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Chapter 12

Contents

CHAPTER XII

Anesthesia

George E. Donaghy, M. D., Ernest A. Doud, M. D.,
Werner F. Hoeflich, M. D., and Charles W. Westerfield, M. D.

For the most part, anesthesia in the 3,154 abdominal injuries treated by the teams of the 2d Auxiliary Surgical Group during 1944 and 1945 was administered by physicians. Many of the 45 anesthetists attached to the group had received formal training. Others had had limited training and experience, but some had had neither training nor experience. Ideally, because soldiers with abdominal injuries may present incredible difficulties in anesthetic management, anesthetists who care for them should possess a good general medical background, an understanding of the principles of management of the physiologic disturbances following abdominal and thoracoabdominal wounds, and proficiency in the diagnosis and treatment of shock and in the recognition and care of complications. For obvious reasons, this ideal was frequently not achieved.

STATUS OF CASUALTIES

Detailed information concerning the status of casualties on their arrival at the field hospital after triage at the division clearing station is set forth elsewhere (p. 124), but certain of these facts should be reiterated here; they furnish the background for the discussion of anesthesia in abdominal injuries in wartime.

The majority (approximately 90 percent) of the casualties with abdominal wounds treated in the field hospitals by surgeons of the 2d Auxiliary Surgical Group were nontransportable; that is, they required immediate operation. The timelag from wounding until hospitalization ranged from between 15 and 30 minutes to between 30 and 40 hours. Exclusive of the cases in which the abdominal wall was penetrated without visceral injury, the injuries varied from a small wound of a single viscus to penetrating and perforating wounds of several organs. More than a quarter of the patients (26.6 percent) had thoracoabdominal injuries. All types of associated (extra-abdominal) injuries were present in all conceivable sites. The physical status of many of the casualties was only fair or actually poor. Some degree of shock was present in most cases; frequently it was extremely severe. In a representative sample of 957 cases, 14.6 percent of the patients had systolic blood-pressure readings from 0 to 40 mm. Hg, 12.7 percent from 41 to 70 mm. Hg, 26.1 percent from 71 to 100 mm. Hg, and 46.6 percent from 101 to 120 mm. Hg. Often there had been periods, sometimes long periods, of fatigue, exposure, and dietary limitations before the injuries had occurred.


182

Pulmonary blast injuries deserve special mention. The small number in this series suggests that only the most severe were put on record and that the majority, because they were minimal, were either not recognized or not entered on the charts. The gravity of this particular problem naturally varied with the degree of injury. Casualties who had sustained severe bilateral injuries furnished the anesthetists with many special problems. It was a real achievement to anesthetize a patient with this type of injury without losing him on the table from pulmonary edema. No form of anesthesia, least of all ether, was well tolerated, and it was always difficult to maintain an adequate airway during operation and afterward.

AGENTS AND METHODS

Although a wide variety of anesthetic agents was available in the Mediterranean theater, anesthesia, for practical reasons, was accomplished in more than 90 percent of all cases with ether (table 23). The agents supplied included, in addition to ether, chloroform, ethyl chloride, nitrous oxide, Pentothal, procaine, Pontocaine, cocaine, and oxygen. Methods employed included the open-drop method; the closed-circle flow absorption method, with Heidbrink and McKesson machines; the closed to-and-fro absorption method, with the Beecher model machine; intravenous injection; intratracheal injection; local, regional, and field block; and topical application.

TABLE 23.-Distribution of anesthetic agents in 3,154 abdominal injuries

Anesthetic agents

1944

1945

Total

Cases

Proportion

Cases

Proportion

Cases

Proportion

 

 

Percent

 

Percent

 

Percent

Nitrous oxide-oxygen-ether

1,306

54.81

642

83.3

1,948

61.77

Ether

752

31.56

48

6.2

800

25.37

Ethyl chloride-ether

224

9.40

57

7.4

281

8.91

Pentothal-ether

49

2.06

1

.1

50

1.59

Chloroform-ether

1

.04

0

0

1

.03

Nitrous oxide-oxygen-ether-Pentothal

1

.04

0

0

1

.03

Ether-procaine

3

.13

0

0

3

.09

Procaine (local)

5

.21

1

.1

6

.19

Procaine (spinal)

2

.08

0

0

2

.06

Procaine-Pentothal (spinal)

1

.04

0

0

1

.03

Nitrous oxide-oxygen1

1

.04

0

0

1

.03

Pentothal2

1

.04

0

0

1

.03

Oxygen3

1

.04

0

0

1

.03

Not stated

36

1.51

22

2.9

58

1.84


Total

2,383

100.00

771

100.0

3,154

100.00


1Patient died from aspiration of gastric contents following vomiting during induction of anesthesia.
2Simple debridement of thoracoabdominal wound of entrance.
3Patient unconscious and moribund.


183

Routine Agents and Method

The 2d Auxiliary Surgical Group found soon after it had become operational that the most satisfactory anesthesia for severely wounded battle casualties was secured by (1) induction by nitrous oxide-oxygen and (2) maintenance by ether-oxygen in a closed carbon dioxide absorption system. This method was adopted and came into general use because of its ready availability, its simplicity of administration, its satisfactory tolerance by patients, and its wide margin of safety. The possible toxic effects of ether on the heart, liver, and kidneys were fully realized, but simplicity of administration and the wide margin of safety were considerations of greater importance in view of the fact that, as already mentioned, the anesthetics were administered by some 45 anesthetists of widely varying training, experience, capabilities, and judgment.

Although ether, combined with oxygen and following induction with nitrous oxide, was the most popular anesthetic agent in this series, its use by the open-drop method was considerably less extensive than might have been expected (table 24). This method was used in 12.5 percent of all cases treated in 1944, when anesthesia machines were in limited supply, but in only 2.7 percent of the operations in 1945, when equipment had become widely available.

Closed anesthesia had many desirable features for military surgery, including conservation of body heat and moisture, the maintenance of a high oxygen content and the control of carbon dioxide content in the blood, ease of attaining and maintaining desired levels of anesthesia, and control of respiration and maintenance of positive pressure when these special conditions had to be met. The necessity for an anesthesia in which these objectives could be accomplished was naturally magnified in casualties in critical condition. There was therefore an increasing use of the closed technique as the war progressed (table 24).

The endotracheal technique also had an extensive and increasing use, which in most cases was essential rather than preferential. By it, a patent airway was provided and maintained, no matter what the position of the patient.

TABLE 24.-Distribution of techniques of administration of anesthesia in 3,154 abdominal injuries

Method

1944

1945

Total

Cases

Proportion

Cases

Proportion

 

Cases

Proportion

 

 

Percent

 

Percent

 

Percent

Inhalation:

 

 

 

 

 

 

     Closed

2,028

85.1

727

94.3

2,755

87.4

     Open

298

12.5

21

2.7

319

10.1

     Semiopen

7

.3

0

0

7

.2

Others

14

.6

1

.1

15

.5

Not stated

36

1.5

22

2.9

58

1.8


Total

2,383

100.0

771

100.0

3,154

100.0


184

The anesthetist, as a result, had sufficient freedom of action to aspirate blood and accumulated secretions easily via the tube and to supervise or administer transfusions when they were required. The endotracheal technique facilitated the control of respiration by positive pressure and assisted in the attainment of desired levels of anesthesia, while the increased smoothness of respiration achieved with a tube in situ simplified the task of the surgeon working in the abdominal cavity. The endotracheal technique was employed in 1944 in 89.8 percent of the 2,108 cases in which a definite statement was made on the matter. The fact that in 1945 it was employed in every one of the 749 cases in which technique was recorded is an indication of the increased appreciation by the surgeons of the group of its numerous advantages.

Other Agents and Methods

Chloroform.-Why chloroform was used for induction in one case in this series is not clear. The dangers of this agent were so well known to both the surgeons and the anesthetists of the group that there was no temptation to employ it to anesthetize casualties with such injuries as these men had sustained.

Pentothal.-In 1944, Pentothal was used 49 times as an induction agent preceding ether anesthesia and once as an adjunct to spinal analgesia (table 23). In this same year, it was used in one instance as the sole anesthetic agent, for simple debridement of a thoracoabdominal wound of entrance. In 1945, it was used only once, as the induction agent.

The extremely limited use of Pentothal by the surgeons of the 2d Auxiliary Surgical Group has significant implications. This anesthetic agent was reported to have been used extensively elsewhere, in some areas in 95 percent of all cases, and it may be that the discrepancy between this usage and the usage of the group can be explained by the type of cases handled, the problem of supply, the echelon at which surgery was done, or a combination of these factors. In the opinion of the group surgeons, all the well-recognized contraindications to Pentothal were present in most of the abdominal injuries which came under their observation. A large proportion of the patients were in shock. Hemorrhage before hospitalization was often serious, and further loss of blood could be expected during operation. Anoxia of varying degrees resulted from hemorrhage and shock, and the accumulation of secretions in the tracheobronchial tree, hemothorax and pneumothorax, painful respiration, and other derangements of cardiorespiratory physiology furnished other problems. The surgery required was frequently formidable and time consuming. Muscular relaxation was essential during operation, particularly while exploration and closure were being carried out. Endotracheal intubation, which was almost universally employed, was difficult to accomplish under Pentothal anesthesia, because of irritability of the larynx and poor relaxation of the muscles of the jaw. The status of the patient thus militated against the use of Pentothal, while the criteria of desirable anesthesia for this type of injury were difficult or impossible to attain when it was used. Finally, serious reactions often occurred


185

when the tube was inserted, and a second reaction was likely to occur when the catheter was moved as the patient was shifted on the operating table or when his head was turned.

Nitrous oxide-Nitrous oxide, although it was used routinely as an induction agent, was never used as the sole anesthetic agent (table 23). It was always employed with oxygen concentrations of at least 20 percent, and many anesthetists preferred concentrations of 30 percent or more. Concentrations of 60 to 75 percent were frequently used, and no difficulties were experienced in the brief periods in which they were necessary. Such concentrations, however, are not compatible with a satisfactory level of anesthesia, and nitrous oxide would therefore have been impractical as the primary anesthetic for patients who, like these, were in shock, who had serious and often multiple wounds, who required prolonged major surgical procedures, and who had to be provided with the highest possible concentrations of oxygen to compensate for the loss of their own oxygen-carrying powers.

Ethyl chloride-Ethyl chloride was used as an induction agent in a large number of cases (table 23) and was satisfactory for this purpose when it was administered cautiously. It was not ordinarily used in patients who presented poor risks, and it was never used as the sole anesthetic agent.

Spinal analgesia-Spinal analgesia was not regarded as suitable for frontline military surgery for a number of reasons, including the following: The length, as well as the variability, of the time necessary for surgery; the unstable cardiovascular balance of casualties in shock, who had sustained large blood losses; the frequency of associated wounds in areas which cannot be affected by this anesthetic method; and the undesirability of full consciousness in an apprehensive casualty not long removed from the battlefield. Spinal analgesia was used only 3 times in the 3,154 cases (table 23). In each instance, the patient was in excellent condition and there was no doubt that intra-abdominal injury was minimal.

Procaine.-Procaine was occasionally used to secure regional or field block analgesia (table 23), each time in combination with a light inhalation anesthetic. In retrospect, the combined method seems to have excellent potentialities in military surgery, and it is regrettable that it was not given a more adequate test.

Cocaine.-Cocaine was used according to the ordinary indications for bronchoscopy on conscious patients and, occasionally, to facilitate a difficult intubation.

PREOPERATIVE MANAGEMENT

When a field-hospital platoon was well organized and fully staffed, patients with abdominal and thoracoabdominal injuries were placed in charge of experienced shock teams as soon as they were received from the clearing station. These ideal circumstances did not always exist. In the absence of a shock team, or when the flow of casualties was extremely heavy, both anesthetists and surgeons worked in the resuscitation ward. It was therefore


186

necessary, as already intimated, for the anesthetist to be familiar with shock therapy because emergencies might arise during which the full responsibility for resuscitation would fall upon him.

It was always desirable for the anesthetist to make a preliminary study of the patient before he received him in the operating room, but during rush periods such contacts were not always possible. The anesthetist, however, always determined the pre-anesthetic medication to be administered in the particular case. As a rule, atropine gr. 1/100 was given, in combination with morphine if that drug was indicated (p. 76). Before operation, morphine was usually given by the intravenous route.

MANAGEMENT DURING OPERATION

The patient was kept in the shock ward until the anesthetic equipment was in order and the instruments were set up for operation. Resuscitation therapy was interrupted as briefly as possible during his transfer to the operating room. If oxygen, for instance, was being administered, it was discontinued only during the actual interval of transportation by the litter carriers.

Induction was seldom difficult. Many of the wounded had gone without sleep for long periods and were completely exhausted, and those who were in shock, or who had been in shock, were, as usual, easy to anesthetize. Severe excitement stages seldom occurred, in contrast to their relative frequency in civilian practice. This was surprising. It had been expected, if only because of the sounds of Allied and enemy artillery and the unavoidable noise and bustle in a busy surgical tent, that excitement would have been frequent and violent.

Anesthesia was maintained in the lightest possible plane compatible with the surgery required in a given case. Men in the condition of these casualties could not usually tolerate deep planes of anesthesia for more than brief periods of time.

Two of the anesthetists in the group were authorized to employ a preparation of curare, on a trial basis, as a supplementary anesthetic agent, to facilitate intraperitoneal manipulations during periods of light anesthesia.1 Included in the 26 casualties in whom the method was used were 10 with thoracoabdominal wounds and 13 who had recently been in shock. All received nitrous oxide-oxygen-ether anesthesia by the closed endotracheal technique and were given curare in various dosages and at various times during the operation.

The immediate results of this method were excellent in all cases in which it was tested; there were no postoperative complications and no deaths which could possibly be attributed to the use of curare. Abdominal relaxation was entirely satisfactory in every instance, and ether anesthesia could be maintained in the lower part of the first plane, which was thought to be more desirable than the deeper levels ordinarily necessary in military surgery within the abdomen. Both anesthetists who conducted the trials with curare stressed the importance of employing the endotracheal technique when it was used.

1Doud, E. A.; and Shortz, G.: The Use of Curare for Abdominal Surgery in Seriously Injured Patients. Anesthesiology 7: 522-525, September 1946.


187

The foot of the litter was frequently raised before anesthesia was induced, and many operations were performed with the patient in the Trendelenburg position. All anesthetists commented on the fall in blood pressure which occurred when the position was changed. The drop was most notable when patients were changed from the supine to the prone position, or vice versa, but alterations also occurred when they were turned on the side. This phenomenon was interpreted as direct evidence of the instability of the vasomotor system in severely wounded, anesthetized patients. Experience soon showed that unnecessary movement of the patient on the operating table must be avoided, and that when changes of position were necessary, they must be accomplished slowly and gently, so that the decrease in tension would be minimized as far as possible. Ephedrine (gr. ) was occasionally administered a few minutes before the position was to be changed, in an attempt to produce a general vasoconstriction and increased cardiac output and thus to sustain the blood-pressure level.

A clear airway was maintained at all times. Attention to this point was particularly necessary during the winter, when many of the wounded came to operation with bronchitis and had large accumulations of thick mucoid material. Attention has already been called to the increase in the number of patients handled under endotracheal anesthesia as the anesthetists gained proficiency in this method.

In other respects, the management of patients during operation was also a continuation of resuscitative measures. Pain was abolished by anesthesia. Reestablishment of normal metabolism was aided by the administration of oxygen in high concentrations. Restoration and maintenance of the blood volume were accomplished by transfusions. Solutions of dextrose and saline were used only to combat dehydration. When there had been a decrease in the adequate circulating blood volume, citrated blood in the necessary amounts was administered. Very large amounts (up to 6,500 cc.) were used in patients who had sustained injuries to the major blood vessels. Stimulating drugs were seldom administered.

It is well recognized in civilian practice that the longer the duration of an operation, and therefore of anesthesia, the more likely the patient is to leave the operating table in poor condition and to present postoperative complications. The observation was equally valid in military surgery, but little could be done to alter the unfavorable circumstances. In dealing with seriously wounded men, especially when their wounds were multiple, there were few short cuts available to the surgeon by which the operating time could be reduced. The anesthetist did all in his power to maintain a viable patient, by the use of oxygen, Coramine (nikethamide), ephedrine, Adrenalin (epinephrine hydrochloride), transfusions (sometimes into every extremity), sternal transfusion, and artificial respiration, according to the indications. All that the surgeon could do was to work as quickly as he could in the light of the needs of the patient.


188

Differences in techniques and in individual speed among the various surgeons of the group, as well as differences in injuries among the casualties, resulted in wide variations in operating time. The average time was between 2 and 3 hours, but the range was between 45 minutes and 6 hours. The duration of anesthesia was always 10 to 15 minutes longer than the duration of the surgical procedure.

POSTOPERATIVE COMPLICATIONS OF ANESTHETIC ORIGIN

The postoperative care of the patient was the joint responsibility of the anesthetist and the surgeon, with the anesthetist, as a rule, concerned primarily with the prevention of shock and pulmonary complications. In times of stress, however, he was obliged to take over the entire responsibility for postoperative care, including nasogastric suction, the maintenance of an adequate fluid balance, thoracentesis for the removal of fluid and air, to facilitate the pulmonary exchange, and the administration of drugs. The essentials of the postoperative regimen are discussed elsewhere.

Postoperative pulmonary complications which occurred within the first 48 hours after operation were classified as of anesthetic origin. Atelectasis (table 31, p. 206) was most frequent. In most instances, the condition was transitory and cleared uneventfully. No deaths occurred from this cause alone within the specified 48-hour period. The atelectasis found at autopsy and not recognized ante mortem in 12 fatalities which occurred within this period was regarded as an incidental rather than a causative factor; all the patients had serious injuries and other serious postoperative complications.

Prophylaxis against atelectasis included the measures already listed; that is, voluntary coughing, frequent changes of position, measures to relieve pain, and the administration of oxygen. Atropine was also frequently administered, though not if the patient presented any signs of increased pulmonary transudation.

Lobar pneumonia and bronchopneumonia were infrequent complications (p. 206). They might have been expected to occur more often following prolonged anesthesia and operation, especially since, as already noted, the patients had often been fighting in intolerable weather; had suffered long periods of exposure before, and sometimes after, wounding; and often had preexisting upper respiratory infections or tracheobronchitis. Undoubtedly, the prophylactic measures employed routinely after operation and the routine use of penicillin and the sulfonamides prevented serious consequences, even in these cases.

ANESTHETIC-CONNECTED DEATHS

The majority of the 86 deaths which occurred on the operating table (11.4 percent of the total number of fatalities) were caused by shock, hemorrhage, or fulminating infection. Nine, however, were attributable to anesthetic causes. In some of these fatalities, the position had been changed just


189

before death occurred. In four instances, the patients vomited and aspirated gastric contents. Two similar fatalities, incidentally, occurred on the wards shortly after operation; the patients had not completely reacted, and the fatalities must be charged to inadequate supervision. The same accident occurred in four other cases in which the patients survived.

Two deaths occurred at the conclusion of the operation, during bronchoscopy, presumably from a vagovagal reflex. These cases represented 0.4 percent of the 436 recorded bronchoscopies. The vagovagal reflex is a foreseeable catastrophe, and in each of these cases it had been guarded against by the usual measures, namely, intravenous atropinization just before bronchoscopy was undertaken; light anesthesia; and rapid, careful instrumentation, so that mechanical stimulation of the cough reflex would aid in clearing the air passages. In spite of these precautions, a vagovagal reflex ensued and proved fatal.

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