Battle Casualties in Korea: Studies of the Surgical Research Team, Volume II
Studies of the Absorption and Equilibration of Water(Deuterium Oxide) From the Gastrointestinal Tract Following Abdominal Surgery under Spinal Anesthesia*
Captain John M. Howard, MC, USAR
and
Captain John H. Davis, MC, USAR
in collaboration with
The Division of Atomic and Radiation Physics
National Bureau of Standards
Washington, D. C.
Schloerb and his co-workers3 described an equilibration curve in venous blood following the oral ingestion of deuterium oxide (heavy water) in a human subject. They found an equilibration time of approximately 3 hours.
As part of a study of the systemic response to trauma, this observation was confirmed and extended.1 Similar studies were made in battle casualties who had suffered injuries involving the abdominal viscera. It was found that in such a casualty, equilibration of deuterium oxide from the gastrointestinal tract was markedly slowed. Evidence was presented which suggested that this defect involved an actual decrease in the rate of absorption of water from the bowel. The deficiency was found to persist as long as7 days following the return of normal gastrointestinal function as measured by clinical observations.
This study of patients undergoing abdominal surgery of the types commonly done in civilian practice is an extension of the work done on battle casualties.
The methods of handling the blood samples and of analyzing the plasma for deuterium have been previously described.1
Patient No. 1. This 33-year-old healthy man, after fasting for 12 hours, and while at bed rest, drank 100 grams of deterium oxide. The changing concentration of deuterium in the plasma is demonstrated in Figure 1. Equilibration of the deuterium throughout the body occurred within 90 minutes. Immediately following the uncom-
*Previously published in Surgery 36: 1127, 1954.
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FIGURE 1. Deuterium equilibration curves before and during spinal anesthesia.
Note. The concentration of deuterium for the second study has been corrected for the residual plasma concentration following the first study.
plicated repair of bilateral indirect inguinal herniae, under spinal (procaine)anesthesia, the study was repeated (Fig. 1). At the time of the second study, the patient was still anesthetized below the level of the eighth intercostal nerve.
The operation required only 60 minutes and involved entering the abdomen only at the time of ligating the peritoneal sac. The bowel was not handled at any time.
Postoperatively, the patient took fluids orally in amounts sufficient to control thirst. There were no gastrointestinal symptoms other than constipation for 72 hours.
Patient No. 2. This 23-year-old soldier entered the hospital after an illness of2 days` duration. Laparotomy under spinal (procaine) anesthesia revealed a gangrenous appendix, without perforation. Appendectomy, without additional exploration, was performed, requiring 30 minutes.
Immediately after operation, the stomach was emptied and the patient was given 100grams of deuterium oxide, orally.
The results of the study are demonstrated in Figure 2.
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Patient No. 3. This 25-year-old soldier was admitted to the hospital with abdominal pain of approximately 48 hours` duration. Laparotomy under spinal anesthesia revealed a perforated appendix with generalized peritonitis. Appendectomy was performed.
On the first postoperative day, 15 hours after operation, his blood pressure was128/80, pulse 100, oral temperature 99.8?. No peristalsis could be heard. He had received no medication except antibiotics. He was given at this time 100 grams of deuterium oxide orally, his stomach having been emptied previously by means of a gastric tube.
The results of the study are demonstrated in Figure 3.
Fluids were given intravenously for 48 hours. His subsequent course was uneventful.
Patient No. 4. This 22-year-old soldier became ill 4 hours prior to hospitalization. Examination demonstrated an incarcerated inguinal hernia which was immediately repaired under spinal (procaine) anesthesia. The incarcerated small bowel was discolored but was viable.
He was placed on a course of parenteral fluids and gastric suction.
On the first postoperative day he had no audible peristalsis. Twenty-four hours after operation, he was given 100 grams of deuterium oxide orally. He had received no drugs during the previous 18 hours.
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The equilibration curve is demonstrated in Figure 4.
His subsequent course was uncomplicated.
Discussion
All four patients demonstrated a delayed equilibration time following surgery.
Patient No. 1 demonstrated an equilibration time of 90 minutes following the oral ingestion of 100 grams of deuterium oxide. When the study was repeated following herniorrhaphy and while still under spinal anesthesia, the plasma concentration of deuterium rose to greater levels than had been noted during the control study. This increased concentration gradually subsided to the level of equilibration.
This high concentration cannot be explained simply on the basis of splanchnic vasodilatation and increased rate of absorption for deuterium equilibrates rapidly following its intravenous injection.2, 3 The prolonged period during which the deuterium concentration is elevated must represent a slow diffusion from the blood stream and a continued diffusion or absorption from the gastrointestinal tract during this period.
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FIGURE 4. Equilibration has not been reached within 240 minutes.
The second patient demonstrated an equilibration curve qualitatively similar to that of the first patient. Both patients were studied immediately following the completion of the operation.
The third patient had a generalized peritonitis. His slowly rising deuterium concentration (Fig. 3) and prolonged equilibration period is similar to the pattern found following intestinal perforations due to combat injuries.1 The delayed equilibration in this patient was due primarily to the decreased rate of absorption or diffusion from the bowel.
Patient No. 4 had a rapid increase in the plasma deuterium concentration which reached a peak in 20 minutes (Fig. 4) and then subsided. This has been described as occurring in the normal subject.3 Equilibration, however, was delayed.
Summary
The equilibration time of deuterium oxide, following oral ingestion of 100 grams, was prolonged in four patients who had undergone appendectomy or inguinal herniorrhaphy within the preceding 24 hours. This deficiency appears to be proportional to the magnitude of the original disease or injury.
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References
1. Howard, J. M.: Studies on the Absorption and Equilibration of Water (Deuterium Oxide) from the Gastrointestinal Tract following Injury. Surg., Gynec. & Obst. 100: 69, 1955 (Chapter 2, this volume).
2. Howard, J. M., and Scott, R. Jr.: Equilibration Times of Water (Deuterium Oxide) following Intravenous Injection in the Battle Casualty. Surg., Gynec. & Obst. 99: 703, 1954 (Chapter 4, this volume).
3. Schloerb, P. R., Friis-Hansen, B. J., Edelman, I. S., Solomon, A. K., and Moore, F. D.: The Measurement of Total Body Water in the Human Subject by Deuterium Oxide Dilution. J. Clin. Invest. 29: 1296, 1950.
