Incidence and predictive risk factors of postoperative sepsis in orthopedic trauma patients
Tóm tắt
Postoperative sepsis is associated with high mortality and the national costs of septicemia exceed those of any other diagnosis. While numerous studies in the basic orthopedic science literature suggest that traumatic injuries facilitate the development of sepsis, it is currently unclear whether orthopedic trauma patients are at increased risk. The purpose of this study was thus to assess the incidence of sepsis and determine the risk factors that significantly predicted septicemia following orthopedic trauma surgery. 56,336 orthopedic trauma patients treated between 2006 and 2013 were identified in the ACS-NSQIP database. Documentation of postoperative sepsis/septic shock, demographics, surgical variables, and preoperative comorbidities was collected. Chi-squared analyses were used to assess differences in the rates of sepsis between trauma and nontrauma groups. Binary multivariable regressions identified risk factors that significantly predicted the development of postoperative septicemia in orthopedic trauma patients. There was a significant difference in the overall rates of both sepsis and septic shock between orthopedic trauma (1.6%) and nontrauma (0.5%) patients (p < 0.001). For orthopedic trauma patients, ventilator use (OR = 15.1, p = 0.002), history of pain at rest (OR = 2.8, p = 0.036), and prior sepsis (OR = 2.6, p < 0.001) were significantly associated with septicemia. Statistically predictive, modifiable comorbidities included hypertension (OR = 2.1, p = 0.003) and the use of corticosteroids (OR = 2.1, p = 0.016). There is a significantly greater incidence of postoperative sepsis in the trauma cohort. Clinicians should be aware of these predictive characteristics, may seek to counsel at-risk patients, and should consider addressing modifiable risk factors such as hypertension and corticosteroid use preoperatively.
Level of evidence Level III.
Tài liệu tham khảo
Hall MJ, Williams SN, DeFrances CJ et al (2011) Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS Data Brief 62:1–8
Hund E (2001) Neurological complications of sepsis: critical illness polyneuropathy and myopathy. J Neurol 248(11):929–934
Brun-Buisson C, Doyon F, Carlet J et al (1995) Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. French ICU Group for Severe Sepsis. JAMA 274(12):968–974
Daniels R (2011) Surviving the first hours in sepsis: getting the basics right (an intensivist’s perspective). J Antimicrob Chemother 66(Suppl 2):11–23
Mokart D, Leone M, Sannini A et al (2005) Predictive perioperative factors for developing severe sepsis after major surgery. Br J Anaesth 95(6):776–781
Bateman BT, Schmidt U, Berman MF et al (2010) Temporal trends in the epidemiology of severe postoperative sepsis after elective surgery: a large, nationwide sample. Anesthesiology 112(4):917–925
Vogel TR, Dombrovskiy VY, Carson JL et al (2010) Postoperative sepsis in the United States. Ann Surg 252(6):1065–1071
Malina RM (2010) Early sport specialization: roots, effectiveness, risks. Curr Sports Med Rep 9(6):364–371
Fitzgerald RH, Nolan DR, Ilstrup DM et al (1977) Deep wound sepsis following total hip arthroplasty. J Bone Joint Surg Am 59(7):847–855
Angus DC, Linde-Zwirble WT, Lidicker J et al (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 29(7):1303–1310
Torio CM, Andrews RM (2006, 2011) National inpatient hospital costs: the most expensive conditions by payer: statistical brief #160. In: Healthcare Cost and Utilization Project (HCUP) statistical briefs. Agency for Health Care Policy and Research, Rockville
Mechanic RE (2011) Opportunities and challenges for episode-based payment. N Engl J Med 365(9):777–779
Hemmila MR, Jakubus JL, Maggio PM et al (2008) Real money: complications and hospital costs in trauma patients. Surgery 144(2):307–316
Chen C, Ackerly D (2014) Beyond ACOs and bundled payments: Medicare’s shift toward accountability in fee-for-service. JAMA 311(7):673–674
Wanner GA, Keel M, Steckholzer U et al (2000) Relationship between procalcitonin plasma levels and severity of injury, sepsis, organ failure, and mortality in injured patients. Crit Care Med 28(4):950–957
Smith RM, Giannoudis PV, Bellamy MC et al (2000) Interleukin-10 release and monocyte human leukocyte antigen-DR expression during femoral nailing. Clin Orthop 373:233–240
Giannoudis PV, Smith RM, Perry SL et al (2000) Immediate IL-10 expression following major orthopaedic trauma: relationship to anti-inflammatory response and subsequent development of sepsis. Intensive Care Med 26(8):1076–1081
Giannoudis PV, Smith RM, Banks RE et al (1998) Stimulation of inflammatory markers after blunt trauma. Br J Surg 85(7):986–990
Pape H-C, Griensven MV, Hildebrand FF et al (2008) Systemic inflammatory response after extremity or truncal fracture operations. J Trauma 65(6):1379–1384
Sathiyakumar V, Greenberg SE, Molina CS et al (2015) Hip fractures are risky business: an analysis of the NSQIP data. Injury 46(4):703–708
Sathiyakumar V, Thakore RV, Greenberg SE et al (2015) Adverse events in orthopaedics: is trauma more risky? An analysis of the NSQIP data. J Orthop Trauma 29(7):337–341
Lakomkin N, Greenberg SE, Obremskey WT, et al. (2015) The risk of adverse events in orthopaedic trauma varies by anatomic region of surgery: an analysis of fifty thousand four hundred and twenty one patients. Int Orthop 39(11):2153–2159.
Wafaisade A, Lefering R, Bouillon B et al (2011) Epidemiology and risk factors of sepsis after multiple trauma: an analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery. Crit Care Med 39(4):621–628
Belmont PJ, Goodman GP, Kusnezov NA et al (2014) Postoperative myocardial infarction and cardiac arrest following primary total knee and hip arthroplasty: rates, risk factors, and time of occurrence. J Bone Joint Surg Am 96(24):2025–2031
Schoenfeld AJ, Ochoa LM, Bader JO et al (2011) Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National Surgical Quality Improvement Program. J Bone Jt Surg 93(17):1577–1582
Schoenfeld AJ, Carey PA, Cleveland AW et al (2013) Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J Off J N Am Spine Soc 13(10):1171–1179
Shiloach M, Frencher SK, Steeger JE et al (2010) Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 210(1):6–16
Ingraham AM, Richards KE, Hall BL et al (2010) Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Adv Surg 44:251–267
Schilling PL, Hallstrom BR, Birkmeyer JD et al (2010) Prioritizing perioperative quality improvement in orthopaedic surgery. J Bone Joint Surg Am 92(9):1884–1889
Molina CS, Thakore RV, Blumer A et al (2015) Use of the National Surgical Quality Improvement Program in orthopaedic surgery. Clin Orthop 473(5):1574–1581
Moore LJ, Moore FA, Todd SR et al (2010) Sepsis in general surgery: the 2005–2007 National Surgical Quality Improvement Program perspective. Arch Surg Chic 145(7):695–700
Osborn TM, Tracy JK, Dunne JR et al (2004) Epidemiology of sepsis in patients with traumatic injury. Crit Care Med 32(11):2234–2240
Ertel W, Keel M, Bonaccio M et al (1995) Release of anti-inflammatory mediators after mechanical trauma correlates with severity of injury and clinical outcome. J Trauma 39(5):879–885 (discussion 885–887)
Tan LR, Waxman K, Scannell G et al (1993) Trauma causes early release of soluble receptors for tumor necrosis factor. J Trauma 34(5):634–638
Roberts CS, Pape H-C, Jones AL et al (2005) Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect 54:447–462
Meakins JL, Pietsch JB, Bubenick O et al (1977) Delayed hypersensitivity: indicator of acquired failure of host defenses in sepsis and trauma. Ann Surg 186(3):241–250
Giannoudis PV (2003) Current concepts of the inflammatory response after major trauma: an update. Injury 34(6):397–404
Aube H, Milan C, Blettery B (1992) Risk factors for septic shock in the early management of bacteremia. Am J Med 93(3):283–288
Martin GS, Mannino DM, Eaton S et al (2003) The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 348(16):1546–1554
Martin GS, Mannino DM, Moss M (2006) The effect of age on the development and outcome of adult sepsis. Crit Care Med 34(1):15–21
Simsic JM, Kanter KR, Kirshbom PM et al (2007) Does preoperative mechanical ventilation affect outcomes in neonates undergoing cardiac surgery? Cardiol Young 17(1):90–94
Kercher J, Xerogeanes J, Tannenbaum A et al (2009) Anterior cruciate ligament reconstruction in the skeletally immature: an anatomical study utilizing 3-dimensional magnetic resonance imaging reconstructions. J Pediatr Orthop 29(2):124–129
Sibbald WJ (1978) Pulmonary hypertension in sepsis: measurement by the pulmonary arterial diastolic-pulmonary wedge pressure gradient and the influence of passive and active factors. Chest 73(5):583
Yang S, Nguyen ND, Center JR, Eisman JA, Nguyen TV (2014) Association between hypertension and fragility fracture: a longitudinal study. Osteoporos Int 25(1):97–103
Henderson CY, Ryan JP (2015) Predicting mortality following hip fracture: an analysis of comorbidities and complications. Ir J Med Sci 184(3):667–671
Jiang JJ, Phillips CS, Levitz SP, Benson LS (2014) Risk factors for complications following open reduction internal fixation of distal radius fractures. J Hand Surg Am 39(12):2365–2372
Harstedt M, Rogmark C, Sutton R, Melander O, Fedorowski A (2015) Impact of comorbidity on 6-month hospital readmission and mortality after hip fracture surgery. Injury 46(4):713–718
Mastropietro CW, Barrett R, Davalos MC et al (2013) Cumulative corticosteroid exposure and infection risk after complex pediatric cardiac surgery. Ann Thorac Surg 95(6):2133–2139
Aberra FN, Lewis JD, Hass D et al (2003) Corticosteroids and immunomodulators: postoperative infectious complication risk in inflammatory bowel disease patients. Gastroenterology 125(2):320–327
Merkler AE, Saini V, Kamel H et al (2014) Preoperative steroid use and the risk of infectious complications after neurosurgery. Neurohospitalist 4(2):80–85
Sprung CL, Brezis M, Goodman S et al (2011) Corticosteroid therapy for patients in septic shock: some progress in a difficult decision. Crit Care Med 39(3):571–574
Polk HC (1987) Non-specific host defence stimulation in the reduction of surgical infection in man. Br J Surg 74(11):969–970
Toufektzian L, Patris V, Sepsas E et al (2015) Does postoperative mechanical ventilation predispose to bronchopleural fistula formation in patients undergoing pneumonectomy? Interact Cardiovasc Thorac Surg