The Primary Empirical And Clinical Application Study Of Damage Control Operation On Senile Patient In Orthopaedics

Research background: As a special kind of trauma, surgical procedures has been receiving more and more attentions. With the increasing of age, human organ function gradually decayed. For those with chronic internal diseases, the operation tolerance is more decreased. This problem makes it difficult for clinician, patients and their families to decide whether or not to have operation. So the problem on disclaiming operation therapy or having operation till the patient's physiological function gets properly adjusted, routine operation or damage control operation, which of them should be carried out, remains to be a critical clinical issue to be resolved urgently.The concept of damage control and its related techniques originated from the abdominal surgery. If the abdominal viscera get severely damaged, it is impossible to get one-stage operation. The step-by-step operation strategy is adopted to avoid the irreversible stage of physiological functions caused by mass hemorrhage or others. So it should make the same sense while we are tackling with senile patient in orthopedics. Damage control operation is a relative secure and receptive therapeutic measure for those with poor organ function reserve, low tolerance to routine operation and easy facility to complications or even mortality perioperatively. Not all senile patients should take damage control operation and indications are needed to make selection on direct routine operation, damage control operation and sometimes the operation still can not be accomplished with damage control.Therefore, an operation risk scoring system for senile patient in orthopedics need to be established to make objective evaluation to reduce perioperative complications or mortalities when taking damage control operation.Objective:1.To find risk factors influencing perioperative complications or mortalities of senile patients in orthopedics. 2. Reference the method of APACHE and POSSUM scoring system to establish Daping orthopedics operation risk scoring system for senile patients and to develop an associated scoring system software for retrospective study. 3.To make prospective study with this software and take damage control operation on patients with high risk factors.4.To explore the perioperative relevance among operation risk scoring system, stress reaction of senile patients and postoperative complications. 5. To establish senile rat model with multiple injury and get fundamental research basis for damage control operation so as to improve survival rate and reduce perioperative complications.Methods: 1. Screening for risk factors: to design and make registration forms about the inpatients'detailed information. data of 760 senile patients after operation in our orthopaedics department in the recent 7 years were filled into the forms and retrospectively studied. The experimental group included those with mortality or complications while the control group included those having no complications. Statistical analysis was made and the possible correlated risk factors and those having effect on postoperative prognostications were screened out. 2. Weight assignment was given to each risk factor according to statistical analysis and Daping orthopedics operation risk scoring system for senile patient (DORSSSP)was established with its related software developed. Retrospective study on this software was taken to 260 senile patients with fractures of hip and the software potency for prognostication was observed. 3. Prospective study of 100 senile patients in the department of orthopaedics was undertaken with this software, operation damage control strategies were carried out on patients with high risk factors and the information about their postoperative prognostications was recorded at the same time. 4. Twenty senile patients were scored preoperatively with DORSSSP and divided into A and B groups according to the score. Haemospasia at different postoperative phases were taken to detect the expression of GR protein and the diversification of T lymphocyte subpopulation. The correlation among preoperative scores, postoperative stress and poor prognosis was observed. 5.To establish senile rat model with multiple injuries and observe diversification of inflammatory cytokines such as IL-6, TNF-αand IL-10 in peripheral blood. The expression of GR protein on leukocytes was also detected to evaluate the therapeutic effect of operation damage control on rats with multiple injuries.Results: 1. Among the 760 senile patients, the complications rate and the mortality rate was 56.7%, 2.1% respectively, and 23.3% of them had 1 or more complications. After statistical analysis we found that heart and pulmonary function were above grade 2, malnutrition, hypertension, diabetes, mind abnormality, renal inadequacy, electrolyte disturbance, big operation trauma, mass hemorrhage during operation and excessive operation time were main causes of poor postoperative prognostications.2. Weight assignment was given to each factor after statistical analysis based on the prior part of work and DORSSSP was initially established (table2-1). The related software had been proved to run fast and stably on windows operating system. Retrospective study on 260 senile patients with hip fracture was taken with this software. There were 100 cases in low-risk group with score of 12.5±0.8 and no mortality was reported in their duration of hospital. While 10 cases had complications;there were 80 cases in mid-risk group with score 17.6±2.2,no mortality and 21 patients having complications;there were 50 cases in high-risk group with score 23.3±2.9, 2 mortalities and 27 patients having complications. For the ex-high-risk group we got 30 cases with score 33.8±4.7, 4 mortalities and 26 patients having complications in their duration of hospital. A total of 92 cases were predicted to have complications with DORSSSP. With POSSUM, 119 cases had complications with the actual number of 84.With mortality DORSSSP got the result of 9 cases, while P-POSSUM 10 cases and APACHEⅡ12 cases, the actual number was 6.3. Operation damage control was taken for those in both high-risk and ex-high-risk group with DORSSSP. On these patients'first day of admission, physiology score (PS) was from 12 to 42 with average of 21.4±6.7 and operation risk score (OS) was from 12 to 24 with average of 15.2±4.5. The preoperative PS was from 12 to 30 with average of 18.3±6.2,while OS was from 5 to 18 with average of 9.1±3.4. The complication incidence was 46% with mortality rate of 11% according to the prediction based on PS and OS and operation schedule. After operation damage control, the predicted rate of complication cases was 34% with mortality of 5%. With the preoperative prediction using POSSUM and P-POSSUM, the complication rate and mortality rate was 39%, 6%respectively. For APACHEⅡthe predicted mortality rate was 8% while the actual complication rate was 32% and mortality rate 3%.4. One patient appeared complication in group A, three patients presented complications and one patient died in group B. The peripheral blood GR protein expression of senile patients decreased to different extent. In group A, GR protein was decreased and reached the the lowest point on the first day after surgery .Though GR expression increased later, it was significantly lower than the preoperative level(p<0.01)until the 7th day, Restore normal till 14th day.In group B, GR protein was also decreased and reached the lowest point on the first day, lower than the preoperative level until the 14th day. There was significant difference between the two groups(p<0.01), which meant the prolonged low level expression of GR protein was statistically associated with DORSSSP. For the diversification of T lymphocyte subpopulation, CD3 and CD4 levels of two groups got significantly lower than the preoperative ones (P<0.05) on the 1st ,3rd and 5th day with the level of the first day lowest. CD3 and CD4 levels increased on the 5th day. For group A, CD3 and CD4 expression returned to their normal level on the 7th day while group B stayed at a relatively low level. CD8 level from the 1st , 3rd and 5th day detection showed decrease in group A after surgery while it increased in group B. In conclusion, CD3 and CD4 expression decreased shortly after surgery and returned to their normal value on the 7th day from its lowest point on the 1st day. With DORSSSP score the higher, CD3 and CD4 expression decrease the more and return to their normal value the slower. 5. Results of IL-6, IL-10 and TNF-αdiversification in blood plasma of senile rat with multiple injuries: IL-6, IL-10 and TNF-αlevel sharply increased to their peak on the 1st day after trauma and was significantly different from the control group(P<0.001).The fall-off tendency of IL-6, IL-10 and TNF-αwas more significant in group C than in group B. On the 14th day, group C almostly got the normal level while group B stayed at a fairly high level which indicated a significant difference between them(P<0.05). Results of GR protein expression on leucocytes in senile rat: Peripheral blood decreased to different extent after surgery trauma. GR expression in group C decreased on the first day and reached the lowest point on the 5th day. The expression got higher later,but it was still lower than its preoperative level(p<0.01)until the 14th day. GR expression in group B reached the lowest point on the 7th day and didn't return to its preoperative level till the 14th day(p<0.01). Low level expression of GR protein may be prolonged in relation to the trauma severity.Conclusions:1. Heart and pulmonary function above grade 2, malnutrition, hypertension, diabetes, mind abnormality, renal inadequacy, electrolyte disturbance, big operation trauma, mass hemorrhage during operation and excessive operation time are main causes of poor postoperative prognostications for senile patients. Using PS and OS to evaluate the possible danger and positively adjusting their physiological functions state or altering operation modus are important measures to avoid postoperative complications and mortalities.2. DORSSSP can work as an important preoperative risk assessment tool for senile patients and our software based on it can run stably on windows operating system. It is convenient and fast in clinical and can well predict postoperative complication and mortality rate in our clinical retrospective study. It is easier to obtain, simpler to calculate with less indexes and can predict more accurately than APCHEⅡa nd POSSUM scoring system.3. Operation damage control was taken to those senile patients with high relatively surgery risk score under DORSSSP evaluation and this can significantly reduce incidence of postoperative complications and mortalities.DORSSSP showes good consistency with POSSUM, P-POSSUM and APACHEⅡscoring system. Though there was prediction error in these three operation risk scoring systems, the system could get better with the renewal of surgery knowledge.4. Changes of GR protein expression on peripheral blood leucocytes and T lymphocyte subpopulation diversifications have conspicuous correlations with the operation risk scoring and perioperative stress of senile patients. For those senile patients with high preoperative score, GR protein expression stays at a persistent low level while the low level expression time of CD3 and CD4 is even longer. CD4/CD8 expression decreases quite significantly and the probability of postoperative complication remarkably increases. Through DORSSSP plus GR protein expression on peripheral blood leucocytes and T lymphocyte subpopulation diversifications, we can better predict the incidence rate of postoperative complications and mortalities and use this as a clinical therapy guide for senile patients with high risks.5. The practice of operation damage control could improve senile rats'physiological function state. Simple, micro-invasive and fast measures to stabilize bone fracture,early effective liquid transfusion resuscitation and less hemorrhage in the operation can improve GR protein expression on peripheral blood leucocytes , reduce the release of local inflammatory cytokines into blood and avoid the happening of waterfall effect. The postoperative complication and mortality rate of senile rats could get effectively decreased. In conclusion, operation damage control is validly effective for senile rats with multiple injuries and this can provide us favourable clinical evidence for senile patients with the same trauma in orthopaedics.