2018年 · 第21卷第01期

Early adequate fluid loading was the corner stone of hemodynamic optimization for sepsis and septic shock. Meanwhile, recent recommended protocol for fluid resuscitation was increasingly debated on hemodynamic stability vs risk of overloading. In recent publications, it was found that a priority was often given to hemodynamic stability rather than organ function alternation in the early fluid resuscitation of sepsis. However, no safety limits were used at all in most of these reports. In this article, the rationality and safety of early aggressive fluid loading for septic patients were discussed. It was concluded that early aggressive fluid loading improved hemodynamics transitorily, but was probably traded off with a follow-up organ function impairment, such as worsening oxygenation by reduction of lung aeration, in a part of septic patients at least. Thus, a safeguard is needed against unnecessary excessive fluids in early aggressive fluid loading for septic patients.

The efficacy and safety of normal saline (NS) for fluid therapy in critically ill patients remain controversy. In this review, we summarized the evidence of randomized controlled trials (RCTs) which compared NS with other solutions in critically ill patients. The results showed that when compared with 6% hydroxyethyl starch (HES), NS may reduce the onset of acute kidney injury (AKI). However, there is no significant different in mortality and incidence of AKI when compared with 10% HES, albumin and buffered crystalloid solution. Therefore, it is important to prescribe intravenous fluid for patients according to their individual condition.

The kidneys have a close functional relationship with other organs especially the lungs. This connection makes the kidney and the lungs as the most organs involved in the multi-organ failure syndrome. The combination of acute lung injury (ALI) and renal failure results a great clinical significance of 80% mortality rate. Acute kidney injury (AKI) leads to an increase in circulating cytokines, chemokines, activated innate immune cells and diffuse of these agents to other organs such as the lungs. These factors initiate pathological cascade that ultimately leads to ALI and acute respiratory distress syndrome (ARDS). We comprehensively searched the English medical literature focusing on AKI, ALI, organs cross talk, renal failure, multi organ failure and ARDS using the databases of PubMed, Embase, Scopus and directory of open access journals. In this narrative review, we summarized the pathophysiology and treatment of respiratory distress syndrome following AKI. This review promotes knowledge of the link between kidney and lung with mechanisms, diagnostic biomarkers, and treatment involved ARDS induced by AKI.

Purpose: The aim of our study was to determine predictive factors and requirement for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary device.　 Methods: Seventy-nine patients with extra capsular hip fractures treated with cephalo-medullary nailing were included in the study. Age, sex, ASA grade, timing of surgery, preoperative and postoperative haemoglobin, length of hospital stay, fracture type, number of units transfused and 30-day mortality were recorded.　 Results: The mean age was 82.3 years. Forty-seven patients underwent a short nail and 32 patients a long nail; 53.4% patients required blood transfusion postoperatively. Transfusion was required in 71.8% of the long nails (p < 0.05), 65.8% patients above the age of 80 (p < 0.05), 100% of the patients with hemoglobin below 90 g/L and 20 patients with a ASA grade of 3 (p < 0.05). 78.5% patients with A2 fracture and 75% of A3 fractures needed blood transfusion (p > 0.05). Length of hospital stay in non-transfusion group was 13 days and in transfusion group was 19 days (p < 0.05). 55.1% operated within 36 h and 47.6% operated after 36 h of admission needed transfusion (p > 0.05). Thirty-day mortality in patients needing blood transfusion was 5% and in non-transfusion group was 3.7% (p > 0.05).　 Conclusion: Patient age, ASA grade, preoperative haemoglobin and length of nail are reliable predictors for perioperative blood transfusion in extra capsular hip fractures in elderly patients treated with cephalo-medullary nailing and reinforce a selective transfusion policy.

Purpose: To evaluate the effect of retention sutures on abdominal pressure and postoperative prognosis in abdominal surgery patients.　 Methods: This prospective cohort study included patients who were admitted to Daping Hospital from May 15, 2014 to October 11, 2014. A total of 57 patients were enrolled, including 18 patients in the "U" type retention suture group, 17 patients in the intermittent retention suture group, and 22 patients in non-retention suture group. The demographic data, clinical data and risk factors for abdominal wound dehiscence were recorded. The bladder pressure (IVP) was monitored preoperatively, intraoperatively, and four days postoperatively. Additionally, the incidence of abdominal wound dehiscence and infection 14 days after the operation was recorded.　 Results: During the operation, the IVP decreased and then increased; it was at its lowest 1 h after the start of the operation (5.3 mmHg ± 3.2 mmHg) and peaked after tension-reducing (8.8 mmHg ± 4.0 mmHg). The IVP values in the "U" type retention suture group and intermittent retention suture group were higher than in the non-retention suture group 4 days after operation (p < 0.005). The Visual Analogue Scale (VAS) pain scores were 3.9 ± 2.2, 3.8 ± 2.0, and 3.0 ± 1.0 in the retention suture group, intermittent retention suture group and non-retention suture group, respectively. The VAS pain scores in the "U" type tension-reducing group and intermittent tension-reducing group were higher than in the non-tension-reducing group (p < 0.005).　 Conclusion: Although retention sutures may reduce the incidence of postoperative wound dehiscence in abdominal surgery patients, they can increase the IVP and postoperative pain.

Purpose: To observe the therapeutic effect of interventional embolization and haemorrhage control in multiple trauma patients with a major abdominal or pelvic injury.　 Methods: Data of 160 multiple trauma patients with a major abdominal or pelvic injury were retrospectively analyzed. They were admitted into the Department of Emergency of the First Affiliated Hospital of Zunyi Medical College from October 2013 to April 2016. Eighty-seven patients who received emergent intervention for embolization and haemorrhage control were set as group A, including 72 males and 15 females, with an average age of (39.32 ± 14.0) years. Patients underwent emergent intervention for embolization and hemostasis. The other 73 patients who received traditional surgeries were set as group B, including 62 males and 11 females, with an average age of (38.48 ± 13.12) years. The time from admission to emergency intervention, the time of interventional embolization, transfusion during hospitalization, length of stay and prognosis were observed. The whole treatment and prognosis were compared between group A and group B.　 Results: In group A, the average time from admission to intervention exploration was (132.05 ± 86.80) min, the average operation time was (149 ± 49.69) min, the average hospitalization time was (18.37 ± 4.71) days, the average amount of RBC transfusion during hospitalization was (7.2 ± 4.33) units, and the mortality was 4.60% (4 patients died). The corresponding data in group B were respectively (138.95 ± 82.49) min, (183 ± 52.39) min, (22.72 ± 6.63) days, (12.23 ± 5.43) units, and 9.59% (7 cases died). There was no statistical difference in the time from admission to operation between the two groups (p > 0.05), but there was statistical difference in operation time, RBC transfusion, hospitalization time, prognosis, and mortality between the two groups (all p < 0.05).　 Conclusion: The emergent intervention for embolization and haemorrhage control of multiple trauma patients with a major abdominal or pelvic injury and visceral organ haemorrhage has the advantages of less trauma, shorter operation time, shorter hospital stay, less blood transfusion in comparison to the traditional emergency surgeries.

Purpose: To study the effects of surgical and nonoperative treatment on wrist function in patients with distal radius fracture.　 Methods: In total, 97 patients treated for distal radius fracture in the Department of Orthopedic Trauma at the People's Hospital of Peking University from Jan. 2010 to Jun. 2016 were selected for outpatient follow-up, including manipulative reduction and dorsal splint fixation in 24 cases, bivalve cast fixation in 19 cases and open reduction and internal fixation in 54 cases. Evaluation was based on Sartiento's modification of the Gartland and Werley score. Efficacy was assessed with wrist pain as the focus.　 Results: The wrist function scores of the surgical group were better than nonoperative groups. There was no significant difference in wrist function scores between the dorsal splint group and the bivalve cast group. The ulnar wrist pain incidence had no significant difference in surgical and nonoperative groups. The displace rate in dorsal splint group was higher than other groups.　 Conclusion: The overall effect of surgical treatment of distal radius fracture is better than nonoperative treatment. The ulnar wrist pain incidence has no significant difference in these groups. Dorsal splint fixation is more prone to displace than bivalve cast fixation.

Purpose: The aim of this study is to discuss the results of different intramedullary devices used in the management of paediatric radial neck fractures and to suggest methods to avoid the pitfalls of the technique.　 Methods: Thirty patients with isolated Judet III and IV fractures were included in this prospective study. Judet I and II fractures and radial neck fractures associated with other injuries were excluded. The final results were graded using the Metaizeau functional scoring system and Oxford Elbow Score.　 Results: The functional result was good to excellent in 24 of 30 cases (80%). The mean Oxford Elbow Score was 44.32. The mean follow-up was 40.11 months. The complications seen were radiocapitellar joint penetration-6 cases at mean 4.87 weeks, redisplacement-6, radial epiphyseal sclerosis-5, and heterotopic ossification-1 case.　 Conclusion: Intramedullary K wires may result in radiocapitellar joint penetration. Titanium Elastic Nail System should not be used as purely fixation devices as they may not prevent redisplacement. Regular follow-up until at least 6 weeks is essential. Patients who have a Judet IV fracture and need open reduction should be given a guarded prognosis. The paper highlights the pitfalls of the technique and makes recommendations regarding the type of implant, follow-up and patient counselling in Judet IV fractures.

Purpose: Bear maul injuries are the most common wild animal inflicted injuries in India. More than 300 bear maul injuries report to our hospital per year.　 Methods: Twenty-one consecutive patients over a period of 1 year reported to our department for orthopaedic management of bear maul injuries. All the patients were referred either from peripheral hospitals or from other surgical departments of our hospital.　 Results: All the patients had facial/scalp injuries of variable severity. In all the patients the severity of limb and facial trauma was inversely proportional to each other. Pattern of upper limb trauma in most of the patients was similar. Fifteen patients had either fractures of distal humerus or mid shaft/proximal forearm bone fracture. Two had distal forearm bone fracture, 2 had carpal/metacarpal fractures and 1 had clavicle fracture. Only 1 had lower limb fracture. Thirteen out of 21 patients had associated neurovascular injury of the involved limb. The characteristic feature was extensive soft tissue involvement of the affected limb.　 Conclusion: Upper limb injuries in bear maul patients usually have similar pattern. The severity of upper limb and facial/scalp trauma is inversely proportional to each other. Multistage orthopaedic surgeries are needed for such complex limb injuries.

Purpose: Cerclage wire application has emerged as a potential therapeutic adjunct to intramedullary nailing for subtrochanteric fractures. But its popularity is plagued by the concern of possible negative effect on fracture zone biology. This study was intended to analyze the clinico-radiological outcome and complications associated with cerclage wire application.　 Methods: Retrospective analysis was performed on all the subtrochanteric fractures operated with intramedullary nailing between January 2012 and January 2016. After exclusion, 48 patients were available with an average follow-up of 20.8 months. Long oblique, spiral, spiral wedge or comminuted fracture configurations with butterfly fragments were particularly considered for cerclage wire application, which was employed by percutaneous cerclage passer in 21 patients. Assessment was done in terms of operation time, blood loss, quality of reduction, neck-shaft angle, follow-up redisplacement, union time, complications, and final functional evaluation by Merle d’Aubigne'-Postel score.　 Results: Average operation time and blood loss were significantly higher in cerclage group (p < 0.05). However, cerclage use substantially improved quality of reduction in terms of maximum cortical displacement (p = 0.003) and fracture angulation (p = 0.045); anatomical reduction was achieved in 95.23% of cases as compared to 74.07% without cerclage. Union time was shorter, although not statistically different (p = 0.208), in cerclage group. Four patients in non-cerclage group developed non-union, 2 of them had nail breakage. No infection or any other implant related complications were reported with cerclage use.　 Conclusion: Minimally-invasive cerclage wire application has proved to be beneficial for anatomical reconstruction in difficult subtrochanteric fractures, whenever applicable, without any harmful effect on fracture biology.

Purpose: We conducted this study to correlate the short term clinical outcomes after anterior cruciate ligament (ACL) reconstruction with patients' age, time since injury and associated meniscal injury.　 Methods: A total of 43 patients who underwent ACL reconstruction between October 2013 and February 2015 were taken for the study. Preoperative demographic data, clinical scores (Lysholm, IKDC) were recorded for each patient. Time since injury and associated meniscal injuries were recorded. Then a standardized surgical technique was used for each graft type. They were followed up for 6 months and the Lysholm and IKDC scores were evaluated.　 Results: Only 33 patients completed 6 months follow-up at the end of this study. Twenty-four patients (72.7%) were in the age group of 18-30 years. Nine patients belonged to age group 30-50 years (27.3%). The p value for differences in Lysholm scores between the two age groups was not significant (0.339). The p value for differences in IKDC scores between the two age groups was not significant either (0.138). The mean Lysholm scores were 93.86 ± 3.024 for the group who presented <6 months post-injury, 92 ± 5.494 for the group who presented between 6 months and 1 year and 94.64 ± 3.104 for the group who presented after 1 year; whereas the mean IKDC scores were 92.43 ± 0.793, 90.64 ± 6.598 and 90.89 ± 2.113 respectively. The correlation of outcomes with meniscal injury had no statistical significance.　 Conclusion: Based on our study, we conclude that age, time since injury and associated meniscal injury does not affect short term functional outcome in ACL reconstruction.

Purpose: The aim of this study was to analyze the trend of road traffic fatalities in Kashan Region, Iran, in a period of eight years.　 Methods: Through a cross-sectional study, all road traffic deaths classified under the V01-V99 codes according to ICD-10 in Kashan region, central Iran, from March 2006 to March 2013 and population data were collected from the registration system of Kashan University of Medical Sciences. Years of lost life (YLL) and mortality rates were calculated regarding age, gender and year of the accident. Generalized linear model (GLM) with Poisson log-linear link was used to evaluate the effects of the mentioned variables on mortality rate.　 Results: During the period of the study (8 years), 928 people (767 men) died due to road traffic injuries (RTIs). The total YLL was 20,818. The mortality rate due to RTIs has been declined constantly from 43.1 in March 2006 to 21.1 per 100,000 in March 2013. The highest mortality rate was found in the age group of over 60 years old and the lowest in the age group of 0-14 years old. Both mortality rate and YLL was greater in men than in women. Poisson regression showed that age, gender and year of the accidents had a significant effect on mortality rate (p < 0.001).　 Conclusion: Although there has been a constant decline of mortality rate in Kashan area within the study period, the value remains higher than the mean level of Eastern Mediterranean region and the global average, which is a notable fact for policymakers and authorities.

Purpose: The results for fixation of comminuted posterior wall acetabular fractures are not very promising with reported complications in terms of osteoarthritis, nonunion and malunion which subsequently require conversion to total hip arthroplasty. The conversion to total hip arthroplasty is possible in patients over 50 years of age but not in younger patients. So this requires new methods for salvage of the native hip in young patients.　 Methods: There were six patients in our series with highly comminuted posterior wall acetabular fractures where the fragments were excised and the gap filled with tricortical anterior iliac-crest strut autograft, fixed with screws and plate.　 Results: Good results were achieved in four out of six patients analyzed clinically using the Merle d'Aubinge score modified by Matta and radiologically by Matta scoring. These patients have returned to original work and are walking independently. The good result in one patient deteriorated from good to poor between one and two years. One patient developed infection and excision arthroplasty was done. The graft incorporated well in five out of six patients.　 Conclusion: The use of iliac crest autograft is a better, advanced and promising technique as it provides a new wall to the weight bearing dome of the acetabulum for articulation with the femoral head. The rates of nonunion, malunion, post traumatic osteoarthritis are less as compared to the fixation of the comminuted fragments. The need for conversion to total hip arthroplasty is also less.