surgery at days 2-4) and a late secondary surgery group (group LSS, surgery at days 5-8), During the posttraumatic co urse, inflammatory markers (interleukin [IL]-6, tumor necrosis factor-alpha ) were determined on a daily basis, Perioperatively, these markers were add itionally evaluated at 30 minutes, 7 hours, and 24 hours after initiation o f surgery. Results: Secondary surgery on days 2 to 4 was associated with a higher inci dence of postoperative organ dysfunction (n = 33 [46.5%]) than secondary su rgery on days 5 to 8 (n = 9 [15.7%], p = 0.01), A significant association b etween the combination of initial IL-6 values > 500 pg/dL plus surgery on d ays 2 to 4 and the development of multiple organ failure (r = 0.96, p < 0.0 01) occurred, A correlation between the initial IL-6 values > 500 pg/dL and surgery on days 5 to 8 (r = 0.57, p < 0.07) could not be found. IL-6 also demonstrated a predictive value for the development of multiple organ failu re: IL-6 > 500 pg/dL in group ESS, r = 0.96, p < 0.001; IL-6 > 500 pg/dL in group LSS, r = 0.57, p < 0.07. Conclusion: According to our data, no distinct clinical advantage in carryi ng out secondary definitive fracture fixation early could be determined. In contrast, in patients who demonstrated initial IL-6 values above 500 pg/dL , it may be advantageous to delay the interval between primary temporary fr acture stabilization and secondary definitive fracture fixation for more th an 4 days. In patients with blunt multiple injuries undergoing primary temp orary fixation of major fractures, the timing of secondary definitive surge ry should be carefully selected, because it may act as a second hit phenome non and cause a deterioration of the clinical status.