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A report of postoperative pulmonary complications
A
POSTOPERATIVE
REPORT
OF
PULMONARY
JAMES N.
M.D.,
COOMBS,
PHILADELPHIA,
A
I
ANESTHETIC AGENTS USED AND LUNG COMPLICATIONS WITH EACH TYPE OF ANESTHESIA
Anesthetic
SpinaI
Number of Lung CompIications
Number
Recovered
Died
.. ......
SpinaI and gas or ethe~<~~~-.~z
l-1 Gas-oxygen
.
Ether.
-___
..
I65
ChIoroform. LocaI.. Avertin.
-I
1 2542 /
and ether.
-I-
I
/
..
1
I
~~-
___.
. .
During this period there were 13 proved postoperative puImonary compIications incIuding 8 cases of pneumonia, 2 cases of ateIectasis, 2 cases df puImonary emboIism and one case of accidenta pleura1 effusion. SeasonaI inffuence seemed to pIay a smaI1 part, as there was onIy one case of * From the Senior SurgicaI Service TempIe__ University ._Hospital,
P.A.C.S.
PA.
pneumonia that couId be traced to epidemic infections of the winter months. From the standpoint of age, eight compIications occurred in patients between fifty-five and eighty-four years of age. The compIications resuIting in recovery were: one case of ateIectasis, in a patient fifty-five years of age, and one case of pneumonia in a patient aged twenty-two. The compIications resuIting in death were eIeven. In anaIyzing this group of cases, a11 deaths occurred in bad risk patients, viz.; patients suffering from severe infections, cardiovascuIar disease, asthenic seniIe types and carcinoma. Six of the 7 pneumonia cases recorded were of the termina1 type preceding death, in most instances verified by autopsy. There are two Iung compIications in the series that deserve specia1 mention. AteIectasis occurred in a femaIe aged fifty-five, upon whom a choIecystostomy had been done for empyema of the gaI1 bIadder. The patient had been iI for fit;e days, was dehydrated and showed some evidence of cardiac decompensation. Local anesthesia was used unaided. No narcotic was administered. The duration of the operation was one hour. ImmediateIy on return to bed from the operating room, cyanosis, cough and Iabored breathing was noted. Examination of the chest reveaIed tota absence of breath sounds in the Ieft chest, with over-breathing on the right side. Carbon dioxide and oxygen inhaIations were ordered, with improvement in coIor. X-ray examination showed coIIapse of the left Iung with dispIacement of the heart and mediastinum to the Ieft. Carbon-dioxide and oxygen inhaIations were continued for forty-eight hours with
of the postoperative puImonary compbcations in the TempIe University HospitaI during the past fourteen months has been made to determine their frequency and cause. On the various surgica1 services, $394 operations have been performed from JuIy I, 193 I to October I, 1932, excIuding bIood transfusions and artificia1 pneumothorax cases. STUDY
TABLE
COMPLICATIONS*
Hospital.
October 428
Read before the Staff of Temple
14, 1932.
University
NEW
Coombs-PuImonary
SERIES Var. XXI, No. 3
rather rapid improvement. X-ray nation of the chest, ten days Iater, recovery.
CompIications
examishowed
AND
TYPE
OF
OPERATION
Pneumonia
EmboIism
Operation
PIeuraI Effusion
-1.
Recovery
Gall bladder..
429
of SUQX~Y
II
COMPLICATIONS
AteIectasis
JOUI~
to the right. Sixteen ounces of fluid were aspirated from the Ieft pIeura1 cavity. The chiId died three days Iater from
TABLE SUMMARY OF LUNG
A mrrican
.
.
Death
Recovery
Death
..
..
2
,
..
I
..
I
. .
I
.
.
..
I
..
.. ____ ..
I
. ..
Stomach........................
Death
/ Recovery
I
-
Appendectomy.
.
Laryngectomy
...
Death
I __
I
..
Recovery
I
._
. .
I
-____
Radical operation neuralgia,
for
trigeminal
.
.I.
Prostatectomy
_______~_ Ludwig’s
.-_____ Hernia.
angina..
.
--__
-I-
I-
I
I-----
~-
_I.
.
.
...
Amputation of leg for ununited fracture of femur..
.
..
I
..
..
-~----I
.
The second interesting compIication occurred in a boy, tweIve years of age, who had been operated upon for perforative appendicitis with peritonitis under The patient was respina anesthesia. ceiving continuous hypodermocIysis of 2 per cent gIucose in saIine solution in both pectora1 regions. Six days after operation, the resident was hurriedIy caIIed to see the patient, who was having diffIcuIty in breathing and crying aIoud with pain. It was noted that IOOO C.C. of soIution had been taken in Iess than one hour, without engorgement of the tissues, and that the Ieft chest was flat on percussion, with absence of breath sounds. BeIieving that Auid had entered the pIeura1 cavity, an emergency x-ray examination was ordered, which showed a Iarge amount of fIuid in the Ieft pIeura1 cavity, with the heart and trachea dispIaced nearIy 3 cm.
..
sepsis due to and peritonitis. STATISTICS
I
.
perforative
FROM
OTHER
appendicitis
HOSPITALS
Lyons, l reporting upon 66 19 operations under genera1 anesthesia in the Presbyterian HospitaI, Chicago, covering a period from 1921 to 1930, noted that puImonary compIications occurred in 63 patients. Pneumonia occurred in 29 patients, bronchitis in 21. There were no cases of postoperative ateIectasis diagnosed. Sixty-one and nine-tenths per cent deveIoped Iung compIications in the winter months; 34.9 per cent of compIications foIIowed upper abdomina1 operations. FuIIer2 anaIyzed the surgica1 records of the University CoIIege HospitaI, London, for the year 1927 and found 121. puImonary sequeIae in 1478 cases, a percentage of 8.3; the mortaIity was 1.8 per cent. There
430
American Journal of Surgery
Coombs-PuImonary
were 74 cases of bronchopneumonia, a Iarger number, he pointed out, than in any of the recentIy pubIished series. The series contains g cases of infarction; this compIication, he says, never occurs before the seventh day. Sise,3 after compiIing statistics of severa observers incIuding Brunn and BriII, Foss and Kupp and others, showed that the percentage of compIications are practicaIIy the same under spinai or ether anesthesia for a11 types of operations. Sise then combined statistics of these observers incIuding those of the Lahey CIinic and found that for upper abdomina1 operations under spina or gas anesthesias, twice as many compIications occurred under ether anesthesia. For Iower abdomina1 operations no practica1 difference was noted between the two anesthetics. ETIOLOGY
It is evident that respiratory compIications foIIow a11 types of anesthetics. MikuIicz has said that Iung compIications occur as frequentIy after IocaI as after genera1 anesthesia. In this report 30 per cent of compIications occurred with IocaI anesthesia. It is apparent that the severity of disease and the operation are the main factors in the production of Iung compIications. Other probabIe causes as outIined by Lyons] are pre-existing cardiac or puImonary disease; poor mouth hygiene; cooIing-off of the patient; aspiration of stomach contents; decrease in expectoration and poor ventiIation of the bases because of pain; disorganization of the abdomina1 pump mechanism by an abdomina1 incision producing a tendency to stasis in the spIanchnic vesseIs which predisposes to thrombosis; and pneumostasis from the patient Iying continuaIIy in the dorsa1 position. In her experience
CompIications
SEPTEMBER,
,933
bronchitis is more IikeIy to occur in heavy smokers than in those who do not smoke or smoke onIy moderateIy. Foss and Kupp4 beIieve that emboIism pIays the chief part in the production of most of these complications. They affirm that infarctions (minor emboIi) are far more common than has been generaIIy supposed. Many theories have been advanced and much experimentation has been done by the group beIieving that most compIications are ateIectatic in origin. Their concIusions are IargeIy drawn from upper abdomina1 operations where the respiratory mechanism is pIaced under a distinct handicap. It is in this type of case that the untoward effects, as pointed out by BriII and others5 may be counteracted in part by carbon dioxide and oxygen inhaIations. COMMENT
For a11 types of patients it seems that individua1 care before, during, and after the operation is paramount. As a coroIIary it seems that the shortest operation, the Ieast handIing of tissues, the maintenance of body heat, and support to the circuIation are a11 important issues to be considered in fortifying patients against these compIications. When compIications do arise, the earIy recognition by a11 avaiIabIe diagnostic aids is to be sought for, so that appropriate treatment may Ibe instituted. REFERENCES I. LYONS. Surg. Gynec. Obst., 55: 162, 1932.
2. Quoted by Lyons.’
3. SISE. Anestb. FY Anal., I I: 23-28, 1932. 4. Foss and KUPP. Surg. Gynec. Obst., 5 I : 798, 1930. 5. BRILL et aI. J. Tborac. Surg., I : 243~26g. 1932.
POSTOPERATIVE
REPORT
OF
PULMONARY
JAMES N.
M.D.,
COOMBS,
PHILADELPHIA,
A
I
ANESTHETIC AGENTS USED AND LUNG COMPLICATIONS WITH EACH TYPE OF ANESTHESIA
Anesthetic
SpinaI
Number of Lung CompIications
Number
Recovered
Died
.. ......
SpinaI and gas or ethe~<~~~-.~z
l-1 Gas-oxygen
.
Ether.
-___
..
I65
ChIoroform. LocaI.. Avertin.
-I
1 2542 /
and ether.
-I-
I
/
..
1
I
~~-
___.
. .
During this period there were 13 proved postoperative puImonary compIications incIuding 8 cases of pneumonia, 2 cases of ateIectasis, 2 cases df puImonary emboIism and one case of accidenta pleura1 effusion. SeasonaI inffuence seemed to pIay a smaI1 part, as there was onIy one case of * From the Senior SurgicaI Service TempIe__ University ._Hospital,
P.A.C.S.
PA.
pneumonia that couId be traced to epidemic infections of the winter months. From the standpoint of age, eight compIications occurred in patients between fifty-five and eighty-four years of age. The compIications resuIting in recovery were: one case of ateIectasis, in a patient fifty-five years of age, and one case of pneumonia in a patient aged twenty-two. The compIications resuIting in death were eIeven. In anaIyzing this group of cases, a11 deaths occurred in bad risk patients, viz.; patients suffering from severe infections, cardiovascuIar disease, asthenic seniIe types and carcinoma. Six of the 7 pneumonia cases recorded were of the termina1 type preceding death, in most instances verified by autopsy. There are two Iung compIications in the series that deserve specia1 mention. AteIectasis occurred in a femaIe aged fifty-five, upon whom a choIecystostomy had been done for empyema of the gaI1 bIadder. The patient had been iI for fit;e days, was dehydrated and showed some evidence of cardiac decompensation. Local anesthesia was used unaided. No narcotic was administered. The duration of the operation was one hour. ImmediateIy on return to bed from the operating room, cyanosis, cough and Iabored breathing was noted. Examination of the chest reveaIed tota absence of breath sounds in the Ieft chest, with over-breathing on the right side. Carbon dioxide and oxygen inhaIations were ordered, with improvement in coIor. X-ray examination showed coIIapse of the left Iung with dispIacement of the heart and mediastinum to the Ieft. Carbon-dioxide and oxygen inhaIations were continued for forty-eight hours with
of the postoperative puImonary compbcations in the TempIe University HospitaI during the past fourteen months has been made to determine their frequency and cause. On the various surgica1 services, $394 operations have been performed from JuIy I, 193 I to October I, 1932, excIuding bIood transfusions and artificia1 pneumothorax cases. STUDY
TABLE
COMPLICATIONS*
Hospital.
October 428
Read before the Staff of Temple
14, 1932.
University
NEW
Coombs-PuImonary
SERIES Var. XXI, No. 3
rather rapid improvement. X-ray nation of the chest, ten days Iater, recovery.
CompIications
examishowed
AND
TYPE
OF
OPERATION
Pneumonia
EmboIism
Operation
PIeuraI Effusion
-1.
Recovery
Gall bladder..
429
of SUQX~Y
II
COMPLICATIONS
AteIectasis
JOUI~
to the right. Sixteen ounces of fluid were aspirated from the Ieft pIeura1 cavity. The chiId died three days Iater from
TABLE SUMMARY OF LUNG
A mrrican
.
.
Death
Recovery
Death
..
..
2
,
..
I
..
I
. .
I
.
.
..
I
..
.. ____ ..
I
. ..
Stomach........................
Death
/ Recovery
I
-
Appendectomy.
.
Laryngectomy
...
Death
I __
I
..
Recovery
I
._
. .
I
-____
Radical operation neuralgia,
for
trigeminal
.
.I.
Prostatectomy
_______~_ Ludwig’s
.-_____ Hernia.
angina..
.
--__
-I-
I-
I
I-----
~-
_I.
.
.
...
Amputation of leg for ununited fracture of femur..
.
..
I
..
..
-~----I
.
The second interesting compIication occurred in a boy, tweIve years of age, who had been operated upon for perforative appendicitis with peritonitis under The patient was respina anesthesia. ceiving continuous hypodermocIysis of 2 per cent gIucose in saIine solution in both pectora1 regions. Six days after operation, the resident was hurriedIy caIIed to see the patient, who was having diffIcuIty in breathing and crying aIoud with pain. It was noted that IOOO C.C. of soIution had been taken in Iess than one hour, without engorgement of the tissues, and that the Ieft chest was flat on percussion, with absence of breath sounds. BeIieving that Auid had entered the pIeura1 cavity, an emergency x-ray examination was ordered, which showed a Iarge amount of fIuid in the Ieft pIeura1 cavity, with the heart and trachea dispIaced nearIy 3 cm.
..
sepsis due to and peritonitis. STATISTICS
I
.
perforative
FROM
OTHER
appendicitis
HOSPITALS
Lyons, l reporting upon 66 19 operations under genera1 anesthesia in the Presbyterian HospitaI, Chicago, covering a period from 1921 to 1930, noted that puImonary compIications occurred in 63 patients. Pneumonia occurred in 29 patients, bronchitis in 21. There were no cases of postoperative ateIectasis diagnosed. Sixty-one and nine-tenths per cent deveIoped Iung compIications in the winter months; 34.9 per cent of compIications foIIowed upper abdomina1 operations. FuIIer2 anaIyzed the surgica1 records of the University CoIIege HospitaI, London, for the year 1927 and found 121. puImonary sequeIae in 1478 cases, a percentage of 8.3; the mortaIity was 1.8 per cent. There
430
American Journal of Surgery
Coombs-PuImonary
were 74 cases of bronchopneumonia, a Iarger number, he pointed out, than in any of the recentIy pubIished series. The series contains g cases of infarction; this compIication, he says, never occurs before the seventh day. Sise,3 after compiIing statistics of severa observers incIuding Brunn and BriII, Foss and Kupp and others, showed that the percentage of compIications are practicaIIy the same under spinai or ether anesthesia for a11 types of operations. Sise then combined statistics of these observers incIuding those of the Lahey CIinic and found that for upper abdomina1 operations under spina or gas anesthesias, twice as many compIications occurred under ether anesthesia. For Iower abdomina1 operations no practica1 difference was noted between the two anesthetics. ETIOLOGY
It is evident that respiratory compIications foIIow a11 types of anesthetics. MikuIicz has said that Iung compIications occur as frequentIy after IocaI as after genera1 anesthesia. In this report 30 per cent of compIications occurred with IocaI anesthesia. It is apparent that the severity of disease and the operation are the main factors in the production of Iung compIications. Other probabIe causes as outIined by Lyons] are pre-existing cardiac or puImonary disease; poor mouth hygiene; cooIing-off of the patient; aspiration of stomach contents; decrease in expectoration and poor ventiIation of the bases because of pain; disorganization of the abdomina1 pump mechanism by an abdomina1 incision producing a tendency to stasis in the spIanchnic vesseIs which predisposes to thrombosis; and pneumostasis from the patient Iying continuaIIy in the dorsa1 position. In her experience
CompIications
SEPTEMBER,
,933
bronchitis is more IikeIy to occur in heavy smokers than in those who do not smoke or smoke onIy moderateIy. Foss and Kupp4 beIieve that emboIism pIays the chief part in the production of most of these complications. They affirm that infarctions (minor emboIi) are far more common than has been generaIIy supposed. Many theories have been advanced and much experimentation has been done by the group beIieving that most compIications are ateIectatic in origin. Their concIusions are IargeIy drawn from upper abdomina1 operations where the respiratory mechanism is pIaced under a distinct handicap. It is in this type of case that the untoward effects, as pointed out by BriII and others5 may be counteracted in part by carbon dioxide and oxygen inhaIations. COMMENT
For a11 types of patients it seems that individua1 care before, during, and after the operation is paramount. As a coroIIary it seems that the shortest operation, the Ieast handIing of tissues, the maintenance of body heat, and support to the circuIation are a11 important issues to be considered in fortifying patients against these compIications. When compIications do arise, the earIy recognition by a11 avaiIabIe diagnostic aids is to be sought for, so that appropriate treatment may Ibe instituted. REFERENCES I. LYONS. Surg. Gynec. Obst., 55: 162, 1932.
2. Quoted by Lyons.’
3. SISE. Anestb. FY Anal., I I: 23-28, 1932. 4. Foss and KUPP. Surg. Gynec. Obst., 5 I : 798, 1930. 5. BRILL et aI. J. Tborac. Surg., I : 243~26g. 1932.