MILITARY MEDICINE, 175, 5:357, 2010

Surgical Morbidity in an Austere Surgical Environment

CDR Paul A. Lucha , Jr., MC USN * ; CDR Douglas Wallace , MC USN * ; LCDR Charles Pasque , MC USNR † ; LT Neal Brickhouse , MC USNR ‡ ; LT David Olsen , NC USN § ; LT Stan Styk , NC USN || ; LT Myra Dortch , NC USN || ; LT William A. Beckman , Jr., MC USNR *

ABSTRACT Surgical wound morbidity was analyzed for a U.S. military fi eld hospital deployed to the Republic of Haiti in support of Operation New Horizons 1998. The purpose of the analysis was to determine whether procedures per- formed in the fi eld hospital had greater infectious risks as a result of the environment compared with historical reports for traditional hospital or clinic settings. Acceptable historical rates of 1.5% for clean surgical cases, 7.7% for clean Downloaded from https://academic.oup.com/milmed/article/175/5/357/4344592 by guest on 23 September 2021 contaminated cases, 15.2% for contaminated cases, and 40% for dirty cases have been noted. There were 827 operations performed during a 6-month period, with the majority of patients assigned American Society of Anesthesiologists (ASA) Physical Status Classifi cation class I or II. The distribution of these cases was: 72% clean cases, 5% clean contaminated cases, 4% contaminated cases, and 19% dirty cases. The overall wound complication rate was 3.6%, which included 5 wound , 11 wound hematomas, 8 superfi cial wound separations, and 6 seromas. The infectious morbidity for clean cases, the index for evaluation of infectious complications, was 0.8%, well within the accepted standards. There were two major complications that required a return to the operating room: a wound dehiscence with infection in an orchiectomy and a postoperative hematoma with airway compromise in a subtotal thyroidectomy. There were no surgical mortalities. The infectious wound morbidity for operations performed in the fi eld hospital environment was found to be equivalent to that described for the fi xed hospital or clinic settings. No special precautions were necessary to ensure a low infection rate. The safety for patients undergoing elective surgical procedures has been established. Further training using these types of facilities should not be limited based on concerns for surgical wound morbidity.

INTRODUCTION and can vary considerably. They can range from standard Surgical wound morbidity can place a considerable burden operating theaters, found in medical treatment facilities or on both the patient and the physician. Patients with wound hospital ships, to those erected out of canvas tents and col- complications often have to withstand multiple surgical pro- lapsible shelters, such as those seen in fl eet hospitals or surgi- cedures, extended recovery times, and potentially adverse cal companies. The surrounding physical environment, local surgical outcomes. Physicians bear the responsibility of rec- medical systems, and local cultural standards can further ognizing and then appropriately treating such wound prob- challenge the effectiveness of these facilities. What increased lems. Estimated costs in time, money, and resources to all morbidity do these medical facilities add to the care we pro- those involved may exceed $1 billion (U.S.) annually. 1 Thus, vide for surgical patients? This is the question we attempt to improvements in morbidity rates can be expected to decrease answer. both patient suffering and medical costs.2,3 Surgical wound risk for postoperative infection can be It has long been recognized that morbidity associated categorized in many different ways. In the 1960s, surgical with surgical is related not only to host factors but wounds were divided into the four categories listed in Table I .7 to technical and environmental factors as well.4 Modifying In 1992, additional factors were noted to contribute to the some of these factors may lead to improvements in surgical risks for wound infection.7–10 These included case length, morbidity.5,6 Certain factors, when modifi ed, may reduce the general assessment of patient health, American Society of risk of wound infection, whereas others seem to play little if Anesthesiologists (ASA) Physical Status Classifi cation, and any role. 3 Many factors associated with surgical wound mor- wound classifi cation. The majority of wound complications bidity, such as the surrounding environment or the available are noted within the fi rst 2 weeks after surgery, and up to 90% surgical facility, cannot be controlled or optimized. Medical are noted 3 weeks after surgery. 5,11 Wound infections are usu- facilities that are used to provide surgical support in times ally divided into the subcategories superfi cial and deep. Most of armed confl ict or humanitarian care fall into this category superfi cial wound infections are noted between the 4th and 8th postoperative day, whereas the deeper infections can present as late as 30 days postoperatively.5 Deeper infections are those Departments of *Surgery, †Orthopedic Surgery, §Anesthesia, and that occur at or below the level of the fascia, occur from a pre- ||Nursing, Naval Medical Center Porsmouth, 620 John Paul Jones Circle, vious drain site, result in spontaneous dehiscence, or result in Portsmouth, VA 23708-2197. greater than 38°C.5 ‡ 2nd Medical Battalion, 2n FSSG, Camp LeJeune, Jacksonville, NC 28542. The wound morbidity of surgical procedures performed by This manuscript was received for review in January 1999 and was accepted for publication in February 1999. the Haiti detachment of the 2nd Medical Battalion assigned in Reprint & Copyright © by Association of Military Surgeons of U.S., 2000. support of Operation New Horizons 1998 was reviewed. The This article originally appeared in Military Medicine 2000; 165(1): 13–7. purpose of the review was to determine whether the wound

MILITARY MEDICINE, Vol. 175, May 2010 357 Surgical Wound Morbidity

TABLE I. Wound Classifi cation Categories

Classifi cation Description Clean Wounds Elective wounds in which there is no infl ammation and no entry into the genitourinary, gastrointestinal, oropharyngeal, biliary, or tracheo- bronchial tract. Clean Contaminated Wounds Wounds in which entrance into the genitourinary, gastrointes- tinal, oropharyngeal, biliary, or tracheobronchial tract occurs

without obvious infection or with Downloaded from https://academic.oup.com/milmed/article/175/5/357/4344592 by guest on 23 September 2021 minimal spillage or break in sterile technique. Contaminated Wounds Acute nonpurulent infl ammation, major break in sterile technique, or spill from hollow viscous; FIGURE 1. Brothers Mission Surgical Facility. Open-air courtyard of the penetrating trauma less than compound serves as the “surgical suite,” where only minor procedures are 4 hours old. performed, usually on stretchers beneath trees. Dirty or Infected Wounds Purulence or abscess encountered; preoperative perforation of the gastrointestinal, genitourinary, tracheobronchial, or biliary tract.

complication rate was higher in this austere environment com- pared with historical reports for procedures performed in a traditional hospital or clinic setting. Infectious wound mor- bidity was used as an index. The information gathered could then be used to determine whether alterations of any morbid- ity risk factors or surgical techniques would be necessary to improve results.

METHODS Data were collected prospectively from all surgical proce- dures performed by the U.S. Navy 2nd Medical Battalion sur- gical staff deployed to Port-au-Prince, Haiti, from July 1998 to FIGURE 2. Vaudriel Surgical Facility. Small room capable of regional anesthesia with monitoring, air conditioning, and electricity provided by gas- January 1999 in support of Operation New Horizons 1998. All powered generators. It was maintained by the host nation. cases were assigned an American Society of Anesthesiologists Physical Status Classifi cation (ASA class).12 Cases were ascertained to be major if the case involved entry into the peritoneal cavity, thoracic cavity, or cranial (or spinal) vault or were of life- or limb-threatening nature. Those not fi tting these criteria were deemed minor cases. One of four wound classifi cations was then assigned to each case: clean cases, clean contaminated cases, contaminated cases, and dirty cases ( Table I ).7 Demographic data, anesthetic type, surgical facility used, operating surgeon, and procedure type were recorded. All procedures were performed in one of four primitive surgi- cal facilities (Figs. 1–4) and were performed or directly super- vised by one of three board-certifi ed surgical staff members. All procedures were performed on an outpatient ambulatory surgery basis and were prepped with iodophor isopropyl alco- hol or providone iodine swabs. Major surgical patients were draped with standard sterile drapes, and the procedures were FIGURE 3. Bernard Mevs Surgical Facility. Open-air ward without air performed wearing sterile gowns and gloves with a preoper- conditioning with open windows to allow air circulation, maintained by the ative hand scrub. Minor surgical patients were draped with host nation. Multiple procedures are typically performed at the same time.

358 MILITARY MEDICINE, Vol. 175, May 2010 Surgical Wound Morbidity

FIGURE 5. Distribution of cases by wound class. Downloaded from https://academic.oup.com/milmed/article/175/5/357/4344592 by guest on 23 September 2021

U.S. Embassy. The male-to-female ratio was 1.1:1, with a median age of 26 years (range, 2 months to 88 years). FIGURE 4. U.S. Field Hospital Surgical Facility. ISO container with fi eld anesthesia machine, fi xed overhead lighting, and an air conditioning unit. It is usually attached to a canvas tent. Surgical Wound Morbidity There were 31 postoperative wound complications identifi ed, for an overall rate of 3.7%. There were 5 infectious wound sterile towels, and the procedures were performed wearing complications, 11 wound hematomas, 6 wound seromas, and sterile gloves without preoperative hand scrubbing. 9 superfi cial wound separations. Of the 5 infectious compli- prophylaxis was used only for clean contaminated cases or cations, none occurred from the most austere surgical facility cases in which orthopedic hardware was placed. Contaminated ( Fig. 1 ). The clinical wound infection rate for clean cases or dirty cases received therapeutic as indicated. was 1.7% for major cases and 0.5% for minor cases. Two All instruments used were cleansed in a fi eld central ster- patients required a return to the operating room. The fi rst was ile supply room and were steam sterilized using a fi eld ster- a 70-year-old male who developed a wound dehiscence and ilization unit. Sterilizer quality control was performed once abscess after an orchiectomy for chronic purulent orchitis that daily using a biological control test (Attest, 3M Health Care, was refractory to antibiotic therapy. The second was a 35-year- St. Paul, Minnesota). Morbidity and mortality for all cases old female who developed a postoperative hematoma after a were reviewed weekly. subtotal thyroidectomy, which caused respiratory embarrass- All patients were followed postoperatively for at least ment and required surgical evacuation. All remaining compli- 14 days, and patients were allowed ready access to further cations required only local wound care, with or without oral postoperative follow-up via weekly clinics at each of the sur- antibiotic therapy. There were no surgical mortalities. gical facilities used. All wound complications were verifi ed by one of the board-certifi ed surgeons. Wound infection was Wound Classifi cation defi ned as purulent discharge from a surgical incision, cellu- litis of an incision, or when antibiotics were instituted dur- The distribution of cases by wound class is noted in Figure 5. ing the postoperative period (excluding prophylaxis) by one of There was no signifi cant relationship between the occurrence the board-certifi ed surgeons. Wound infections were further of wound complications and wound classifi cation. There was divided into superfi cial or deep. Wound seromas were defi ned a wide variety of procedures performed, which were grouped as fl uid collections in a wound without cellulitis, erythema, into the “other” category. The majority of similar procedures or purulent discharge for which no antibiotics had been insti- were incision and drainage of soft tissue abscesses (Fig. 6). tuted. Wound hematomas were collections of blood within a There was no signifi cant relationship between the occurrence wound without cellulitis, erythema, or fever. A wound sepa- of complications and the type of procedure or whether the ration was defi ned as dehiscence of the wound edges without case was a major or minor case. Major cases accounted for underlying seroma, hematoma, or abscess. 21% of the total number of cases. Anesthesia RESULTS The majority of procedures were performed under local anes- Patient Population thesia (68%), followed by general anesthesia (12%), spi- There were 827 surgical procedures performed during the nal anesthesia (8%), and regional anesthetic blocks (5%). 6-month period studied. This was a consecutive series of pro- The majority of cases were ASA class I or II (95%), with the cedures with no cases excluded. The majority of procedures remaining cases ASA class III. There were no ASA class IV or were performed on Haitian nationals (98%), with the remain- V cases. There were only three emergency cases (all were ASA der performed on active duty U.S. military personnel, United class I). Surgical wound morbidity had no direct association Nations military personnel, or others at the discretion of the with the type of anesthesia used or the patient’s ASA class.

MILITARY MEDICINE, Vol. 175, May 2010 359 Surgical Wound Morbidity Downloaded from https://academic.oup.com/milmed/article/175/5/357/4344592 by guest on 23 September 2021

FIGURE 6. Surgical case distribution.

Surgical Facility The number of minor procedures performed at each of the four surgical facilities was: Brothers Mission, 37%; the mil- itary treatment facility, 16%; Bernard Mevs Clinic, 25%; and Vaudriel Clinic, 20%. The majority of the major surgi- cal procedures were performed at the military treatment facil- ity (70%), followed equally by Bernard Mevs and Vaudriel Clinics (15%). No major procedures were performed at the Brothers Mission. The wound morbidities were equally dis- tributed among the surgical facilities.

DISCUSSION The infectious morbidity rates of 0.6% overall and 0.8% for clean surgical cases in this population are consistent with rates found in the literature for procedures performed FIGURE 7. Haitian patients bathing and washing clothes in a drainage in “standard” clinics or operating rooms. Infection rates of ditch. 1.5% are accepted for clean surgical cases, 7.7% for clean contaminated cases, 15.2% for contaminated cases, and challenging, and it was surprising that more infectious com- 40% for dirty cases. Infection rates for clean surgical cases plications were not noted. Many of our patients wash cloth- are often used as an index for the surgeon’s (or facility’s) ing, bathe, and discharge bodily wastes in roadside drainage wound morbidity rate.2,4 As noted in Figures 1–4, the envi- ditches (Fig. 7). ronment in which these procedures were performed was less The short follow-up period for this population may have than ideal. Some procedures were performed on stretchers missed some wound complications, although the majority of in an open courtyard under trees, and the remaining proce- wound complications should present within the fi rst 2 weeks dures were performed in open-air rooms maintained by the after surgery.5,11 Deeper infections may have presented after host nation. These rooms lacked adequate traffi c control, the follow-up period, but the majority of surgical procedures infection control measures, and air circulation or fi ltration were minor and complications expected thus would have been compared with traditional surgical facilities in the United superfi cial. The paucity of available medical care in this poor States. In addition, no standardized sanitation procedures Caribbean nation encouraged the population to use the U.S. were followed in these fi xed facilities ( Figs. 2–4 ). The host Support Group medical facilities. Allowing ready access to nation facilities and the fi xed military facility had no oper- care via weekly clinics at each of the surgical facilities further ating room traffi c control measures when procedures were facilitated follow-up care. Thus, it is doubtful that any signifi - not being performed. Sanitation in this environment can be cant wound complications were missed, because the majority

360 MILITARY MEDICINE, Vol. 175, May 2010 Surgical Wound Morbidity of the population visited these medical facilities on a regular 2. Sawyer RG , Pruett TL : Wound infections . Surg Clin North Am 1994 ; 74: basis. 519 – 36 . 3. Pryor F , Messmer PR : The effect of traffi c patterns in the OR on surgical site infections . AORN J 1998 ; 68: 649 – 60 . CONCLUSIONS 4. Garibaldi RA , Cushing D , Lerer T : Risk factors for postoperative infec- The infectious complication rate for clean surgical procedures tion . Am J Med 1991 ; 91: 158S – 62S . performed in a fi eld hospital environment were found to be 5. Nichols RL : Surgical wound infection . Am J Med 1991 ; 91: 54S – 64S . 6. Olser MM , Lee JT : Continuous, 10-year wound infection surveillance . equivalent to historical reports for fi xed hospital or clinic settings. Arch Surg 1990 ; 125 : 794 . The low overall wound morbidity rate of 3.7% may be attrib- 7. Taylor GD : Determining risk of surgical site infections . Can Med Assoc uted to selection bias, because only relatively healthy patients J 1995 ; 152: 1381 . with uncomplicated surgical problems were treated. An increase 8. The Society for Hospital Epidemiology of America; the Association for Practioners in Infection Control; the Centers for Disease Control; the in infectious morbidity was expected because of the environ- Downloaded from https://academic.oup.com/milmed/article/175/5/357/4344592 by guest on 23 September 2021 Surgical Infection Society : Consensus paper on the surveillance of surgi- ment, but none was noted. No special precautions are needed to cal wound infections. [review] Infect Control Hosp Epidemiol 1992 ; 13: ensure a low infection rate. Attention to surgical technique by 599 – 605 . all personnel involved in procedures, as well as proper patient 9. Culver DH , Horan TC , Gaynes RP , et al : Surgical wound infection rates selection, was undoubtedly contributory. The safety of this envi- by wound class, operative procedure, and patient risk index . Am J Med ronment for performing selected surgical procedures has been 1991 ; 91: 152S – 7S . 10. Ferraz EM , Bacelar TS , Aguiar JL , Ferraz AA , Pagnossin G , Batista JE : established. Further training using these facilities should not be Wound infection rates in clean surgery: a potentially misleading risk clas- hampered by safety concerns based on wound morbidity. sifi cation . Infect Control Hosp Epidemiol 1992 ; 13: 457 – 61 . 11. Weigelt JA , Dryer D , Haley RW : The necessity and effi ciency of wound surveillance after discharge . Arch Surg 1992 ; 127: 77 – 82 . REFERENCES 12. Davison JK , Eckhard WF , Perese DA (editors): Clinical Anesthesia 1. Wenze RP : Preoperative antibiotic prophylaxis . N Engl J Med 1992 ; 326: Procedures of the Massachusetts General Hospital , Ed 4 , pp 10 – 11 . 281 – 6 . Boston , Little, Brown , 1993 .

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