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The local use of ice after orthopedic procedures
THE LOCAL USE OF ICE AFTER ORTHOPEDIC PROCEDURES* HOWARD J. SCHAUBEL, M.D.? GRAND RAPIDS, MICHIGAN
I
T is the purpose of this paper to point out the benefits of IocaIIy apphed coId in orthopedic surgery. Ice takes up heat rapidIy from its surroundings. When the IocaI temperature of a part is reduced, the tissue metaboIism is decreased, the IocaI bIood suppIy is diminished and sensory end organs are duIIed. According to Jensen,’ the range of temperature in storage ice destructive for certain bacteria is from - 2’~. to -5’~. (28.4”F. to 23°F.). This range of temperature is considered to be germicidal for some bacteria. At Iower temperatures, down to that of Iiquid air, bacteria Iike the typhoid baciIIus remain viabIe nineteen months or Ionger. According to BaIdyreva,2 the temperature of natura1 ice varies between o’c and -5’~. (32’~, and 23’~). Fay and Henny3 in their monograph demonstrated the benefits of IocaI ice appIication for the reIief of pain in metastatic carcinoma. They pointed out that this method of refrigeratron when appIied to the area of metastatic invoIvement brought about prompt reIief of pain as we11 as temporary improvement in the genera1 nutrition of the patient. Krieg4 has used ice postoperativeIy on the breast, abdomen and neck, and states that the temperature induced by the application of ice caps is 6”~. (42°F.). In Krieg’s opinion his patients had Iess postoperative discomfort, required fewer narcotics and had fewer postoperative compIications when ice packs were used. AIIen’s5 experimenta work in the use of ice indicates that reduction in IocaI temperature in the Iigated Iegs of rats reduces the danger as regards both gangrene and
shock. He states that in the rat “whenever the temperature can be effrcientIy maintained at 2’~. the Iimbs can survive asphyxia for a Iong period, the maximum of which has not been estabIished but which is certainIy more than fifty hours.” In a Iater paper6 he points out that “If an operation, shockIess in itseIf, has Ieft damaged tissues which may set up postoperative shock, this danger can be bridged by temperature contro1. Shock production by tissues is inhibited in proportion as their temperature is reduced.” When threatening signs of Ioss of vitaIity in skin or other tissues appear, the bIood suppIy cannot be increased effectiveIy, but the metaboIism can be cut down by reducing the IocaI temperature, which in turn decreases the demand for oxygen and nutrition. AIIen mentions that heaIing in the presence of ice is adequate and firm and that the danger of thrombosis is minimized. EXPERIMENTAL In order to determine the faI1 of temperature inside a pIaster cast when ice is appIied to the outside, Ieg and arm cyIinders of varied thicknesses were prepared of pIaster of paris roIIs and sheet cotton. In each case the casts were removed in fifteen minutes, fitted together and held with an additiona Iayer of pIaster. A Fahrenheit thermometer was pIaced inside the empty cyIinder and the cyIinder ends pIugged with gauze. Two covered ice bags were then wrapped on the cyIinders and heId in pIace with bandage. It was found repeatedIy that within two hours the temperature inside the cast dropped to 40°F., and within three hours after the application of the ice caps to 33’~.
* From the Orthopedic Division, Department of Surgery, Duke University SchooI of Medicine, Durham, t Aided by a Grant from the National Foundation for Infantile ParaIysis, Inc. 7x1
N.C.
American
7 I2
SchaubeI-Ice
Journal of Surgery
and Orthopedic
By refiIIing the ice bags every seven hours the temperature inside the empty cyIinder couId be maintained at from 32’~. to 34’~. TABLE SURGICAL
Type
Cases with Ice
No. o Casts
vo. 0
... .
CELL
COUNTS
HOURS
30 2
43 28
30 13 57 17 * 20 6
82 4 51 25 72 58 : 60
.
APplied
Split
39 4
White
Blood Count
Cell
II
of casts
36 6
2
43
19
479
-
OF
SEVENTY-
wth
Elevations
132 42.3% -
APPLICATION
ImmediateIy postoperativeIy the cIoth covered ice bags are applied directly to the pIaster or soft bandage over the operative site. A suffxcient number of ice caps shouId
Third Postoperative Day
Icei Icei Ice
Ice
\No
jNo Ice
140
9
40
4
21
15 5
2 0
17 2
1 0
5 I
160
II
59
5
27
33.4%
3.181
1.4%
5.6%
I 0 --__-_____
By pIacing a thermometer beneath soft bandage dressings, directIy upon the skin of patients on whom ice was used postoperativeIy it was found that the temperature dropped to 44’~. within two hours and to 41’~. within four hours. The temperature couId be maintained at 41’~. therafter if the ice caps were refiIIed every six hours. In an extremity sheet cotton and pIaster cast a thermometer when pIaced next to the skin was found to remain at 41’~. if covered ice bags were wrapped snugIy onto the cast and refiIIed every six hours. The temperature at the hip or shouIder beneath a pIaster spica couId not be heId Iower than 50’~. The method has not been used in the postoperative care of spine fusion cases. METHOD
of Patients
INo
42
72 58
5 ,314 -
FIRST
First Postoperative Day
Ice
7 0 0
-_ 207
THE
OPERATION
f
42 22 0
345
AFTER
No.
of ,casts ,No. Casts 0
II
DURING
Ice
-
2.4%
Totals Percentage split..
BLOOD
--
66 2
57 18 8 20 28
Cases without
1vo.
Kneesurgery.... Wrist fusions.. Foot surgery.. Hip surgery., Fractures.. Tendon surgery Shoulder surgery Bone grafts. Tumors.. Sequestrectomles and ssucerizatmns. Osteotomies. Mampulatmns. Nerve surgery.. Elbow fusions Amputations
T
WHITE
CASTS
TWO
Jo. of 3ases
APplied
3ases
PLASTER
,946
be used to surround the extremity compIeteIy at the operative site. When used on the extremity the bags can be heId in place TABLE
AND
-
of Surgery
NOVEMBER,
I
PROCEDURES
I
Surgery
12.3%
by eIastic bandages. On the hip or shouIder cases scuhetus binders may be used. The ice caps are refiIIed every four hours and are used for forty-eight hours postoperativeIy. The accumuIated air in the ice caps shouId be reIeased at hourIy intervaIs to aIIow them to hug the cast snugIy. RESULTS
Eight hundred twenty-four consecutive cases have been studied. FoIIowing surgery or manipuIation ice caps were used on 345 patients; ice was not used on 479 patients. TabIe I Iist the types of procedures incIuded in this series. In those patients on whom ice was used postoperativeIy 207 pIaster casts were appIied. EIeven (5.31 per cent) of these casts had to be spIit because of pain, sweIIing or other signs of circulatory embarrassment. AI1 eIeven casts were spIit within the first seventy-two hours. In contrast, of the 3 I 2 casts appIied when no ice was used, 132 (42.3 per cent) had to be spIit within seventy-two hours. Of the patients treated with ice on whom postoperative white bIood ceI1 counts were done, 12.4 per cent showed white bIood cel1 counts of over 10,000 on the first postoperative day, 3.18 per cent on the second postoperative day and 1.4 per cent on the
VOL.LXX&
No. 5
Schaubel-Ice
and Orthopedic
third day. Of the patients not treated with ice on whom postoperative white blood cell counts were done, 33.4 per cent showed white blood celI counts of over 10,000 on the first postoperative day, 12.3 per cent on the second postoperative day and 5.64 per cent on the third day. TABLE III TEMPERATURE, PCLSE AND RESPIRATION DURING THE FIRST SEVENTY-TWO HOURS AFTER OPERATION
I
Am&can
Surgery
of Surgery
7 I3
When no ice was used postoperativeIy sixty (12.5 per cent) patients deveIoped complications such as ileus, circuIatory embarrassment, thrombophIebitis, etc., severe enough to warrant special attention. When ice was used, nineteen (5.5 per cent) patients developed complications severe enough to demand special attention. TABLE POSTOPERATIVE
No Ice
Ice
Journal
IV COMPLICATIONS
of Cases
No.
Complication EIevation
No.
of
Percent-
Cases if:_
1
!
No. of Cases
vation
Percentage Elevation
________ Temperature higher than 38.3%. Pulse rate over I If per minute. . . Respiratory rate greater than zo per minute.
39
II
3
III
23.18
39
II
3
120
25.05
70
14.6
2.6
9
-
-
The postoperative temperature, p&e and respiration have remained nearer norma1 in those patients on whom ice was used. In the group in which ice was not used, I I I (23.1 per cent) patients had temperature elevations of 38.3’c. (IoI’F.) or over for the first seventy-two hours postoperatively. Of the 345 cases in which ice was used, thirty-nine (I 1.3 per cent) had a temperature elevation over 38.3”~. for the immediate seventy-two hours postoperatively. A pulse rate of over I 15 per minute for at least three postoperative days was noted in 120 (25.0 per cent) patients out of the group in which cooling was not used. When ice was used, thirtynine (I I .3 per cent) cases showed a p&e rate over I 15 per minute in the seventytwo-hour period after surgery. The respiratory rate was found to run higher than 20 per minute for seventy (14.6 per cent) patients where ice was not used. When ice was used, nine (2.6 per cent) cases had a respiratory rate of over 20 for the first three postoperative days.
No
Ice
Gangrene Woundslough.: 1: :.‘:::” Gastrointestinal upset. Paralytic ileus.. Wound break down. Hematoma or hemarthrosis ThrombophIebitis
___________-_
TotaI Percentage
Ice
2 0
4 II
3 0 0
__-
/
2 I7 12
9 16 2 60 r2.57;
A survey of the average of tota amount of narcotic used by each patient for the seventy-two hour period foIlowing surgery is given in Table v. The figures were arrived at as foIIows: the type and amount of narcotic taken by each patient during the postoperative period and the quantity used by a11 patients having a similar type of surgery was computed. This Iatter amount was then divided by the total number of patients in each category. A subjective factor was repeatedIy demonstrated by the patients who received local applications of ice to the operative site. Voluntary comments concerning the reIative comfort when ice was used about the operative site were gratifying. When ice was discontinued after the first forty-eighthour postoperative period, frequentIy the patient asked that it be repIaced because of the relief of pain which it afforded. The patient upon whom ice was used rested more comfortabIy, took fluids with greater ease and demonstrated a norma appetite
7 I4
AmericanJournalof Surgery
SchaubeI-Ice
and Orthopedic
Surgery
NOVEMBER,1946
TABLE V AVERAGE*
OF TOTAL
AMOUNT
OF NARCOTICS AFTER
-
I
REQUIRED
T Codeine mgm .
FIRST
Morphine mgm.
Panto-
6.0
30.3 360.5 98.0
fs::
3.1
5.0 ‘5. I 2.3 10. I I.0
5.3
mgm.
20.0
89.2 I.4
I _-
13.9
I.2
11.8
7.7
195.0 250.5 115.0
12.5
75.7
I.9
zig.0
_-
--
.26
,004
Pantopon mgm.
100.0 19.6 26.5
23.4 9.2 30.5 15.0 18.3 15. I 26 o 6.0
firs.3 162.4
,001
3.8 .06
mgm.
36.4 30.0 28.4 62.6
249.3 406.0
2.8
.-
Ilemerc )I -.
256.0 610.5 260.0 240.6 204.0
2.8
20.0
1.5 60.0
-
--
27.0
13.
Ice
Morphine mgm.
ICodeine
pon mgm.
--
8.5 15.0 14.0 18.4
HOURS
Cases without
1Demero mgm.
76.5 360.0 70.4 70.7 48.6
49.7 72.0 41.3
SEVENTY-TWO
-
._
Average per case ................ Average dosage in grains per case
THE
Cases with Ice
Type of Surgery
Knee surgery ................ Wrist fusions. ................ Footsurgery ................. Hipsurgery ..................... Fractures ....................... Tendon surgery ................ Shoulder surgery ................ Bone grafts. ................... Tumors. ................... ... Sequestrectomies and saucerizations Osteotomies. ................ Manipulations. ................. Nervesurgery .................. Elbowsurgery .................. Amputations. ...................
DURING
OPERATION
.-
268.5 4.2
50.8
16.4
6.0
_-
.4
-
-_ 12.0
25. I
. ‘9
-
* The figures were arrived at as fohows: The type and amount of narcotic taken by each patient during the postoperative period, and the quantity used by all patients having a simiIar type of surgery was computed. This Iatter amount was then divided by the tota number of patients in each category. As a rule, codeine was given in doses of 60 mg., morphine 12 mg., demerol 50 mg. and pantopon 15 mg. -
sooner foIIowing surgery than when no ice was used. The entire convaIescent period of a11 patients on whom ice has been used has been satisfactory. CONCLUSIONS
The skin temperature beneath soft dressings or under padded pIaster casts can be reduced by the IocaI appIication of covered ice bags. On 345 patients when ice was used IocaIIy : in the seventy-two-hour period foIIowing surgery fewer casts were spIit; the temperature, puIse and respiration were Iower; white bIood ceI1 counts were nearer normaI; postoperative compIications were fewer; and the amount of narcotic per patient was reduced. SubjectiveIy, the patients who have ice appIied IocaIIy fare better in a11 respects
-
than the patients who have no ice appIication during the postoperative period. The postoperative use of ice appIied IocaIIy to the operative site is a vaIuabIe adjunct in the treatment of surgical patients. REFERENCES I.
2.
3.
4. 5.
6.
L. B. The bacterioIogy of ice. Food Research, 8: 265-272, 1943. BALDYREVA. Quoted by Jensen from Tanner, F. W. Microbiology of Foods. Champaign, IIIinois, 1932. Twin City Printing Co. FAY, T. and HENNY, G. C. CorreIation of body segmentaI temperature and its relation to the Iocation of carcinomatous metastasis. CIinicaI observations and response to methods of refrigeration. Surg., Gynec. & Obst., 66: 512-524, 1938. KRIEG, E. G. Control of postoperative pain. Am. J. Surg., 62: 114-116, 1943. ALLEN, F. M. Resistance of periphera1 tissues to asphyxia at various temperatures. Surg., Gynec. 0 Obst., 67: 746751. 1938. ALLEN, F. M. Reduced temperatures in surgery. Am. J. Surg., 52: 225-237. 1941. JENSEN,
I
T is the purpose of this paper to point out the benefits of IocaIIy apphed coId in orthopedic surgery. Ice takes up heat rapidIy from its surroundings. When the IocaI temperature of a part is reduced, the tissue metaboIism is decreased, the IocaI bIood suppIy is diminished and sensory end organs are duIIed. According to Jensen,’ the range of temperature in storage ice destructive for certain bacteria is from - 2’~. to -5’~. (28.4”F. to 23°F.). This range of temperature is considered to be germicidal for some bacteria. At Iower temperatures, down to that of Iiquid air, bacteria Iike the typhoid baciIIus remain viabIe nineteen months or Ionger. According to BaIdyreva,2 the temperature of natura1 ice varies between o’c and -5’~. (32’~, and 23’~). Fay and Henny3 in their monograph demonstrated the benefits of IocaI ice appIication for the reIief of pain in metastatic carcinoma. They pointed out that this method of refrigeratron when appIied to the area of metastatic invoIvement brought about prompt reIief of pain as we11 as temporary improvement in the genera1 nutrition of the patient. Krieg4 has used ice postoperativeIy on the breast, abdomen and neck, and states that the temperature induced by the application of ice caps is 6”~. (42°F.). In Krieg’s opinion his patients had Iess postoperative discomfort, required fewer narcotics and had fewer postoperative compIications when ice packs were used. AIIen’s5 experimenta work in the use of ice indicates that reduction in IocaI temperature in the Iigated Iegs of rats reduces the danger as regards both gangrene and
shock. He states that in the rat “whenever the temperature can be effrcientIy maintained at 2’~. the Iimbs can survive asphyxia for a Iong period, the maximum of which has not been estabIished but which is certainIy more than fifty hours.” In a Iater paper6 he points out that “If an operation, shockIess in itseIf, has Ieft damaged tissues which may set up postoperative shock, this danger can be bridged by temperature contro1. Shock production by tissues is inhibited in proportion as their temperature is reduced.” When threatening signs of Ioss of vitaIity in skin or other tissues appear, the bIood suppIy cannot be increased effectiveIy, but the metaboIism can be cut down by reducing the IocaI temperature, which in turn decreases the demand for oxygen and nutrition. AIIen mentions that heaIing in the presence of ice is adequate and firm and that the danger of thrombosis is minimized. EXPERIMENTAL In order to determine the faI1 of temperature inside a pIaster cast when ice is appIied to the outside, Ieg and arm cyIinders of varied thicknesses were prepared of pIaster of paris roIIs and sheet cotton. In each case the casts were removed in fifteen minutes, fitted together and held with an additiona Iayer of pIaster. A Fahrenheit thermometer was pIaced inside the empty cyIinder and the cyIinder ends pIugged with gauze. Two covered ice bags were then wrapped on the cyIinders and heId in pIace with bandage. It was found repeatedIy that within two hours the temperature inside the cast dropped to 40°F., and within three hours after the application of the ice caps to 33’~.
* From the Orthopedic Division, Department of Surgery, Duke University SchooI of Medicine, Durham, t Aided by a Grant from the National Foundation for Infantile ParaIysis, Inc. 7x1
N.C.
American
7 I2
SchaubeI-Ice
Journal of Surgery
and Orthopedic
By refiIIing the ice bags every seven hours the temperature inside the empty cyIinder couId be maintained at from 32’~. to 34’~. TABLE SURGICAL
Type
Cases with Ice
No. o Casts
vo. 0
... .
CELL
COUNTS
HOURS
30 2
43 28
30 13 57 17 * 20 6
82 4 51 25 72 58 : 60
.
APplied
Split
39 4
White
Blood Count
Cell
II
of casts
36 6
2
43
19
479
-
OF
SEVENTY-
wth
Elevations
132 42.3% -
APPLICATION
ImmediateIy postoperativeIy the cIoth covered ice bags are applied directly to the pIaster or soft bandage over the operative site. A suffxcient number of ice caps shouId
Third Postoperative Day
Icei Icei Ice
Ice
\No
jNo Ice
140
9
40
4
21
15 5
2 0
17 2
1 0
5 I
160
II
59
5
27
33.4%
3.181
1.4%
5.6%
I 0 --__-_____
By pIacing a thermometer beneath soft bandage dressings, directIy upon the skin of patients on whom ice was used postoperativeIy it was found that the temperature dropped to 44’~. within two hours and to 41’~. within four hours. The temperature couId be maintained at 41’~. therafter if the ice caps were refiIIed every six hours. In an extremity sheet cotton and pIaster cast a thermometer when pIaced next to the skin was found to remain at 41’~. if covered ice bags were wrapped snugIy onto the cast and refiIIed every six hours. The temperature at the hip or shouIder beneath a pIaster spica couId not be heId Iower than 50’~. The method has not been used in the postoperative care of spine fusion cases. METHOD
of Patients
INo
42
72 58
5 ,314 -
FIRST
First Postoperative Day
Ice
7 0 0
-_ 207
THE
OPERATION
f
42 22 0
345
AFTER
No.
of ,casts ,No. Casts 0
II
DURING
Ice
-
2.4%
Totals Percentage split..
BLOOD
--
66 2
57 18 8 20 28
Cases without
1vo.
Kneesurgery.... Wrist fusions.. Foot surgery.. Hip surgery., Fractures.. Tendon surgery Shoulder surgery Bone grafts. Tumors.. Sequestrectomles and ssucerizatmns. Osteotomies. Mampulatmns. Nerve surgery.. Elbow fusions Amputations
T
WHITE
CASTS
TWO
Jo. of 3ases
APplied
3ases
PLASTER
,946
be used to surround the extremity compIeteIy at the operative site. When used on the extremity the bags can be heId in place TABLE
AND
-
of Surgery
NOVEMBER,
I
PROCEDURES
I
Surgery
12.3%
by eIastic bandages. On the hip or shouIder cases scuhetus binders may be used. The ice caps are refiIIed every four hours and are used for forty-eight hours postoperativeIy. The accumuIated air in the ice caps shouId be reIeased at hourIy intervaIs to aIIow them to hug the cast snugIy. RESULTS
Eight hundred twenty-four consecutive cases have been studied. FoIIowing surgery or manipuIation ice caps were used on 345 patients; ice was not used on 479 patients. TabIe I Iist the types of procedures incIuded in this series. In those patients on whom ice was used postoperativeIy 207 pIaster casts were appIied. EIeven (5.31 per cent) of these casts had to be spIit because of pain, sweIIing or other signs of circulatory embarrassment. AI1 eIeven casts were spIit within the first seventy-two hours. In contrast, of the 3 I 2 casts appIied when no ice was used, 132 (42.3 per cent) had to be spIit within seventy-two hours. Of the patients treated with ice on whom postoperative white bIood ceI1 counts were done, 12.4 per cent showed white bIood cel1 counts of over 10,000 on the first postoperative day, 3.18 per cent on the second postoperative day and 1.4 per cent on the
VOL.LXX&
No. 5
Schaubel-Ice
and Orthopedic
third day. Of the patients not treated with ice on whom postoperative white blood cell counts were done, 33.4 per cent showed white blood celI counts of over 10,000 on the first postoperative day, 12.3 per cent on the second postoperative day and 5.64 per cent on the third day. TABLE III TEMPERATURE, PCLSE AND RESPIRATION DURING THE FIRST SEVENTY-TWO HOURS AFTER OPERATION
I
Am&can
Surgery
of Surgery
7 I3
When no ice was used postoperativeIy sixty (12.5 per cent) patients deveIoped complications such as ileus, circuIatory embarrassment, thrombophIebitis, etc., severe enough to warrant special attention. When ice was used, nineteen (5.5 per cent) patients developed complications severe enough to demand special attention. TABLE POSTOPERATIVE
No Ice
Ice
Journal
IV COMPLICATIONS
of Cases
No.
Complication EIevation
No.
of
Percent-
Cases if:_
1
!
No. of Cases
vation
Percentage Elevation
________ Temperature higher than 38.3%. Pulse rate over I If per minute. . . Respiratory rate greater than zo per minute.
39
II
3
III
23.18
39
II
3
120
25.05
70
14.6
2.6
9
-
-
The postoperative temperature, p&e and respiration have remained nearer norma1 in those patients on whom ice was used. In the group in which ice was not used, I I I (23.1 per cent) patients had temperature elevations of 38.3’c. (IoI’F.) or over for the first seventy-two hours postoperatively. Of the 345 cases in which ice was used, thirty-nine (I 1.3 per cent) had a temperature elevation over 38.3”~. for the immediate seventy-two hours postoperatively. A pulse rate of over I 15 per minute for at least three postoperative days was noted in 120 (25.0 per cent) patients out of the group in which cooling was not used. When ice was used, thirtynine (I I .3 per cent) cases showed a p&e rate over I 15 per minute in the seventytwo-hour period after surgery. The respiratory rate was found to run higher than 20 per minute for seventy (14.6 per cent) patients where ice was not used. When ice was used, nine (2.6 per cent) cases had a respiratory rate of over 20 for the first three postoperative days.
No
Ice
Gangrene Woundslough.: 1: :.‘:::” Gastrointestinal upset. Paralytic ileus.. Wound break down. Hematoma or hemarthrosis ThrombophIebitis
___________-_
TotaI Percentage
Ice
2 0
4 II
3 0 0
__-
/
2 I7 12
9 16 2 60 r2.57;
A survey of the average of tota amount of narcotic used by each patient for the seventy-two hour period foIlowing surgery is given in Table v. The figures were arrived at as foIIows: the type and amount of narcotic taken by each patient during the postoperative period and the quantity used by a11 patients having a similar type of surgery was computed. This Iatter amount was then divided by the total number of patients in each category. A subjective factor was repeatedIy demonstrated by the patients who received local applications of ice to the operative site. Voluntary comments concerning the reIative comfort when ice was used about the operative site were gratifying. When ice was discontinued after the first forty-eighthour postoperative period, frequentIy the patient asked that it be repIaced because of the relief of pain which it afforded. The patient upon whom ice was used rested more comfortabIy, took fluids with greater ease and demonstrated a norma appetite
7 I4
AmericanJournalof Surgery
SchaubeI-Ice
and Orthopedic
Surgery
NOVEMBER,1946
TABLE V AVERAGE*
OF TOTAL
AMOUNT
OF NARCOTICS AFTER
-
I
REQUIRED
T Codeine mgm .
FIRST
Morphine mgm.
Panto-
6.0
30.3 360.5 98.0
fs::
3.1
5.0 ‘5. I 2.3 10. I I.0
5.3
mgm.
20.0
89.2 I.4
I _-
13.9
I.2
11.8
7.7
195.0 250.5 115.0
12.5
75.7
I.9
zig.0
_-
--
.26
,004
Pantopon mgm.
100.0 19.6 26.5
23.4 9.2 30.5 15.0 18.3 15. I 26 o 6.0
firs.3 162.4
,001
3.8 .06
mgm.
36.4 30.0 28.4 62.6
249.3 406.0
2.8
.-
Ilemerc )I -.
256.0 610.5 260.0 240.6 204.0
2.8
20.0
1.5 60.0
-
--
27.0
13.
Ice
Morphine mgm.
ICodeine
pon mgm.
--
8.5 15.0 14.0 18.4
HOURS
Cases without
1Demero mgm.
76.5 360.0 70.4 70.7 48.6
49.7 72.0 41.3
SEVENTY-TWO
-
._
Average per case ................ Average dosage in grains per case
THE
Cases with Ice
Type of Surgery
Knee surgery ................ Wrist fusions. ................ Footsurgery ................. Hipsurgery ..................... Fractures ....................... Tendon surgery ................ Shoulder surgery ................ Bone grafts. ................... Tumors. ................... ... Sequestrectomies and saucerizations Osteotomies. ................ Manipulations. ................. Nervesurgery .................. Elbowsurgery .................. Amputations. ...................
DURING
OPERATION
.-
268.5 4.2
50.8
16.4
6.0
_-
.4
-
-_ 12.0
25. I
. ‘9
-
* The figures were arrived at as fohows: The type and amount of narcotic taken by each patient during the postoperative period, and the quantity used by all patients having a simiIar type of surgery was computed. This Iatter amount was then divided by the tota number of patients in each category. As a rule, codeine was given in doses of 60 mg., morphine 12 mg., demerol 50 mg. and pantopon 15 mg. -
sooner foIIowing surgery than when no ice was used. The entire convaIescent period of a11 patients on whom ice has been used has been satisfactory. CONCLUSIONS
The skin temperature beneath soft dressings or under padded pIaster casts can be reduced by the IocaI appIication of covered ice bags. On 345 patients when ice was used IocaIIy : in the seventy-two-hour period foIIowing surgery fewer casts were spIit; the temperature, puIse and respiration were Iower; white bIood ceI1 counts were nearer normaI; postoperative compIications were fewer; and the amount of narcotic per patient was reduced. SubjectiveIy, the patients who have ice appIied IocaIIy fare better in a11 respects
-
than the patients who have no ice appIication during the postoperative period. The postoperative use of ice appIied IocaIIy to the operative site is a vaIuabIe adjunct in the treatment of surgical patients. REFERENCES I.
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L. B. The bacterioIogy of ice. Food Research, 8: 265-272, 1943. BALDYREVA. Quoted by Jensen from Tanner, F. W. Microbiology of Foods. Champaign, IIIinois, 1932. Twin City Printing Co. FAY, T. and HENNY, G. C. CorreIation of body segmentaI temperature and its relation to the Iocation of carcinomatous metastasis. CIinicaI observations and response to methods of refrigeration. Surg., Gynec. & Obst., 66: 512-524, 1938. KRIEG, E. G. Control of postoperative pain. Am. J. Surg., 62: 114-116, 1943. ALLEN, F. M. Resistance of periphera1 tissues to asphyxia at various temperatures. Surg., Gynec. 0 Obst., 67: 746751. 1938. ALLEN, F. M. Reduced temperatures in surgery. Am. J. Surg., 52: 225-237. 1941. JENSEN,