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Chapter 15

Contents

CHAPTER XV

Postoperative Complications: Prophylaxis and Therapy

James C. Drye, M. D., and W. Philip Giddings, M. D.

The records of the 2d Auxiliary Surgical Group are not complete in respect to postoperative complications and are particularly fragmentary in respect to less severe and nonfatal types. For these deficiencies, there are two explanations. The first is, as already pointed out, that the circumstances of war did not permit the keeping of clinical records which were complete and accurate in all details. The second is that many postoperative processes which in civilian practice would be regarded as complications were so frequent in battle wounds that they came to be regarded as almost implicit in certain injuries and after certain operations. Such complications were seldom made a matter of record. That is why, in this series, it is impossible to make any accurate determination of mild incisional sepsis, ileus of brief duration, pulmonary complications of minor severity, and similar processes.

Early in the war, it was found that premature evacuation of casualties with abdominal injuries increased the incidence of wound dehiscence, ileus, peritonitis, and other major postoperative complications. The trauma and discomfort of ambulance transport over rough roads, as well as the loss of continuity of treatment in a critical stage of convalescence, made these results almost inevitable. It therefore became the policy that, whenever the tactical situation permitted, patients with abdominal wounds should not be evacuated earlier than the eighth day after operation (p. 85). In practice, evacuation was delayed for 14 days in a great many cases, and, if the injuries were unusually severe, it was sometimes delayed for as long as 30 days. The tactical situation frequently prevented complete adherence to this policy, but the majority of the patients in this series were nevertheless held in forward hospitals from 8 to 14 days. It was the emphatic opinion of the surgeons of the group that this policy, quite as much as any other consideration, produced the low morbidity and case fatality rates generally observed in casualties with abdominal injuries in World War II.

Only 3,090 of the 3,154 records used in this analysis were sufficiently complete to permit an analysis of the presence or absence of postoperative complications. All of the complications discussed are also discussed under special headings in other sections of this report. In spite of the inevitable repetition, however, it was thought worthwhile to bring them together at this point and comment upon them briefly.


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PULMONARY COMPLICATIONS

In spite of the known frequency of postoperative pulmonary complications, their recorded occurrence is less accurate than that of other complications in this series (table 31). In addition to the general reasons already listed, still other reasons can be advanced to explain this situation: An accurate diagnosis of pulmonary conditions was likely to be difficult under field conditions. Even though an adequate physical examination was sometimes impossible, the diagnosis usually had to be based entirely on physical findings. Postoperative roentgenograms of the chest were seldom made. When they were, they were usually unsatisfactory because of the limited technical facilities in forward hospitals. In many other instances, examination was precluded by the precarious state of the patient or by the presence of heavy plaster casts.

Sputum examinations were seldom made, because bacteriologic facilities were not easily available. For these various reasons, the statistics tabulated are admittedly deficient. They are, however, in accord with mature, clinical impressions, and the trends which they indicate can be accepted as accurate. 

Pulmonary complications were frequent after operation in patients with abdominal injuries, as might have been expected, because conditions in the theater favored the development of such complications. A large proportion of the casualties occurred during the period of the year which is cold and wet in Italy (p. 216). Troops fought in mud and were almost constantly exposed to heavy rainfall or snow from October through March. As a result, more casualties were received with established respiratory infections during this period than during the summer months, the common cold following the same seasonal trend in Italy as it does in the temperate zones of the United States. Furthermore, many patients passed the critical hours immediately before and after operation in damp tents (fig. 26), in environmental temperatures of 60 or 50 F., or lower. All of these circumstances combined to cause a high incidence of infectious pulmonary complications, particularly during the winter months.

The recorded case fatality rate, almost 40 percent (table 31), is further proof that only the most severe pulmonary complications were listed. It was the general impression that their severity, as well as their frequency, was greater during the winter than during the summer, and the case fatality rates for the two periods lent support to this opinion. Available figures, however (table 31), suggest that the presence of associated chest wounds did not appreciably affect either the frequency or the case fatality rate of the usual infectious pulmonary complications which occurred in abdominal casualties.

There seems no doubt that most of the infectious complications were atelectatic in character and that they arose on the basis of bronchitis or some other respiratory infection already present at the time of operation. In other words, they were those which might be expected to develop in a patient


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FIGURE 26.-Conditions of surgery in field hospital in Italy in winter of 1944-45. 
Resuscitation tent.

population of combat troops carrying a heavy prewounding load of endemic respiratory infections.

The only two instances of lung abscess, both of which were fatal, were not associated with thoracic injuries. Empyema, on the other hand, was associated with chest injuries in 25 of the 29 recorded cases, 11 of which were fatal. All 4 fatalities which occurred in the 7 instances of bile empyema were associated with thoracoabdominal wounds.

The fact that hydropneumothorax was recorded only 91 times in the 3,090 abdominal injuries suggests that note was taken of only the more serious cases, in which repeated thoracenteses were necessary. The incidence was undoubtedly much higher. In most instances, 2 to 3 aspirations of the pleural cavity were sufficient.

The actual incidence of both pulmonary edema and the so-called traumatic wet lung is known to be considerably greater than the recorded figures indicate (table 31). Pulmonary edema was readily precipitated in severely wounded patients, especially in those in shock, if intravenous fluids were given in too great quantities or too rapidly.

As was pointed out in the discussion of the multiplicity factor, the incidence of postoperative pulmonary complications tended to rise with the increase in the number of viscera injured, the observation being, however, of clinical rather than statistical significance (table 32). The explanation was simple: the more


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TABLE 31.-Distribution of recorded pulmonary complications in 3,090 abdominal injuries

Complication

With thoracoabdominal or associated chest wounds (965)1


Without thoracoabdominal or associated chest wounds (2,125)1

Total


Cases

Deaths

Cases

Deaths

Cases

Deaths

Hydropneumothorax

86

9

5

0

91

9

Atelectasis

23

11

37

5

60

16

Bronchopneumonia

12

6

39

19

51

25

Empyema

25

9

4

2

29

11

Pulmonary embolism

5

5

17

16

22

21

Pulmonary edema

6

4

16

11

22

15

Bronchopleural fistula

18

5

0

0

18

5

"Consolidation"

6

4

8

4

14

8

Wet lung

4

3

9

4

13

7

Aspiration of vomitus

1

1

7

5

8

6

Lobar pneumonia

2

2

5

5

7

7

Bile empyema

6

4

1

0

7

4

Blast

2

1

4

3

6

4

Bronchitis

2

1

1

1

3

2

Lung abscess

0

0

2

2

2

2

Other

1

1

6

0

7

1


Total

199

66

161

77

360

143


1Associated wounds include nonpenetrating trauma to the chest wall.

TABLE 32.-Influence of multiplicity factor on development of infectious thoracopulmonary complications in 2,831 abdominal injuries

Item


Number of organs involved

Total cases


One

Two

Three

Four

Five

Cases

1,348

1,014

350

96

23

2,831

Complication

87

55

40

11

3

196

Incidence (percent)

6.5

5.4

11.4

11.5

13.0

7.0


severely wounded patients were the ones most likely to present stagnation of the tracheobronchial secretions, and atelectasis and pneumonia were therefore more likely to develop in them.

Prophylaxis and therapy-The prophylaxis and therapy of pulmonary complications were both based on a few fundamental principles. The most efficient prophylaxis consisted of expertly administered anesthesia, with par-


207

ticular attention to a careful tracheobronchial toilet at the close of the operation. Catheter aspiration or aspiration bronchoscopy was part of the established routine in patients with thoracoabdominal injuries and associated chest wounds and was frequently carried out in patients with other types of injuries, just before they were taken off the operating table. Dressings were applied so as not to restrict the respiratory excursion.

After operation, the first essential was to maintain a clear tracheobronchial tree. For this, frequent changes of position and frequent coughing were essential. In patients with multiple wounds, particularly those in large, bulky casts, changes of position were not always easy to accomplish. Firm manual pressure was of great aid to patients endeavoring to cough, and many learned to support their own incisions.

If the patients refused to cough or could not cough satisfactorily, tracheobronchial suction was again resorted to. If it was not effective, bronchoscopy was employed without delay. Oxygen therapy was employed according to the indications. All of these measures, which were standard practice, approximate the usual methods of prevention of postoperative complications in civilian practices.

Patients with wet lungs, who required repeated tracheal aspirations to clear the airways effectively, were usually treated with tracheal catheter in situ. It was aspirated at regular intervals, and oxygen was usually administered in the interim, sometimes under slight pressure.

Morphine was administered in as small doses and as infrequently as possible, to prevent depression of the respiration. The amount necessary could frequently be reduced by the use of nerve blocks for the relief of pain. Some surgeons of the group made it a practice to block the intercostal nerves from within, while they were exposed in thoracoabdominal wounds, or to perform nerve block before the patient was removed from the operating table.

Pulmonary edema could usually be prevented by care in the administration of intravenous fluids. Hypodermoclysis was occasionally resorted to instead of infusion, but the method was not looked upon with favor because of the possibility of introducing anaerobic organisms. In a few instances in which pulmonary edema appeared soon after operation, venesection was done, with apparent benefit. Preparations of digitalis by the parenteral route also seemed of benefit. These measures were resorted to on empirical grounds. Atropine was used according to the indications.

Although penicillin and sulfadiazine were given routinely as part of the prevention and treatment of pulmonary complications, pneumonias still developed in patients who were adequately treated by these agents. It was thought, although this was merely a clinical impression, that patients with pneumonic processes who did not respond to chemotherapy and antibiotic therapy, or who died under proper treatment, might have the so-called atypical variety of pneumonia.


208

NONPULMONARY COMPLICATIONS

Shock.-Shock was the most important of all postoperative complications (p. 119). Its correct incidence is undoubtedly greater than the figures suggest. The role it played in the case fatality rate in these 3,090 cases is shown by the fact that 64 percent (472) of all the deaths (737) were attributable to it. It was the most frequent cause of death in the first 48 hours after operation, and it was almost invariably fatal in the small number of patients in whom it persisted after this time.

The essentials of management were blood replacement, oxygen by nasal catheter or the Boothby mask, and careful analgesic medication administered with due care to prevent further depression. These measures were instituted as soon as the patient was seen and were continued after operation as long as necessary. When morphine was indicated, the dose was kept small, and it was preferably administered by the intravenous route.

Peritonitis.-Peritonitis of some degree existed a priori in all patients with perforations of hollow viscera. Its frequency can be estimated from the fact that injuries of this type were present in more than half of all cases in the series. The true ante mortem incidence of invasive bacterial peritonitis is not known. It existed in all degrees of virulence, sometimes in so mild a form that the diagnosis was merely academic and sometimes, at the other extreme, in such overwhelming contamination and infection that the patient died within a few hours. The great majority of patients who presented the usual clinical picture of ileus, abdominal tenderness, and fever recovered uneventfully, but 91 (12.3 percent) of all the deaths were due to this cause. The most effective measures in both prevention and therapy were decompression of the gastrointestinal tract and routine parenteral administration of sulfadiazine and penicillin.

Abdominal distention-Abdominal distention, whether as a manifestation of peritonitis or from other causes, was uncommon in this series, undoubtedly as the direct result of the routine practice of postoperative decompression of the gastrointestinal tract. Two- or three-bottle siphonage suction was used, by the Wangensteen method; discarded 1-liter flasks originally used for intravenous solutions were excellent for this purpose. The tube was usually left in place from 3 to 6 days. It was essential to leave it in situ until there was definite evidence of return of intestinal tonus and motility; most instances of distention followed its premature removal.

This simple method of preventing and controlling abdominal distention and subsequent ileus was chiefly responsible for the low incidence of a complication which, with its sequelae, had plagued military surgeons in earlier wars.

Intestinal obstruction-Mechanical intestinal obstruction was recorded in 21 cases, in all but 1 instance in patients with wounds of the small intestine (p. 250). The figure is probably correct; the condition is too serious a complication to be overlooked. Operation was performed in only 3 patients, all of whom survived; there were 7 deaths in the remaining 18 cases. Although


209

operation seems to have been withheld in some of the fatal cases because the patients were in precarious condition, a review of the records suggests that some of these lives might have been saved by a more aggressive policy of surgical intervention.

Incisional sepsis-Minor degrees of incisional sepsis, which were seldom recorded, were not uncommon. Major sepsis was infrequent, the 32 recorded cases representing approximately 1 percent of the whole series.

The best method of preventing wound infection was found to be the routine drainage of subcutaneous tissues. It became the established practice to accomplish this by the following technique: A thin strip of fine-mesh gauze or a small bandage was laid longitudinally in the incision, before the skin was closed, so as to keep the cutaneous margins and subcutaneous fat separated. The skin sutures were then tied loosely across it. The gauze was left in place until the second or third day. It was the clinical impression that drainage of subcutaneous fat, which was particularly vulnerable to infection, materially expedited healing by first intention.

Because the incisions used for abdominal wounds were almost always potentially infected, it was necessary to change the dressings and inspect the wounds more frequently than is customary in civilian practice. Surgical drainage was instituted promptly whenever suppuration developed.

Wound dehiscence-The incidence of wound dehiscence was higher in this series than in civilian practice, for reasons outlined elsewhere (p. 196). Prompt resuture was the treatment of choice.

Gastrointestinal fistula-The 23 instances of gastrointestinal fistula recorded in this series represent a relatively small incidence in view of the large number of perforations of hollow viscera. It is likely that additional fistulas were observed after the patients were evacuated, since this is frequently a somewhat delayed development.

Gastrointestinal fistulas, while they did not represent immediate emergencies, were considered an indication for priority of evacuation to fixed hospitals, where more adequate therapeutic facilities were available than in field and evacuation hospitals. The basis of treatment was to provide the patient with maximum nutritional support and to employ gastrointestinal decompression whenever this measure was indicated.

Intraperitoneal abscess-The 15 subhepatic or subphrenic abscesses and the 9 pelvic abscesses recorded in this series represent an incidence of slightly less than 1 percent. This is not excessive, in view of the type of wounds treated and the fact that this is another complication which probably presented itself in a number of other cases after evacuation. The treatment was surgical drainage.

Anaerobic infections-Clostridial infections of the abdomen were encountered after operation only eight times. Death occurred in every instance. In five cases, the retroperitoneal space was infected. In the other three cases, the process involved the abdominal wall, and en bloc excision of the entire rectus abdominis muscle on one side was followed by wound dehiscence.


210

Treatment always included massive doses of polyvalent anti-gas-gangrene sera, in addition to penicillin and sulfadiazine in large doses.

Secondary hemorrhage-Only eight instances of secondary hemorrhage were recorded. There is no doubt that moderate bleeding, such as might occur after removal of a pack from the liver, took place in many other cases but was not recorded. In 2 of the 8 cases, the bleeding was from remote vessels, in 1 instance an intercostal artery and in 1 instance the femoral artery. In the other 6 cases, the hemorrhage was from sutured gastric wounds (p. 230).

These six cases comprise the only recorded instances of gastrointestinal bleeding, which is probably to be explained by the fact that, although a very large number of gastrointestinal repairs were carried out, the operations were chiefly on the small intestine, in which suture lines are less likely to bleed than suture lines in the colon. The policy of exteriorization of wounds of the colon thus not only protected the patient against necrosis and leakage but apparently reduced the risk of postoperative hemorrhage as well.

Thromboembolism-The 22 instances of proved or suspected pulmonary embolism, 21 of which were fatal, must be considered as merely an approximation, since autopsies were not performed in at least 40 percent of all deaths. Nonfatal emboli undoubtedly occurred, but they were either not diagnosed or not recorded. Nonfatal thrombophlebitis and phlebothrombosis were recorded only five times but were probably much more frequent.

In the majority of cases in which emboli were shown to have originated in the veins of the leg, there had also been wounds in the involved extremities. In one instance, the autopsy showed the source of the embolus to be the right external and common iliac veins. This particular patient had sustained a wound of the pelvis, with perforation of the bladder and extensive extraperitoneal trauma, and the surgeon, because of the evidence of severe damage near the great vessels in the right side of the pelvis, debated at operation the propriety of prophylactic interruption of the right common iliac vein, even though it had not been directly traumatized. Unfortunately, he did not act affirmatively on his premonition of trouble, and the man lost his life.

Prophylactic or therapeutic interruption of the femoral veins was employed only occasionally in this series of abdominal injuries. This prophylactic procedure should probably have been employed more frequently, in view of the apparent tendency for an embolism to arise in a wounded extremity, especially when an associated abdominal wound increased the hazard. This was particularly true when, as was usually the case, the limb had to be immobilized in plaster of paris, which not only compounded the risk of thromboembolism but also precluded frequent examinations for the detection of postoperative phlebothrombosis. The case history just related also indicates the importance of giving serious consideration to ligation of the great veins of the pelvis when trauma to adjacent tissues has occurred.

Since the anticoagulant drugs (heparin, Dicumarol (bishydroxycoumarin, U. S. P.)) were not available in field hospitals, no comment can be made on their efficacy in the treatment of thromboembolism. It can be said, however,


211

that in many abdominal injuries their employment would be both difficult and dangerous. They would certainly be contraindicated in wounds of the liver or in associated wounds of the soft tissues, lung, or head, because of the risk of hemorrhage. Even in future wars, it is doubtful that heparin could be made available in adequate quantities and equally doubtful that adequate facilities could be provided for the use of Dicumarol under field conditions. For these reasons, if needless fatalities from pulmonary embolism are to be prevented, it would seem that the military surgeon of the future must be well versed in the indications for, and techniques of, prophylactic interruption of the femoral veins.

Anuria.-Anuria (posttraumatic renal failure, lower nephron nephrosis, pigment nephropathy) was recorded in 36 cases in this series, 35 of which were fatal. Very little, was known about this complication early in the war, and there is no doubt that the diagnosis was overlooked at that time. With increasing experience, however, surgeons became aware of its frequency and its dangers and were even able to predict that it might develop in certain cases.

There were four major warning signs of impending renal failure:

1. While it was insidious in onset and usually could not be diagnosed positively until the third or fourth postoperative day, it was particularly likely to occur in the most severely wounded men, particularly when shock had been profound and of long duration. Earlier than the third day, renal failure could not be distinguished from the physiologic oliguria which accompanied shock and which might persist for 48 hours after operation.

2. Renal failure was a possibility whenever diuresis did not occur at the end of this time and the patient, if he was out of shock, continued to be oliguric. It was thus of prime importance to measure the daily volume of urine accurately. Once shock had been controlled and the blood pressure was tending to a normal level, a 24-hour output of urine of less than 700 cc. was an ominous sign.

3. Hypertension was the next warning sign. With developing renal failure, there was usually a slow increase in the blood pressure, which sometimes climbed to 180/120 mm. Hg.

4. Azotemia was another sign of impending trouble. It was not uncommon immediately after operation, when the nonprotein nitrogen level of the blood might reach 80 mg. percent. Usually, however, the value returned to normal on or about the second postoperative day, when diuresis occurred. Persistent or increasing azotemia after this time usually meant impending anuria. The nonprotein nitrogen of the blood was readily determined under field conditions by the copper sulfate method.

The treatment of renal failure was chiefly under the direction of the Board for the Study of the Severely Wounded, as a research project, and extensive details are contained in the report of that group.1 Results were disheartening. While management was not standardized, the general plan was to restrict

1Medical Department, United States Army, Surgery in World War II. The Physiologic Effects of Wounds. Washington: U. S. Government Printing Office, 1952.


212

fluid allowances to 1,000 cc. or less for the 24-hour period, this being the minimum required to compensate for insensible fluid losses. Salt was withheld entirely. The purpose of these restrictions was to prevent the pulmonary edema which was common in these cases. The urinary output was accurately measured by means of an indwelling catheter. Diuretics, including ethanol (5 percent) by vein, were tried but proved of little help. Alkalinization of the urine with salts of lactic acid was also tried but was later abandoned as useless and dangerous; renal block prevented the desired effect, and serious alkalosis resulted. Peritoneal lavage was equally ineffective.

Miscellaneous complications-Other complications, most of which were fatal, were recorded only occasionally. According to the clinical charts, urinary fistula occurred 6 times; fat embolism, 4 times; acute gastric dilatation, 3 times; and vesicorectal fistula, acute noncontagious parotitis, acute nonspecific orchitis, encephalomalacia following ligation of the common carotid artery, meningitis secondary to spinal cord injury, cerebral infarct, anaphylactic shock following the use of intravenous protein hydrolysate, cachexia associated with ileostomy, and air embolism, in 1 case each.

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