Chest complications after upper abdominal surgery: their anticipation and prevention.

Abstract

Though many advances have been made in surgery, anaesthetics, and physiotherapy in the past few years, the incidence of post operative chest infection has changed little in the last 30 years. Since the report by King (1933) it has been recognized that upper abdominal operations carry an increased risk of chest complications (Palmer, 1955; Wightman, 1967). This survey was planned primarily to determine whether a combination of penicillin and streptomycin would reduce this incidence if used prophylactically. Crystamycin was used because it contains standard quantities of both penicillin and streptomycin and is easily administered by the nursing staff. Previous trials have failed to show any benefit from prophylactic antibiotics (Palmer and Sellick, 1952; Griffiths, 1957; Thulbourne and Young, 1962) because the antibiotic-penicillin -used in each series is not effective against Haemophilus influenzae. Miller and Jones (1964) examined the sputum of 130 working men in London capable of producing early morning phlegm and found H. influenzae in 45 % and pneumococci in 38%. Mulder et al. (1952) and May (1953) reported that H. influenzae could be isolated from the sputum of 80-90% of patients with chronic mucopurulent bronchitis. Stuart-Harris et al. (1953) found that in Sheffield H. influenzae and pneumococci were the important pathogenic bacteria. It was therefore thought essential to use an antibiotic regimen capable of destroying both the pathogenic bacteria likely to be found in the bronchial system of patients, 40% of whom were expected to have bronchitic symptoms. Penicillin with strepto mycin, given in a five-day course, is known to be therapeutically effective in acute exacerbations of bronchitis and to be free from toxic effects in all but a few hypersensitive patients. This was therefore thought to be the drug combination most likely to reduce the incidence of postoperative chest infections. A secondary objective was to establish the value of isoprenaline inhalations and morphine in frequent regular doses in preventing postoperative chest complications. The opportunity was also taken to assess the importance of preoperative history and ventilatory function on the develop ment of chest complications. From these data an attempt was made to define the characteristics of a group of patients who would be most likely to suffer these complications, and in whom it would therefore be justifiable to institute such prophylactic measures as were shown by the trial to be effective.