Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XVIII: Vascular Injuries

Adjunctive Therapy

United States Department of Defense

Intravenous broad spectrum antibiotic therapy should be initiated as soon as possible after injury. This should be continued throughout the operation and for roughly 24 hours thereafter, assuming there is no continued source of contamination. In most instances, a cephalosporin provides effective prophylaxis.

Anticoagulation of the distal arterial tree is acceptable during operation, but one must be aware that, because of collateral flow, locally injected heparin ultimately becomes systemic. For this reason, relatively small doses of heparin (1500-3000 units at a concentration of 100 units per cc of physiologic saline) are used for anticoagulation of a lower extremity. Systemic anticoagulation is usually not advisable because of the presence of associated injuries. There is rarely, if ever, an indication for postoperative anticoagulation. Adjunctive agents, such as low molecular weight dextran, may be used and may be of value particularly after small artery repairs; however, dextran must be used with caution to prevent volume overload. In most instances, vascular repairs will be successful if the tissues are adequate, the repair is done well, and the hemodynamic and volume status of the patient are kept within normal limits postoperatively.

Although preoperative arteriograms are rarely available in the combat setting, single-shot handinjected intraoperative arteriograms can be easily obtained and are helpful to rule out additional arterial injuries, distal thrombosis, and inadequacy of the repair. Injection of full-strength contrast (Radio-Conray 60) through a 19 gauge needle usually results in an excellent study. Fifteen to 20 cc is usually all that is needed. The film should be exposed while the contrast material is still being injected. At times, run-off may be so rapid that the contrast is washed out by the time the film is exposed. Should this occur, a second injection with inflow occlusion will usually provide adequate visualization. Sympathetic blocks and sympathectomy are of no value in the management of acute arterial injuries. Sympathectomy, as a delayed procedure, may occasionally be helpful to the patient who has had a suboptimal result from arterial repair.

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Operational Medicine 2001

Health Care in Military Settings

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