Whenever a person undergoes any type of treatment for any condition, various changes in the physiological processes in the body are produced. For example, many drugs which are directed at the treatment of certain tissues also have an effect on other tissues. When bed rest is required for the treatment of a certain disease, the body’s adjustments to the unusual length of time at rest produce major physiological alterations. And any such changes in physiology predispose to even greater adjustments within the body. It is not surprising, therefore, that while under even the simplest forms of treatment additional abnormal states may develop. Complications occur with all methods of disease treatment.
Surgery deals with methods which often entail sudden and radical changes in the body’s physiology and anatomy. The administration of an anesthetic, or the performance of an operation, are abnormal states indeed under which the patient must temporarily live. It is astonishing that the body is able to survive such unnatural states, and then, in all but a very few cases, revert to completely normal physiology with no residual effects from the experience.
Throughout the course of surgical therapy close observation is made for signs of any complicating process, so that they may be obviated or their effects minimized through early treatment. Prophylactic measures are taken against all the more common complications. Fortunately, unless there is pre-existing disease, major complicating conditions are extremely rare. The complications encountered more commonly are usually of only minor significance in the final result of surgery. Although surgery is a relatively new art, modern methods have been proved safe and the incidence of all complications is low. Almost any disease process could be listed as a condition which might occur during surgical treatment, but only the commoner ones and those most frequently asked about by patients are included here.
After major anesthesia and operation, certain symptoms are expected to occur as a result of the body’s reaction to the changes in the usual physiology. These are actually not complications at all, as inferred in the usual use of the term, but they may modify the management and may alarm the uninformed patient, so they are mentioned here.
After certain anesthetics, nausea and vomiting and hiccoughs are expected to occur as a normal reaction to the drugs used. These symptoms may appear only in the recovery stages or may last until all the drugs have been eliminated from the body. Pain at the operative site certainly is to be expected, for this symptom naturally occurs after injury to any tissue. Although the operation is designed to improve the anatomy of the body and even though all severed structures are reunited, there has been tissue injury, and pain must be expected. Pain at the site of the operation is normally of greater severity immediately after operation, gradually diminishing as healing progresses.
For the first few days after operation, lethargy and general weakness must be expected. As the normal body physiology re-establishes itself, these symptoms diminish. The degree of weakness experienced is proportionate to the magnitude of the operation and the general state of health. When there is much anxiety and concern about oneself, such symptoms as apprehension and fear and insomnia are not unexpected.
Other symptoms which may be anticipated depend on the specific individual, the site and extent of the operation, the anesthetic, the type of disease encountered, and the various special procedures necessitated.
The control of the expected symptoms throughout surgical therapy is quite effective. Pain is alleviated by use of the pain-obtunding drugs, which inhibit the registration of pain impulses in the pain center of the brain. Other adjuncts to relieve discomfort, such as positioning in bed and padding tender areas, are employed. Occasionally inhalations of pure oxygen are used to allay nausea and vomiting, or certain sedative drugs will minimize these symptoms. Restlessness, anxiety, and insomnia can also be controlled by the sedative drugs. Medications to hasten the return of normal physiology or to stimulate metabolism arc frequently used to regain the lost strength and minimize postoperative weakness. Ambulation as soon as possible after operation also helps to hasten the return of normal body physiology. The drugs used to control the expected postoperative symptoms are carefully calculated by the surgeon. No harm will result from their use for the brief time they will be needed. Undue pain and discomfort may distract from the normal processes of recovery, so patients should not fear the use of pain-relieving remedies.
Inability to initiate the urinary stream and empty the bladder of its urine is not an uncommon symptom after anesthetics, operations, and accidents. It occurs more frequently after operations and injuries in the region of the lower abdomen and pelvis, but may be encountered after any major procedure. This is not an unexpected symptom, and close check of the urinary output for its occurrence is made after operation. It is due to spasm of the ring of muscle at the outlet of the bladder which normally controls the flow of urine, or to suppression of the bladder’s ability to contract itself, as it normally does, to empty its contents. The conscious patient experiences the sensations of a full bladder but is unable to empty it, or he may be able to void only a small amount at a time. This condition occurs in females and males alike, and should not alarm the patient, for it is a common occurrence and with no serious effects except for the temporary discomfort. After the simpler preliminary measures to empty the bladder have failed, drugs to stimulate bladder contraction or catheterization may be ordered.
After an anesthetic there may also be suppression of the normal intestinal movements which propel food through the tract. The slower metabolism of inactivity and bed rest may further decrease the intestinal activity. This frequently gives rise to the symptom of constipation. This is a minor postoperative problem and is easily treated whenever necessary by the use of cathartics, intestinal stimulating drugs, or enemata.
Most often, however, the sensations of constipation are more imaginary than real. After an enema, which is often given before operation, a bowel movement should not be expected for at least 48 hours, since the greater portion of the lower bowel has been cleansed of its residue. Furthermore, the intake of food is always reduced during hospitalization, especially on the day of operation, so residue does not accumulate in the intestinal tract as readily. With the emotional apprehension of hospitalization there may be a greater swallowing of air than normally. After operations upon the abdomen and pelvis, a feeling of increased pressure within the abdomen often is experienced. For these reasons the symptoms of constipation often occur when actually there is no increase at all in food residue within the bowels. Most often the surgeon will prefer to give adequate time for a normal evacuation before applying artificial means. But, when necessary, the most ideal method of augmenting the process will be ordered. Even when true constipation docs exist, there are no harmful physical effects which result from it.
The intestinal contents are semi-solid in character until they reach the last few feet of intestine, which is the colon or large intestine. By the time the contents reach this level, nothing remains except the food residue or pulp from the diet, fractions of digestive juices, and water. One of the major functions of the colon is to absorb the water the body needs from this mixture. When fluid intake is low and dehydration of the body exists, as it frequently does after anesthesia and operation, the extraction of water through the wall of the colon is complete. This results in a very hard fecal residue which is called fecal impaction and is difficult to pass out of the rectum. Further residue may collect above the impaction, causing true constipation. The patient experiences the sensation of a full rectum but cannot empty it. Rectal examination reveals the condition, and the impaction can be broken up into smaller fragments by the examining finger. This is not a very uncomfortable ordeal for the patient; on the contrary, he usually is made much more comfortable from it. Other means of mobilizing a fecal impaction are through the instilling of an oil solution into the rectum via tube to lubricate the action, or by an enema.
This is a more serious condition but not so tragic as it would seem. In certain cases it would seem that the digestive tract has lost all power to perform its usual actions to propel ingested food along its course. This condition is not seen frequently but sometimes occurs in association with severe infections within the abdomen and after severe pelvic and back injuries. The usual suppression of intestinal action from anesthetics, bed rest, and operations which may be necessary in these cases can precipitate the condition. The terms “intestinal paralysis” and ileus have been used to designate this condition. It is manifested by distention of the abdomen with “gas.” This comes from air which is swallowed, even though the individual may not be aware that he is swallowing air. Treatment rests with the administration of drugs to stimulate the intestine to act, and with keeping the digestive tract empty. A stomach tube must be kept in place with constant suction to withdraw all swallowed air and stomach juices. If possible, a tube is placed farther into the tract in the intestines. One to several days of such treatment may be necessary, so artificial feeding through the veins is employed until the digestive system resumes its actions.
Complications involving the respiratory system after operation were formerly more prevalent and constituted a far more serious problem than they do today. Not only is close observation made for symptoms and signs of respiratory disease, but prophylactic measures are taken to prevent their occurrence. When respiratory complications do appear, effective means of treatment are now available.
The respiratory apparatus is a system of air passageways which lead off from one main tube and branches into innumerable smaller and smaller tubes. The main tube is the trachea, which leads from the throat down to the region of the lungs where the branchings begin. This is structurally comparable to the trunk of a tree, which gives rise to its branches and each of which in turn further give rise to many more smaller branches. The largest of the tubular branches is called a bronchus and the smallest a bronchiole. At the tip of each bronchiole in the lung is a minute sac called an alveolus, which would be comparable to the leaves on the tip of each tree branch. These sacs become distended with air with each breath, and the blood in the tiny capillaries lying adjacent to them absorb the oxygen from the air while at the same time expelling its waste gases. This process continues constantly day and night from birth until death.
Complicating diseases of this system most often develop within the first two days after operation but may occur at any time during convalescence. Complications are initiated by the irritating effects on the respiratory lining membranes of the anesthetic gases, through inactivity with failure to keep all sections of the lungs aerated, and by stagnation of secretions with failure to cough them out. In these situations germs may enter and can more easily set up their colonies of infection.
In general, the higher the infection is within the respiratory tree, the lesser are its consequences. The terminology used to describe the sites of inflammation is quite simple. Inflammation of the nasal passages is called rhinitis; of the pharynx, pharyngitis; of the larynx, laryngitis; of the trachea, tracheitis; of the bronchial tubes, bronchitis; and of a section of lung tissue, pneumonitis or pneumonia. If an infection process progresses untreated, it may descend to cause a more serious infection deeper within the system, or a pneumonitis may extend to involve greater segments of the lung. But today the surgeon has at his command several very effective drugs which will kill the invading bacteria to control the infection.
The most common condition which predisposes to lung disorders in postoperative patients is atelectasis. This literally means failure of expansion of a portion of the lung, and occurs from plugging of one of the bronchial tubes with secretions which are not coughed out. The size of the atelectatic patch depends on the site of the obstructing plug in the respiratory tree— that is, involves the group of alveoli the obstructed tube normally keeps supplied with air. The non-acrated sacs collapse, and invading germs can set up an infection unhindered. This may occur in several sections of lung at the same time. Secretions are normally moved up to the upper trachea by normal lung physiological actions, where they may be coughed up. But, when coughing is inhibited, the secretions may accumulate lower and lower in the respiratory tract. Prevention and treatment of this condition lie primarily with encouraging the patient to cough whenever the impulse is experienced.
Medications which obtund the cough reflex may be harmful, but medications which inhibit formation of secretions or make them less viscid are often beneficial. Atelectasis is seen most commonly after operations of the abdomen and chest, for coughing is often inhibited in these cases. But again it must be emphasized that coughing, no matter how forceful, will not disrupt the incision or impair healing. The act of coughing may be painful to the fresh incision, but more harm indeed will result from failure to cough than from any strain on the incision.
Infectious processes which occur in any part of the body in the postoperative period are more often from pre-existing disease than from the surgical treatment. But some infections which ordinarily would not develop are allowed to manifest themselves through the altered physiology of surgical therapy, and through the body’s direction of its inflammatory forces toward the primary surgical illness. Search is made during the preoperative stages for any coexisting infections, and whenever possible operative treatment is postponed until the most ideal conditions arc present. If delay in operation is unwise, treatment of any coexisting infection is carried out simultaneously. Treatment of those infectious processes not apparent until after operation is initiated as soon as recognized.
As already described, infection is a type of inflammatory reaction wherein germs are the offending irritant to the tissues. Specific treatment of an infection depends on the type of germs present and the tissues they attack, but certain basic principles apply in the treatment of all infections. Collections of pus must be liberated, and other devitalized matter and destroyed tissue should be eliminated from the area, if possible. All substances the body is known to need to fight infection and repair the injured tissues should be assured in adequate amounts. Medications which kill the specific germs and protect against invasions by other types are administered. In most instances, these are best dictated to the infected tissues through the medium of the blood rather than by applying to the surface, because the germs are within the tissues rather than on the surface. Injected or ingested medications are absorbed into the blood and transported throughout the body; they are carried to the germ-laden tissues.
Infections have been a great detriment to operative treatment in the past. Prior to the discovery of the germ theory of disease, surgery was very limited in its scope. However, the ever- improving control of infection in modern times has permitted magnificent advances in the field of surgery.
Wound Infection. The body is normally protected against the invasion of germs by its skin and other covering layers. Whenever these are lacerated, whether by operative incision or injury, germs may gain a portal of entry to establish an infection. This may disseminate throughout the body or settle in another site, but most often it is confined to the limits of the wound. Every effort is made to prevent infection in the preoperative, operative, and postoperative periods, but occasionally a wound infection will occur. In cases where the primary disease is an infectious process deeper in the tissues, the source of contamination of the operative wound may be from within rather than from without.
Treatment of wound infections engages the same primary principles as any other infection. If collections of pus have accumulated, they must be released. This may necessitate making a small opening in the wound so that the devitalized matter may drain. Care is taken not to contaminate other areas with the germ-laden pus. Antiseptic drugs may be employed to eliminate surface germs, and specific medicants to aid the body in killing those germs deeper in the tissues arc administered. Application of local heat may be useful to increase the blood supply to the region by dilating the blood vessels and also to increase the resistance to the germs.
The control and treatment of wound infections is quite effective by modern means. Usually the only consequences of an infection of a surgical wound are slightly prolonged healing and perhaps a wider surface scar.
Disruption or breakdown of an operative wound is actually so rare that it need not even be mentioned here. But this is one condition which patients seem to fear more than any other in the postoperative period. Modern methods of reconstructing operative wounds almost completely obviate such an occurrence, unless there ensues a massive wound infection or other serious wound complication. Even if wound disruption should occur, the consequences are not catastrophic. It simply means that the wound has to be repaired once again.
Hernia or “rupture” in an incision is a late complication which occasionally appears. This may first be noted many years after operation. Incisional hernia is the result of incomplete healing of one of the deeper layers of an incision, so that an even deeper structure may protrude through the opening. This produces a bulge beneath the skin over the area. As time passes, the hernial opening may get larger from the pressure and stress on the area. This late postoperative complication is seen most often in wounds which were once infected or otherwise complicated. Prophylaxis against occurrence of a hernia in the incision rests with the surgeon at the time of operation and with the postoperative care. Treatment of incisional hernia is by further operative intervention.
Hemorrhage, or profuse bleeding, has been discussed in previous sections. Hemorrhage from an operative area is extremely rare. Should it occur, treatment engages the same basic principles as in hemorrhage from injury. (After operations where there is left a rather large exposed area, such as after tonsillectomy, bleeding may occur more frequently. This occurs most often 5 to 8 days after operation, when the clots are released from the surface.)
The upset in physiology called shock has been mentioned in preceding sections. Operation, of course, is often a shocking procedure to the physiological processes of the body. But throughout any operation close watch is made for any signs of its appearance and the preventive measures instituted immediately. Further observation for the signs of delayed shock are continued in the immediate postoperative period, until the patient has fully responded from the anesthesia. Before its mechanism and therapy were fully understood, shock was a menacing complication of surgery. But in recent years this has been of far less frequent occurrence as a result of operative treatment.
Blood Clots in Veins
Normally, the blood is a fluid mixture within the blood vessels. But it has the ability to coagulate, or solidify, whenever there is a leakage from the system. This, of course, is a vital power which protects against serious losses of blood by plugging the leakage point with the clot. Clotting of blood is a chain of chemical and physical reactions which begins when the necessary substances and conditions are present (see preceding section). Normally, clotting does not take place within the circulatory tree, but under certain abnormal conditions the process may be initiated within the vessels. The veins are by far the more common site of abnormal clot formation within vessels, because the propelling forces of the circulation are less in this more distant part of the circuit, and because the veins are more often diseased than the arteries. The veins of the legs and those within the pelvis are the most commonly affected.
The conditions which predispose to clotting within the veins are several. Inflammations of the lining membranes of these vessels, whether from compression, germs, injury, heat, allergy, chemicals, or whatever, call out the inflammatory processes which may bring together all the substances and conditions necessary for clot formation. The clot is anchored to the inflamed section of vein. Stagnation of blood within certain segments of veins may also give rise to clot formation. Patients necessarily confined to bed may have a stagnation of blood in unused segments of veins in the legs and pelvis, especially if the legs lie idle for long periods. A slowed circulation as in some forms of heart disease may also lead to stagnation, and parts immobilized by casts or splints are predisposed to venous pooling of blood. Blockage of the return of blood to the heart by compression of veins from tumors, tight dressings, or swollen tissues may induce stagnation. When the ability of the blood to clot is enhanced, as in dehydration states where the viscosity of the blood is greater, clotting within vessels may occur more readily.
The formation of clots in veins is a relatively rare complication, and even more infrequent are any serious consequences from such clots. But one condition which may ensue is pulmonary embolus. This is the breaking loose of a blood clot so that it becomes a free floating body in the blood stream. It passes back to the heart and out through the large veins which lead to the lungs. When it reaches the smaller vessels in the lungs, it cannot pass, so plugs a segment of vessels. The section of lung so involved therefore cannot receive its usual blood, and this amount of lung tissue no longer serves to oxygenate the blood. When the involved section is larger, or if there have been several emboli, a great impairment of respiration will result.
Attention is directed throughout the postoperative course at preventing blood clots in veins and their untoward effects. Close check is kept on the temperature and the pulse and the other general signs of inflammation. Diseased veins are given prompt treatment. Stagnation of blood in usual outer venous pathways is prevented by the use of elastic bandages over their course to prevent their pooling with blood. Bed exercises are often needed to augment the flow of blood in patients confined to bed. As soon as possible, ambulation is begun. Drugs which reduce the blood’s ability to coagulate are used to prevent enlargement of a clot which has already begun to form, and also in cases where clot formation is quite likely. If a clot has formed, blocking its pathway to the lung by ligation of the vein above it prevents pulmonary embolus. Numerous other means arc used in specific instances to prevent and treat blood clots in veins.
A distressing complication which occasionally occurs in patients who are confined to bed is the development of bedsores. These are the result of constant pressure over an area which interferes with the blood supply so that the tissues break down. They occur over the bony prominences and weight-bearing areas, most commonly over the back. They are also called pressure sores or decubitus ulcers.
As a rule, bedsores are not painful during their developing stages, as the pressure anesthetizes the tissues as it kills them. If infection intervenes, the area becomes tender and painful. They can be prevented by frequent changes in position in bed and by padding of all parts necessarily exposed constantly to pressure. The treatment of bedsores employs the same techniques as treating any infected open ulcer, with careful avoidance of further pressure and infection.
Pressure ulcers are usually not a serious problem, but in some instances they may prolong postoperative convalescence. Very large and infected ulcers may distract some of the body’s healing forces from the primary illness; some may even require skin grafting before complete healing will occur. The conscious patient can do much to guard against the development of these ulcers by remembering to move around in bed and by calling attention to any areas constantly exposed to pressure in bed or under casts and other body-supporting appliances.