Tuesday, August 5, 2014

Historical Contribution: 1941, Culp, DVT & PE

1941

Postoperative venous thrombosis and pulmonary embolism: analysis of eighty-eight cases O. S. Culp Anesthesia & Analgesia 1941  20: 47-48

In this early review of perioperative outcomes, Dr. Culp reviews the twenty-year history of the Brady Urological Institute and finds 80 pulmonary emboli (PE).  In this review, 43 cases were fatal, 21 patients had PE and recovered; and the remaining patients were cases of incidental PE.  The majority of fatal cases were patients done under spinal anesthesia with other risk factors including:

  • intravenous infusions
  • drop in blood pressure during the operation
  • postoperative instrumentation
  • abdominal distention
  • circulatory (vascular) disease
Interestingly, these PE were only evident clinically in about 20% of patients.  Eighteen patients were proven to have deep venous thrombosis in the leg or pelvis at autopsy (ultrasound was not yet available).  

Dr. Culp made the following conclusions, many of which we now know to be inaccurate but some are still used today in clinical practice:

(1) Continuous intravenous infusion should not be used unless absolutely necessary. [no impact on DVT/PE risk]
(2) Every effort should be made to prevent peripheral venous stasis by adequate treatment of associated circulatory disease, fall in blood pressure, postoperative abdominal distention and by the elimination of unnecessary pressure on peripheral vessels due to strapping and the like. [continue to be employed today to prevent DVT/PE, however routinely used today are compression stockings, compression devices and early ambulation]
(3) Wound infections should be minimized by careful aseptic operative technique and mild bacteriostatic agents. Drainage of postoperative abscesses should be established immediately. [of particular concern for septic emboli]
(4) The greatest need is the recognition of thrombosis in the lower extremity. The legs should be measured on admission, before operation and before patients get out of bed. [without ultrasound technology, this was the best means of diagnosis of DVT and subsequent PE risk]
(5) Untimely activity should be avoided in the presence of thrombosis. Absolute bed rest is the most conservative and most practical treatment for thrombosis and prevention of embolism, [we know that early ambulation decreases the risk of DVT and "untimely activity" likely has little or no impact on propagation of DVT to PE]

To read the entire manuscript click on the link above or here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 

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