Prophylaxis against sepsis in patients undergoing major surgery

Role of radionuclide imaging in the diagnosis of postoperative infection

Postoperative infections are a serious cause of morbidity and mortality and are difficult to diagnose. Signs and symptoms that are generally associated with infection may be masked by, or mistaken for, normal postoperative changes. Anatomic imaging modalities provide high-quality anatomic detail and are the procedures of choice in affected patients because of their availability, ease of performance, accuracy, and value in the selection of treatment options. However, radionuclide studies demonstrate physiologic processes, which often precede anatomic changes, and can help distinguish normal postoperative inflammation from infection. Radionuclide studies are also useful in identifying complicated orthopedic infections, in which the often extensive distortions produced by metallic hardware can confound the interpretation of anatomic images. Of the three agents (gallium-67 citrate, indium-111-labeled leukocytes, technetium-99m-labeled leukocytes) that are currently approved in the United States for imaging of infection, In-111-labeled leukocyte imaging is the procedure of choice for diagnosing postoperative infection. Gallium scintigraphy is best reserved for those situations in which leukocyte imaging is not available or there is concern that the suspected infection may not incite a neutrophil response. In general, the value of radionuclide imaging is maximized when used only in those patients for whom the results of anatomic imaging are negative, nondiagnostic, or at odds with the clinical impression.

Metabolic basis for the management of patients undergoing major surgery

After reviewing our current knowledge of the metabolic response to major abdominal surgery, we present two new studies in which we have followed the changes in body composition, physiologic function, and psychological function for up to 1 year after major surgery. In the first study, 46 patients had changes in body composition, physiologic function, and psychological function measured perioperatively and again at intervals up to 1 year. There was an average loss of weight of 3000 grams (maximum at 2 weeks), and the tissue composition of this weight loss was composed of 1400 grams fat, 600 grams protein, and 1000 grams water. Normal body composition had returned to normal in most patients by 6 months. In the second study of 84 patients, deficits of skeletal muscle function and fatigue were found to be greatest at postoperative day 7. Most patients were back to preoperative levels of muscle function and fatigue 30 days after surgery, and nearly all had normal values 90 days after surgery. Based on these studies we outline our management program for the metabolic care of patients undergoing major abdominal surgery.