ABSTRACT
BACKGROUND: The intramedullary nailing of a femoral shaft metastatic fracture or an impending fracture has been complicated by hemodynamic accidents in up to 13% of patients. In previous studies, otherwise healthy patients pulled well through the nailing despite high pulmonary shunting and vascular tone and right ventricular strain. We hypothesized that unfavorable hemodynamic and oxygenation trends milder than catastrophic ones can be found intraoperatively in most patients with a pathological fracture and cancer-affected lungs. METHODS: Eleven patients with a femoral metastatic fracture or an impending fracture were studied in general anesthesia. Radial artery and fast-response pulmonary artery catheters were inserted. Pre-, intra-, and postoperatively, 26 variables were measured and/or calculated up to 20 hours. Reamed nailing with a gamma nail was performed. RESULTS: At awake baseline, the mean pulmonary arterial pressure was 20 mm Hg ± 7 mm Hg and the shunt flow was 19% ± 6%. As response to the nailing, shunting increased from 14% ± 7% (mechanically ventilated) to 23% ± 10% (p < 0.05), and mean pulmonary arterial pressure increased to 29 mm Hg ± 6 mm Hg (p < 0.001). Oxygenation deteriorated to a level typical of acute lung injuries (Pao2/FIO2 242 mm Hg ± 73 mm Hg; p < 0.05). Intraoperatively, the oxygen delivery was poor, and acidosis developed (base excess, -2.9, p < 0.05). CONCLUSION: The baseline condition of patients with a pathological femoral fracture was comparable with that of healthy patients subjected to femoral fracture surgery. After reaming, arterial oxygenation deteriorated, being clinically poor for the rest of the study. We suggest increased inspiratory oxygen concentration intra- and postoperatively and maintenance of oxygen delivery by transfusions as needed, especially because hypoxia stimulates the growth of cancer.
Subject(s)
Bone Nails , Bone Neoplasms/secondary , Femoral Fractures/surgery , Fracture Fixation, Intramedullary/adverse effects , Fractures, Spontaneous/surgery , Oxygen/blood , Bone Neoplasms/complications , Bone Neoplasms/physiopathology , Female , Femoral Fractures/blood , Femoral Fractures/etiology , Fractures, Spontaneous/blood , Fractures, Spontaneous/physiopathology , Humans , Intraoperative Complications , Intraoperative Period , Male , Middle Aged , Prognosis , Prospective Studies , Pulmonary Wedge PressureABSTRACT
BACKGROUND: Patients undergoing intramedullary nailing of long bone fractures have pathologically altered pulmonary vascular tone, right heart strain, and transient impairment of pulmonary gas exchange. The purpose of this study was to examine the acute differences in cardiopulmonary variables between reamed and unreamed nailing techniques in 18 (9 + 9) healthy patients with unilateral femoral shaft fractures. METHODS: Intramedullary nailing was performed under general anesthesia within 12 hours after the trauma. For blood sampling, recording, and measurements, the patients were cannulated with radial artery and pulmonary artery catheters. Changes in central hemodynamics and oxygenation were studied pre-, peri-, and postoperatively for 16 to 20 hours. RESULTS: Abnormally high pulmonary shunting (23 +/- 12% in the reamed and 27 +/- 11% in the unreamed group) was observed before the operation. The trends of all variables were very similar in both groups except for the last phase in which the mixed venous oxygen saturation tended to be lower (65 +/- 8 vs. 70 +/- 5%) and the oxygen consumption index was higher (186 +/- 21 vs. 151 +/- 20 mL/min/m) in the unreamed group than in the reamed group (p < 0.05). The timepoints most strenuous to the heart were at the end of operation and in the recovery room. CONCLUSIONS: The unreamed intramedullary nailing technique does not offer any advantage in cardiopulmonary variables over the reamed technique. In both groups, there was considerable deviation in over 10 cardiopulmonary variables from normal reference values during the study. We suggest the use of invasive monitoring on patients with a long bone fracture and poor preoperative oxygenation or a history of cardiopulmonary or cardiac disease.
Subject(s)
Femoral Fractures/surgery , Fracture Fixation, Intramedullary/methods , Oxygen Consumption/physiology , Adult , Anesthesia, General , Blood Pressure/physiology , Bone Nails , Cardiac Output/physiology , Female , Femoral Fractures/physiopathology , Follow-Up Studies , Fracture Fixation, Intramedullary/adverse effects , Hemoglobins/analysis , Humans , Male , Postoperative Period , Prospective Studies , Stroke Volume/physiologyABSTRACT
BACKGROUND: Reamed intramedullary nailing of a long bone fracture is considered to be of crucial importance in the genesis of pulmonary disturbances. Use of unreamed nailing technique has been encouraged to avoid temporary deterioration in lung functions. METHODS: Central hemodynamic changes were recorded in 20 healthy adults with a unilateral simple tibial fracture undergoing reamed or unreamed intramedullary nailing. The patients were cannulated with a pulmonary artery catheter. Intramedullary nailing was performed during general anesthesia. Pre- and immediate postoperative hemodynamic variables were compared. RESULTS: Unchanged cardiac performance but pathologically altered pulmonary vascular tone were unrelated to the type of nailing technique. Increased oxygen consumption was observed as well. CONCLUSION: Changes in cardiac and pulmonary hemodynamics are already present after the trauma and before the intramedullary nailing procedure.
