• Justin E Richards, Paul E Matuszewski, Sean M Griffin, Daniel M Koehler, Oscar D Guillamondegui, Robert V OʼToole, Michael J Bosse, William T Obremskey, and Jason M Evans.
• *Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, Baltimore, MD; †Department of Orthopaedics, R Adams Cowley Shock Trauma Center, Baltimore, MD; ‡Department of Orthopaedics, Carolinas Medical Center, Charlotte, NC; §Vanderbilt Orthopaedic Institute, Vanderbilt University School of Medicine, Nashville, TN; ‖Division of Trauma, Emergency Surgery, and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN; and ¶Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Nashville, TN.
• J Orthop Trauma. 2016 Jun 1; 30 (6): 312-8.

ObjectivesTo evaluate lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation.DesignRetrospective study.SettingThree academic, tertiary care trauma centers.PatientsAge ≥18 years, injury severity score ≥17, admission lactate ≥ 2.5 mmol/L, elevated preoperative lactate = preoperative lactate ≥ 2.5 mmol/L.InterventionReamed IMN of femur fracture within 24 hours.Main Outcome MeasureTotal duration of mechanical ventilation, pulmonary complications (PC) = duration of mechanical ventilation ≥5 days.ResultsFour hundred and fourteen patients identified; 294/414 (71.0%) with admission lactate ≥ 2.5 mmol/L. No difference in PC among the groups (86/294, 29.3% vs. 28/120, 23.3%; P = 0.22). Median admission lactate: 3.7 (interquartile range: 3.0-4.6); median preoperative lactate: 2.8 (interquartile range: 1.9-3.5). 184/294 (62.6%) demonstrated an elevated preoperative lactate (≥ 2.5 mmol/L) before fracture fixation. No difference in elevated preoperative lactate and vent days (4.8 ± 9.9 vs. 3.9 ± 6.0, P = 0.41) or PC (50/86, 58.1% vs. 134/208, 64.4%; P = 0.31). There was no difference in PC when preoperative lactate was considered separately for a lactate ≥3.0 (34/123, 27.6% vs. 52/171, 30.4%; P = 0.61), ≥3.5 (21/79, 26.6% vs. 65/215, 30.2%; P = 0.54), or ≥4.0 (14/50, 28.0% vs. 72/244, 29.5%; P = 0.83). Multivariable linear regression modeling demonstrated that admission lactate [coefficient of variation: 0.84, standard error: 0.33, 95% confidence interval (CI): 0.20-1.49] was correlated with duration of mechanical ventilation, after adjusting for emergency department Glasgow Coma Scale, age, chest Abbreviated Injury Scale (AIS) score, abdominal AIS, and admission glucose. Logistic regression demonstrated admission lactate was also significantly associated with PC (odds ratio: 1.26, 95% CI: 1.03-1.53) after controlling for age, admission Glasgow Coma Scale, chest AIS, abdominal AIS, admission pulse and admission glucose; preoperative lactate was not a risk factor (odds ratio: 0.84, 95% CI: 0.65-1.09) for PC.ConclusionMedian admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation ≥5 days, whereas median preoperative lactate of 2.8 mmol/L was not, when multisystem trauma patients with a femoral shaft fracture were treated with reamed IMN within 24 hours after admission.Level Of EvidencePrognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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