Polymorphonuclear leukocyte activation. An early marker of the postsurgical sepsis response

It has been suggested that major surgery induces polymorphonuclear leukocyte (PMNL) dysfunction, which exposes patients to the development of sepsis. Conversely, the sepsis response and multisystem organ failure in patients after surgery is thought to be mediated by activated PMNLs. In a preliminary attempt to investigate this paradox, we studied functional (hydrogen peroxide production) and phenotypic (the adhesion/complement receptor CD11b) markers of PMNL activation in 28 patients undergoing elective major resectional surgery; 11 (39%) of these patients developed postoperative sepsis (the septic group). The mean (SEM) preoperative level of neutrophil CD11b expression (97.8 [6.2] mean channel fluorescence [MCF] and 101.42 [7.9] MCF; P = .74) and hydrogen peroxide production (109.51 [4.91] MCF and 104.53 [6.3] MCF; P = .5) were similar for the uncomplicated and septic groups, respectively. However, on the first postoperative day, both mean CD11b expression and hydrogen peroxide production were greater in those patients who subsequently developed postoperative sepsis (192.5 [38] MCF vs 128.6 [8.1] MCF for the septic group vs the uncomplicated group, respectively [P < .05], and 120.43 [2.56] MCF vs 109.61 [3.05] MCF for the septic group vs the uncomplicated group, respectively [P < .0001]). We suggest that an exaggerated PMNL activation response to surgery is an early event in those patients destined to develop postsurgical sepsis.

[Early immunoglobulin therapy in high risk patients for infection after heart surgery]

The efficacy of early supplemental intravenous immunoglobulin G (ivIgG) treatment was investigated in 41 patients at risk for sepsis following cardiac surgery (APACHE II score > or = 19 on the 1st postoperative day). The ivIgG preparation (Psomaglobin N) was chosen because of its reported high antibody titers and effectiveness in animal models against gram-positive microorganisms, preponderant as infective agents after heart surgery. The control group consisted of a historical cohort of 42 cardiac surgical patients of comparable pretreatment disease and sepsis severity. Following ivIgG therapy on the 1st and 2nd days after surgery, we found a marked improvement in disease severity (fall in APACHE II scores) in contrast to the control patients, especially evident in the high-risk group of patients with an APACHE II score > or = 24 on the 1st postoperative day (n = 26). In this group, ivIgG therapy led to higher (p < 0.05) response rates defined as a score decrease > or = 7 within 4 days (ivIgG-treated patients 54%, controls 19%), and a reduction in mortality (ivIgG-treated patients 46%, controls 76%; p = 0.08). Given the good comparability of the study groups, the results of this trial indicate, despite its nonrandomized design, that early supplemental ivIgG treatment seems to decrease disease severity and probably also improve the prognosis in APACHE II score identified high-risk patients after cardiac surgery.

Factors influencing the risk of infection after trauma

Infection after injury is characterized by the degree of contamination, the duration of attendant hypotension, and the delay in definitive surgical treatment. Factors further influencing this outcome include the age of the patient and, in most U.S. urban centers, the general health of the patient. Current antibiotic treatment of such patients may soon be assisted by selective and sequential immunostimulants, which are increasingly more specific for defined defects in host defenses after injury. An ever more significant contribution to morbidity and mortality on trauma services is pneumonia, which is often caused by gram-negative aerobes. The design of clinically significant trials with respect to infection in the injury patient will be more difficult and complex.

[Current approaches to the prevention of infectious complications in heart surgery]

Due to changes of humoral immunity, patients with rheumatic heart disease present, even before the operation, a high-risk group with regard to the development of infectious complications. Contamination of intraoperative material was revealed in 61.7% of cases during the operation. Extracorporeal circulation increases the cefotaxime half-life period which is in direct proportional dependence of the period of time between the beginning of the administration of the agent and the beginning of extracorporeal circulation. Immunocorrection by means of myelopid in the early postoperative period accelerates restoration of cellular and humoral immunity, and reduces the frequency of pneumonia occurrence and suppuration of the postoperative wound. Therefore, the prevention of infectious complications after operations on an open heart should be complex and should include broad-spectrum antibiotics and immunocorrective therapy.

Predicting infectious morbidity in elective operations

The determination of surgical risk is a major problem in general surgical practice and many studies have attempted to predict postoperative outcome. Clinical judgment is still a fundamental skill with which the experienced surgeon can estimate the risk of postoperative infectious morbidity. Predictive scores based on statistical analysis have also proven to be valid and useful tools. This discussion analyzes the importance of surgical risk prediction. With future research in this area, it is hoped that therapeutic strategies will result that will reduce or eliminate this risk.

Changes in major histocompatibility complex class II expression in monocytes and T cells of patients developing infection after surgery

Expression of class II major histocompatibility complex (MHC) on monocytes is a prerequisite for effective antigen presentation and processing, an important component of the immune response to infection. It has been reported that the level of monocyte class II expression may identify patients who go on to develop infective complications following trauma. In the present study, flow cytometry was used to measure MHC class II (human leucocyte antigen (HLA)-DR) expression on circulating monocytes and T cells in 36 patients undergoing elective major resectional surgery, of whom 12 developed septic complications. The percentage of HLA-DR positive monocytes fell significantly on the first day after operation in both groups (P < 0.001) but was significantly higher in those without than in those with sepsis on days 1, 3 and 5 (P < 0.05). In contrast, the level of T cell HLA-DR expression rose significantly on the first day after operation (P < 0.05) in patients without sepsis to a level higher than in those who developed infection (P < 0.05). These findings have important implications, as predictive biological elements and for biological response modification, in patients at risk of developing sepsis after surgery.

[The efficacy of specific plasma in the therapy of newborn infants with a Pseudomonas aeruginosa surgical infection]

141 newborn with purulent surgical infection were under observation. In 73 the inflammatory process was not induced by Pseudomonas aeruginosa in 68 the infection was caused by the blue pus bacillus. Bacteriological and immunological examination was conducted, including that with the use of enzyme immunoassay, to monitor the optical density of anti-pyocyanea antibodies during the course of the disease. It was found that the serum of a healthy newborn baby contains antibodies to Pseudomonas pyocyanea and did no differ from that of healthy older children in the level of anti-pyocyanea antibodies. The increase of the level of anti-pyocyanea antibodies in response to infection with Pseudomonas pyocyanea is twice less in newborns than older children with this infection. The use of specific plasma is much more effective than the administration of nonhyperimmune plasma. The efficacy of treatment with anti-pyocyanea plasma is determined by the level of anti-pyocyanea antibodies produced in the patient as a result of plasmatherapy rather than the volume of the dose given for the course.

Postoperative wound infection. A poor prognostic sign for patients with head and neck cancer

BACKGROUND

The development of a wound infection has been identified as a favorable prognostic factor after oncologic surgical procedures.

METHODS

The authors retrospectively studied the relationship between postoperative wound infection, local/regional tumor recurrence, and survival rates in 134 patients undergoing therapeutic surgical resection for squamous cell carcinoma of the head and neck (SCCHN).

RESULTS

The median age was 61 years (range, 25-87 years) with most (75%) patients having advanced disease (Stage III or IV). Patients without evidence of recurrent disease were followed up for a median time of 34 months (range, 24-68 months). Twenty-nine (22%) had local or regional bacterial infections develop postoperatively. Recurrence rates were increased (P = 0.008) in patients with postoperative wound infections compared with patients who had distant infections, e.g., pneumonia or urinary tract infection, or no infection. Disease-free survival also was adversely affected (P = 0.04) in this group. Both advanced tumor stage and postoperative wound infections were independently associated with decreased survival, with odds ratios of 2:3 and 2:4, respectively.

CONCLUSIONS

These data contrast with other reports in the literature of a beneficial effect of postoperative wound infection on outcome. These findings suggest a possible relationship between local/regional immune function and postoperative infection in patients with SCCHN:

[Wound infection]

A present-day view on the problem of wound infection is analyzed with special reference to recent data. Active surgical approach in combination with many-component antibacterial and correcting treatment still remains important in prevention and treatment of wound infection.

[Anomalies of immunoglobulin synthesis in vitro in surgical patients]

It is known that blood mononuclear cells from surgical patients produce large amounts of IgG in vitro, and that this synthesis is not increased by pokeweed mitogen stimulation. The objective of the present study was to determine if this abnormal pattern of IgG synthesis extended to other immunoglobulin classes. Patients were stratified according to delayed type hypersensitivity as reactive (induration > 5 mm to > one skin test antigen), or anergic (no response). Healthy laboratory personnel were studied as controls. Mononuclear cells were cultured for 10 days, without or with pokeweed mitogen. IgG, IgM, and IgA in supernatant was measured using a competitive solid phase radioimmunoassay. Unstimulated IgG and IgA synthesis was increased in surgical patients, especially in those with reduced delayed type hypersensitivity responses. IgM synthesis was normal or low. With mitogen stimulation, normal increases in IgG synthesis were seen in control and reactive subjects. In anergic patients, IgG was not increased by pokeweed mitogen. For IgM, mitogen stimulation increased synthesis but to a lesser degree in patients than in controls. For IgA, synthesis was increased by mitogen stimulation in all groups. In conclusion, surgical patients show abnormalities in the pattern of spontaneous and mitogen stimulated immunoglobulin synthesis. The pattern varies for each isotype. B cell activation is present in surgical patients, especially those with reduced delayed type hypersensitivity. This suggests either recent antigenic stimulation, or non-antigen specific dysregulation of the B cell system in surgical patients.

[Key problems of the pathogenesis of infection]

The authors analyse the results of clinico-immunological studies in 452 patients with various forms of pyogenic surgical infection; 292 of the patients had surgical sepsis. It is proved that the condition of the primary and secondary purulent foci determines the course of the wound process and the occurrence and progress of sepsis. Radical surgical debridement of the wound leads to early optimization of the condition of the immune system and creates conditions for effective immunologic correction and intensive therapy.

[Postoperative complications and mortality; results of skin tests in delayed hypersensitivity]

In 221 patients the test of cutaneous delayed hypersensitivity was done before the operation and 4 days after it, using 3 antigens: tuberculin, distreptase and phytohaemagglutinin. The patients were divided into three groups: I control (109) subjected to minor and moderately serious operations, and study group (II) with peritonitis (IIa 40 cases), digestive tract cancer (IIb 65 cases) and digestive tract diseases (IIc 7 cases). The study showed that in cases with preoperative anergy to antigens the operations were followed significantly more frequently by serious septic complications and mortality from these complications was much higher. No patients with preoperatively normal responses to the antigens died after the operations. The test makes possible preoperative detection of high surgical risk connected with infection, and early treatment reducing postoperative mortality.

Infections in neurologic surgery. Host defenses

Normal host defense mechanisms are effective in preventing central nervous system (CNS) infection. Opsonins and compliment levels are normally low in the CNS, however. The relationship of these factors to CNS infection, specifically surgical wound infection and shunt infection, is discussed.

[A system for the clinico-immunological prognosis of infectious-inflammatory complications in planned surgery]

Postoperative infectious complications in planned surgery are a pressing problem. The preoperative condition of the patient and his immune system play an important role in their development. Fifty patients of the "risk" group were selected from the standpoint of classification of the etiological factors of secondary immunodeficiency states. Fifteen patients who had no symptoms classified as SIDS risk factors formed the control group. The immune status was examined before and on the third day after the operation in all patients of the main and control groups. Various infectious complications developed after the operation in 23 patients of the risk group. No such complications occurred in the control group. The preoperative immune status of the risk group patients differed significantly from that of the controls in 13 of 19 parameters. The patients of the main and control groups formed the instructing selection. An expert system of preoperative clinico-immunological prognostication of postoperative infectious-inflammatory complications was created on oasis of the methods of the theory of image recognition and instructing selection. The system was tested in a direct clinical experiment on 66 patients. The prognoses were correct in 89% of cases. It was thus proved that symptoms classified as SIDS risk factors influence the initial immunity status and the course of the postoperative period in planned surgery. An accurate, sensitive, and specific method for prognosticating postoperative infectious complications is suggested.

[Transplantation of the heart-lung complex (the first clinical experience)]

The article deals with experience in the first transplantation of a heart-lung complex in the USSR. The recipient was a 34-year-old male with dilation cardiomyopathy. It was decided to perform the transplantation because the terminal stage of cardiac failure and secondary pulmonary hypertension developed (cardiac index 1.3 l/m, pressure in pulmonary artery 80/50 mm Hg, resistance of pulmonary vessels 10.4 units after Wood). The heart and lung were transplanted from a 19-year-old male who died from a craniocerebral injury. Cyclosporine, metipred , imuran, dopamine in small doses, cardiotonics, and antibiotics were given in the postoperative period; the patient was kept on artificial respiration for 48 hours. For up to 10 days the patient's condition was relatively stable and his consciousness was clear. Bilateral pneumonia developed, however, from which he died on the 12th postoperative day. The article discusses organizational problems and some questions of immunosuppressive therapy, immunological monitoring, and the management of patients after transplantation of a heart-lung complex.

HLA-DR antigen expression on peripheral blood monocytes correlates with surgical infection

Monocyte human leukocyte antigen-DR (HLA-DR) expression has correlated closely with clinical outcome in severely injured patients at high risk for infection. Monocytes from 77 asymptomatic volunteers expressed HLA-DR antigen with minimal variability in respect to age, gender, race, time of day or year, or serum alcohol level. Patients who developed infection after elective laparotomy had a significantly lower mean percentage of monocytes expressing HLA-DR antigen and a lower mean fluorescent intensity than uninfected patients (p less than 0.05). Severely infected nonsurgical patients had significantly lower values than normal volunteers (p less than 0.01), and the mean fluorescent intensity of those who died from infection was significantly lower than that of those who survived (p less than 0.05). Patients on immunosuppressive regimens after renal transplantation had levels of HLA-DR expression similar to those of the volunteers. Monocyte HLA-DR expression was found to be a reliable marker of clinical infection and showed remarkable reproducibility within the normal uninfected study population.

[Predictive factors of postoperative infection. Value of cutaneous immunologic tests]

A prospective study of the risk of postoperative local and general infectious complications was realized on 93 patients undergoing elective general surgery. The factors usually known to favour these septic complications, such as the length, the importance of the operation, as well as a preoperative loss of weight and thoracic or abdominal surgery are significantly demonstrated. Preoperative laboratory results bring no significant predictive information. On the contrary, when the immune defense mechanisms (determined by the cutaneous sensibility to ubiquitous antigens) were absent or very low before surgery, these patients significantly developed more septic postoperative complications.

[Diagnosis of "excited skin syndrome" from blood. An aid in plastic surgery]

The relevance of hyperergic responsiveness in type IV allergies (synonyms: angry back, excited skin syndrome) for the postoperative course of wound healing and the tolerance against grafts, especially against synthetic materials, is discussed. The common non-specific prophylactic administration of drugs must be re-evaluated. The possibility of improving the diagnosis of the phenomenon by determining T-lymphocyte subpopulations, a method that is not well known, is discussed.

[Lysosomal-cation test in the control of treatment of acute proctological diseases]

An express evaluation of the functional state of neutrophil granulocytes by the indications of the lysosomal-cationic test are thought to be a necessary addition to routine clinico-laboratory methods of assessment of the wound process in patient with the suppurating epithelial coccygeal canal and acute paraproctitis. Use of cytochemical indices allow the antibacterial therapy to be optimized in patients with suppurating epithelial coccygeal canal and thus substantially decrease the amount of complications in the postoperative period.