Anaesthesia, surgery and immunology

Postoperative lymphopenia: An independent risk factor for postoperative pneumonia after lung cancer surgery, results of a case-control study

Objective

Postoperative lymphopenia has been proposed as a risk factor for postoperative infections but has never been identified as such in a multivariate analysis. Postoperative pneumonia (POP) is one of the most common complications after lung cancer surgery and is associated with a worse outcome. We aimed to evaluate the association between postoperative lymphopenia and POP after lung cancer surgery.

Methods

Patients admitted for lung cancer surgery (lobectomy, bilobectomy, or pneumonectomy) aged ≥ 18 years and with no history of an immunosuppressive state were eligible for inclusion. Lymphocyte counts were determined in blood drawn on the day before surgery and at postoperative days 1, 3 and 7. POP diagnosis was based on clinical, biological and radiological data. A logistic regression model adjusted on currently described risk factors for POP was used to explain the onset of this condition.

Results

Two hundred patients were included, of whom 43 (21.5%) developed POP. Preoperative lymphocyte count was 1.8±0.6x10⁹ cells/L and 2.0±0.7x10⁹ cells/L in patients with and without POP, respectively (P = .091). In both groups, the lymphocyte count nadir occurred at postoperative day 1. In multivariate analysis, lymphopenia at postoperative day 1 was significantly associated with increased risk of POP (odds ratio: 2.63, 95% CI [1.03–5.40]). POP rate at postoperative day 7 was higher in patients presenting low lymphocyte counts (≤1.19x10⁹ cells/L) at postoperative day 1 (P = .003).

Conclusions

Our study showed that lymphopenia following lung cancer surgery was maximal at postoperative day 1 and was associated with POP.

Influence of anesthesia on immune responses and its effect on vaccination in children: review of evidence

Anesthesia and surgery exert immunomodulatory effects and some authors argue that they may exert additive or synergistic influences on vaccine efficacy and safety. Alternatively, inflammatory responses and fever elicited by vaccines may interfere with the postoperative course. There is a lack of consensus approach among anesthesiologists to the theoretical risk of anesthesia and vaccination. Few studies have assessed the influence of anesthesia and surgery on pediatric vaccine responses. We have undertaken an extensive review of articles published in English between 1970 and 2006 meeting the criteria: measurement of immune parameters following general anesthesia in children. By searching the major medical databases (OVID Medline, PubMed, ISI Web of Science) and references cited in the articles themselves, among 277 articles obtained none examined directly the influence of anesthesia/surgery on vaccine responses. Only 16 original reports assessed the influence of several anesthetic agents on various markers of immunity including lymphocyte numbers and functions. These results are reinterpreted here in view of our current understanding of the immune mechanisms underlying vaccine efficacy and adverse events. We conclude that the immunomodulatory influence of anesthesia during elective surgery is both minor and transient (around 48 h) and that the current evidence does not provide any contraindication to the immunization of healthy children scheduled for elective surgery. However, respecting a minimal delay of 2 days (inactivated vaccines) or 14-21 days (live attenuated viral vaccines) between immunization and anesthesia may be useful to avoid the risk of misinterpretation of vaccine-driven adverse events as postoperative complications.

Effect of halothane on intercellular adhesion molecule-1 (ICAM-1) in melanoma cells

There have only been a few reports relating to the effect of inhalational anesthetics on the tumor cell morphology in cancer patients undergoing surgery. We hypothesized that some anesthetic agents might influence the spread of unresectable cancer cells and might additionally worsen the condition of the patient due to depressed host immune surveillance. We therefore evaluated the influence of halothane on tumor cell adhesion, which is closely linked to tumor cell metastasis. Human melanoma cells from SK-MEL-37 cell-line were exposed to 4% halothane for 3, 6, 12 or 24 hours, respectively. Furthermore, after 24 hours halothane exposure, they were incubated in a 5% CO2 atmosphere for 12 or 24 hours. The cells were then analyzed using a fluorescence flowcytometer and intercellular adhesion molecule-1 (ICAM-1) expression in SK-MEL-37 cells was quantified as the intensity of fluorescence of ICAM-1 expressed in 10,000 cells. ICAM-1 expression in cells exposed to halothane for 3, 6, 12 or 24 hours was lower than that of non-exposed cells and returned to control level after further incubation in 5% CO2 atmosphere for either 12 or 24 hours. We conclude that halothane might affect the progression of tumor cell metastasis in vitro.

Measurement of intracellular gamma-interferon, interleukin-4, and interleukin-10 levels in patients following laparoscopic cholecystectomy

Major surgery suppresses intracellular T-cell cytokine production. Laparoscopic surgery has been reported to have no effect on in vitro lymphocyte reactivity, but its effects on intracellular cytokine production are unknown. This study measured T-cell intracellular gamma-interferon, interleukin-4 (IL-4), and interleukin-10 (IL-10), along with serum interleukin-6 (IL-6) and cortisol levels, immediately before and 1 day after laparoscopic cholecystectomy in a cohort of six Air Force and veteran patients. Stimulated intracellular levels of gamma-interferon were slightly, but not significantly, elevated during the postoperative period in all T-cell subsets. There were no postoperative changes in stimulated IL-4 or IL-10 levels. Postoperative serum IL-6 levels, but not serum cortisol levels, were significantly elevated compared to preoperative values. In conclusion, laparoscopic surgery causes slight trauma but has no effect on T-cell intracellular interferon, IL-4, and IL-10 responses.

Lymphocytic subpopulation changes after open and laparoscopic cholecystectomy: a prospective and comparative study on 38 patients

Up to now it has been unclear whether laparoscopic surgery has fewer immunosuppressive effects than traditional laparotomic procedures. In a series of 38 patients affected by symptomatic gallstone disease and operated on either by laparoscopy (group 1) or by traditional open surgery (group 2), we determined the postoperative changes in lymphocyte subpopulations up to postoperative day (POD) 30. We collected 15 ml of venous blood from all patients in both groups on the day before surgery and on POD 1, 7, 15, and 30. A control group (group 3) comprised 56 healthy volunteers; the control group was used only to ensure that baseline values were totally comparable with a normal population; only one blood sample was obtained from the subjects in group 3. Patients undergoing open cholecystectomy had a significant decrease in total lymphocyte count on POD 1. Basal levels of lymphocyte subpopulations did not differ significantly in the study and control groups. No differences were found in the preoperative lymphocyte cell counts in the two groups who underwent cholecystectomy. Pan-T cells (CD3) showed a statistically significant marked reduction throughout the observation period. The counts of helper (CD4), suppressor (CD8), and natural killer NK (CD16) T cells were reduced on POD 1; the NK cell (CD16) count remained low until POD 30, B lymphocytes showed no postoperative reduction. In patients who underwent laparoscopic cholecystectomy, a significant postoperative decrease in total lymphocyte count, and in CD3, CD4, and CD8 subpopulations was observed on day 1 only. There was no reduction in CD16 and CD19 subpopulations. A comparative statistical analysis of lymphocyte subpopulations in the two groups was carried out: In the open cholecystectomy group, compared with the laparoscopy group, CD3, CD4, CD8, and CD16 lymphocyte subpopulations showed marked reductions at different time points. In particular, statistically significant differences were found in CD3 levels from POD 1 through POD 30, in CD4 from day 1 through day 7, and in CD8 and CD16 only on day 1.

Impact of thymopentin on the incidence and severity of postoperative infection: a randomized controlled trial

The effectiveness of perioperative administration of thymopentin in preventing postoperative infection was evaluated in 206 patients with cancer (54 gastric, 152 colorectal) who underwent elective major surgery. Comparable subsets of patients were obtained with respect to age (proportion over 65 years) and nutritional status (patients with serum albumin level less than 30 milligrams or weight loss of 10 per cent or more of usual body-weight were considered to be malnourished). Patients were then randomly assigned to a control group or to a group receiving thymopentin. All patients received perioperative short-term antibiotic prophylaxis and postoperative parenteral nutrition. Levels of CD3-, CD4- and CD8-positive T cell subsets were evaluated before and after surgery in 20 (ten elderly) patients from each group. The severity of postoperative infection was evaluated using a sepsis score. In elderly patients thymopentin prevented the postoperative drop in CD3- and CD4-positive T cell subpopulations that was observed in controls (P < 0.05d). The postoperative infection rate was 17.5 per cent in the group given thymopentin and 24.3 per cent in controls (P not significant). The mean (s.d.) sepsis score was 6.7 (3.1) in the group receiving thymopentin and 9.4 (5.8) in controls (P not significant). Considering only elderly patients, the mean (s.d.) sepsis score was significantly lower in those treated with thymopentin than in control patients (6.9(2.1) versus 11.3(4.7)). In conclusion, administration of thymopentin did not significantly reduce the postoperative infection rate. However, it prevented the drop in number of CD3- and CD4-positive T cells after operation and reduced the severity of postoperative infection in elderly patients.

The reduction of anxiety in surgical patients: an important nursing task or the medicalization of preparatory worry?

The reduction of pre-operative anxiety in surgical patients is a routine part of nursing care, but much of the evidence which supports the view that high anxiety is related to worse recovery is based on ambiguous or unreliable indices of recovery. Instead, it has been argued that moderate levels of preoperative anxiety can help patients to prepare for surgery and reduce its stressfulness. On this basis, attempts to reduce anxiety would amount to the "medicalization" of a normal and useful state. Until recently little evidence supported this view, but research which has used hormonal changes to index surgical stress has provided evidence consistent with it. Alternative strategies for psychological preparation can be designed, which are not based on an attempt to reduce anxiety. However, attempts at psychological preparation of surgical patients pre-operatively should be regarded as experimental until more evidence is available about their effects on recovery.

Changes of expression of endogenous sugar receptors by polymorphonuclear leukocytes after prolonged anaesthesia and surgery

Anaesthesia and surgery are known to depress granulocyte function in the early postoperative period, leading to deterioration of the immune defence against infection. Carbohydrate-lectin interactions may play an important role in the activities of phagocytic cells in that they facilitate initial host defence in the event of microbial antigenic challenge. A panel of biotinylated (neo)glycoproteins (chemically glycosilated carrier proteins) was used to detect endogenous carbohydrate-binding receptors /lectins/, on peripheral blood polymorphonuclear leukocytes of patients undergoing prolonged anaesthesia for replantation surgery. Four hours after induction of anaesthesia, a progressive decline of expression of endogenous sugar receptors on granulocytes was detected using the labelled (neo)glycoproteins lactose-BSA, N-acetyl-D-glucosamine-BSA, D-mannose-BSA, sialic-acid-BSA and D-xylose-BSA. Concomitant changes in peripheral white blood cell counts and the lack of depression in the absence of general anaesthetic agents suggested the existence of a possible relationship between reduced expression of (neo)glycoprotein receptors to impaired granulocyte function and anaesthetic-induced immunodepression.

Anesthetic agents induce human mononuclear leucocytes to release cytokines

Studies were carried out on the ability of some anesthetic agents (Propofol, Dormicum, Ketalar and Penthotal) to induce the release of cytokines by human monocytes and lymphocytes in vitro. All anesthetic agents tested at hematic concentrations reached during anesthetic administration cause an increase in the production of Tumor necrosis factor (TNF) from human monocytes; the increase is 4-5 times greater than controls. The greatest Interleukin -1 alpha (IL-1 alpha) production increase was induced by Propofol. The release of Interleukin -6 (IL-6) is notably increased by Ketalar (about 10 times greater than controls). In the presence of different anesthetic agents, human lymphocytes release Interleukin -4 (IL-4) and Interferon gamma- (IFN-gamma). Penthotal and Ketalar increase IL-4 production which appears quite high compared to that obtained with Con A used as standard challenge. Propofol induce IL-4 release which is about the same as that seen with Con A. IFN-gamma is released in high quantities by lymphocytes treated with Propofol. Dormicum, Ketalar and Penthotal induce non-significant increase of IFN-gamma release. The results concern the choice of anesthetic, in relation to its action on host immune response. This aspect is particularly interesting in immunocompromised host.

The risk factors of median sternotomy infection: a current review

Sternal sepsis following median sternotomy is an infrequent yet devastating complication of cardiac surgery, leading to prolonged hospitalization, increased hospital expense, and a high associated morbidity and mortality. The development of sternotomy infection is multifactorial. Numerous prospective and retrospective studies have pointed to a multitude of clinical and perioperative variables as being causative, with as many other studies presenting evidence of the contrary. This has led to confusion about which clinical variables should be modified so as to minimize the individual patient's risk for developing this severe complication. Other less obvious factors also come into play. Malnutrition, whether overt or subclinical, is not uncommon in cardiac patients. Immune competency is affected by operative trauma, as well as a variety of perioperative factors including underlying nutritional status, transfusion, cardiopulmonary bypass, and anesthesia. This creates a complex milieu for the development of postoperative infection. In this review, the multiple risk factors of median sternotomy infection are studied and treatment options briefly discussed.

Anesthesia inhibits poly I:C induced stimulation of natural killer cell cytotoxicity in mice

The effects of general anesthesia on the levels of baseline and inducible splenic natural killer (NK) activity of mice were examined. General anesthesia significantly inhibited the induction of NK activity by Poly I:C, while having no effect on baseline NK. Since this effect was reproduced using three different anesthetics (Avertin, ether, and Ketamine/Xylazan), the inhibition of inducible NK activity is probably due to the state of general anesthesia, rather than to the pharmacological properties of the anesthetics. Inhibition of the Poly I:C mediated induction of NK was observed for at least 4 days after anesthesia. In contrast to anesthesia alone, anesthesia with surgery significantly decreased baseline NK activity. However, the addition of surgery to anesthesia did not significantly alter the level of inhibition of NK stimulation by Poly I:C compared to anesthesia treatment alone. Experiments assessing the NK modulatory effects of surgery alone were not performed. Interestingly, neither anesthesia alone nor anesthesia with surgery were able to significantly decrease splenic NK activity that had been induced with Poly I:C prior to anesthesia. In view of the important role of NK cells in the innate immune defenses, the possible clinical applications of these results are discussed.

Reduced expression of mannose-specific receptors on murine peripheral blood polymorphonuclear leukocytes following prolonged anaesthesia with different inhalation agents

Inhalation anaesthetic agents are known to depress phagocytic functions such as mobilization, attachment, chemotactic motility, engulfment and intracellular killing. Mannose-specific sugar receptors on the surface of leukocytes are involved in a series of phagocytosis-related activities. To investigate the effect of anaesthesia on the expression of this type of sugar receptor, mice were anaesthetized with halothane, enflurane and isoflurane. The presence of mannose-binding receptors on peripheral blood polymorphonuclear leukocytes was examined glycocytochemically using the biotinylated neoglycoprotein mannosylated bovine serum albumin. Prolonged administration of inhalation anaesthetic agents, especially halothane, markedly depressed expression of mannose-specific receptors. This reduction may possibly contribute to postoperative immunodepression, resulting from the impaired cellular interaction which is involved in the phagocytic function of granulocytes.

The effects of anesthesia and surgery on lymphocyte populations and function in infants and children

A study was designed to test the hypothesis that the lymphopenia caused by surgical stress in children may arise through selective depletion of one or more lymphocyte subsets. Blood samples from 22 children were taken pre- and postoperatively and 6, 12, 24, and 48 hours after surgery. Lymphocyte subsets were identified and counted using monoclonal antibodies and indirect immunofluorescence. By six hours postoperatively, the mean total lymphocyte count had fallen by 1.87 x 10(9)/L (P less than .01); this was largely due to the fall in helper T cells (1.53 x 10(9)/L, P less than .01) and both counts remained depressed for at least 48 hours. The helper:suppressor ratio also fell, from 3.42 to 1.92 (P less than .01), but had recovered by 48 hours. Lymphocyte function as measured by the response to pokeweed mitogen and concanavalin A was also reduced six hours postoperatively. These changes were independent of age. Major surgery in infants and children causes a selective reduction in helper T lymphocyte numbers, helper:suppressor ratio, and lymphocyte function. This suggests that immune competence in the immediate postoperative period in children is reduced, as it is in adults. The duration of this and its relationship to infection are not yet known.

Antigen-specific electrophoretic cell separation for immunological investigations

Preincubation of human blood lymphocytes with cell surface antigen specific antibodies under non-capping conditions reduces the electrophoretic mobility of the corresponding lymphocyte subpopulation. Antigen-positive and antigen-negative cells can be separated by free flow electrophoresis with high yield, purity and viability. The use of fluorescence-labelled second antibodies augments the induced decrease in net surface charge density, and allows rapid detection of antigen-positive cells in the fractions of electrophoresis. Carrier-free cell electrophoresis of human peripheral blood lymphocytes after reaction with anti-IgM-antibody or the monoclonal antibodies OKT4 or OKT8, and sandwich staining with tetrarhodamine isothiocyanate-labelled anti-IgG resulted in the large-scale separation of high pure human B and T lymphocyte subpopulations. Their functional integrity was shown in assays of lymphocyte transformation and of antigen-specific induction and regulation of antibody synthesis in vitro. These separate lymphocyte subpopulations are useful tools for immunological investigations. While, for instance, the effects of drugs on human lymphocytes are obscured by coincident changes in cell composition of the peripheral blood tested that do not by themselves reflect whole body immunocompetence, the cell separation and in vitro assays at a defined cell number and cell composition allow the recording of quantitative changes in the function of different cell subpopulations. We studied the influence of the anesthetic thiopental on separated human lymphocyte subsets. In both polyclonal lectin stimulation and in vitro antibody production, thiopental exhibited a noncytotoxic suppression of lymphocyte functions. B-Cells, T-helper and T-suppressor cells were equally affected and showed the same dose response.(ABSTRACT TRUNCATED AT 250 WORDS)

Suppression of natural killer cell activity by high-dose narcotic anesthesia in rats

Suppression of natural killer (NK) cell activity in the postoperative period has been reported in several clinical studies. Endogenous opioids and cerebral injection of morphine have been shown to suppress NK cell activity. Since high-dose opiates are commonly used in anesthetic practice, we sought to determine the effects of three narcotic agents on NK cell activity. Male rats were injected subcutaneously with morphine (30 mg/kg), fentanyl (0.3 mg/kg), or sufentanil (0.06 mg/kg). Three, 12, or 24 h later the cytotoxic activity of splenic NK cells was measured in a 4-h chromium-51 release assay using radiolabeled target cells. All three drugs significantly suppressed NK cytotoxicity at 3 h after administration; this effect was blocked by an opiate antagonist, naltrexone. Fentanyl and sufentanil also caused a significant suppression 12 h after drug administration. By 24 h NK activity of all groups returned to normal values. Interferon is known to augment NK cell activity. Therefore, in another experiment rats were given an interferon inducer, polyinosinic:polycytidylic acid (poly I:C), to determine if it would alter the effects of these narcotics on splenic NK activity. Poly I:C treatment increased NK cytotoxicity to above baseline; fentanyl in these animals reduced NK activity and brought it back to control levels. These findings suggest that clinically used high-dose narcotic anesthesia can suppress NK cytotoxic activity and that pretreatment with interferon can attenuate this suppression.

Detection of thiopentone-reactive IgE antibodies following anaphylactoid reactions during anaesthesia

A radioimmunoassay was developed to detect IgE antibodies to the anaesthetic induction agent thiopentone. Significant levels of thiopentone-reactive IgE antibodies were found in the sera of two patients who had experienced life-threatening anaphylactoid reactions following administration of the drug. Inhibition experiments revealed that cross-reactivity occurs between the drug-reactive IgE antibodies and four barbiturate analogues pentobarbitone, phenobarbitone, barbitone and methohexital. The assay should supplement skin testing for the detection of patients with potentially lethal sensitivity to thiopentone.

Physiological and subjective stress responses in surgical patients

Autonomic responses, mood and psychological coping were assessed in two groups of orthopaedic patients during hospitalisation for major or minor surgery. Eight patients admitted for total hip replacement and seven patients undergoing knee arthroscopy were seen daily for two days before surgery until discharged from hospital. Mood and coping questionnaires were administered on each session, while pain, heart rate, blood pressure, skin conductance level, palmar sweat prints and forearm EMG were also recorded. Heart rate increased from pre- to post-operative assessments, while skin conductance and palmar sweating fell to low levels on the days immediately following surgery, returning to basal values only after several days. Self ratings of anxiety, fatigue, depression and pain were highest on the immediate post-operative days. Patients utilised the coping factors Rational Cognition and Behavioural Action to the greatest extent, but ratings on coping factors fluctuated little over the study period. The interrelations between these measures and possible explanations of the results are discussed.

The influence of surgical operations on components of the human immune system

Surgical operations have been shown to cause a variety of immunological disturbances in man both in vivo and in vitro. With few exceptions the overall picture is one of a generalized state of immunodepression in the postoperative period. The implications of these observations are that host defences may be compromised by surgical procedures, thus providing a 'fertile soil' for bacterial invasion and tumour cell metastasis at the very time when risks from invading pathogens and viable tumour cells are maximal. We have studied the effects of surgical operations on the immune system in 35 patients with benign disease. Surgical procedures were classified as either minor (n = 15) or major (n = 20). A panel of monoclonal antibodies was used to identify peripheral blood lymphocyte subpopulations and analysis was performed using flow cytometry. Simultaneous estimations of plasma alpha-1 proteinase inhibitor (alpha-1-PI), alpha-2-macroglobulin (alpha-2-M), alpha-2-pregnancy-associated glycoprotein (alpha-2-PAG) and plasma suppressive activity (PSA) on stimulated allogeneic lymphocytes were performed before operation and on postoperative days 1, 3, 7, 17 and 21. Circulating numbers of all lymphocyte subpopulations fell significantly following surgery, except for B lymphocytes which did not change. The magnitude, and duration of the reduction in cell numbers and the subpopulation affected was significantly related to the degree of surgical trauma, and returned to pre-operative values by postoperative day 7. Changes in alpha-1-PI, alpha-2-M, alpha-2-PAG and PSA were also significantly related to the degree of surgical trauma, and these plasma changes persisted longer than the cellular disturbances. Surgical operations induce a reversible depression of cellular immunity which precedes plasma suppressive activity in its return to pre-operative levels. Immunostimulating agents such as interferon and the interleukins deserve evaluation as prophylactic agents pre-operatively.

Anaesthetic risks in osteoarticular disorders

Anaesthesia in patients with either treated or untreated osteo-articular disorders poses a number of specific problems. The authors deal with risks resulting from mechanical deformities produced by these disorders, by the involvement of a large number of functional systems, by changes in the immune status of such patients and by alterations in the reactions of arthritic patients resulting from prior or concurrent treatments. The authors emphasize the crucial points which require evaluation and observation before and during anaesthesia.

Skin testing in the preoperative diagnosis of anaesthetic allergy

Intradermal testing is a valid manoeuvre for the determination of the drug responsible for an anaphylactoid reaction during anaesthesia. It does not fill criteria for a screening test and will have limited use in the preoperative diagnosis of anaesthetic allergy unless a high risk group is selected.

Cancer metastasis: experimental approaches, theoretical concepts, and impacts for treatment strategies

It has been the purpose of this article to describe recent advances in cancer metastasis research. Clinical realities and experimental approaches to the study of underlying basic mechanisms of metastasis formation were discussed. Wherever possible, results were reported which led to the development of theoretical concepts. Such results and concepts were finally evaluated in light of their possible impact for the design of new treatment strategies. Experimental findings from many diverse research fields were summarized with the help of tables, figures, and references. It was concluded that the process of metastasis is a dynamic event that can be described as a sequence of interrelated steps. Experimental results indicated that malignant cells that migrate and disseminate from the primary organ to distant sites and there eventually develop into metastases have to survive a series of potentially lethal interactions. Intimate tumor-host interactions were reported to take place all along the metastatic process. They were elucidated at the steps of angiogenesis, invasion, organ interaction, dormancy, tumor rejection, and tumor immune escape. The outcome of such tumor-host interactions seemed to depend on intrinsic properties of the tumor cells themselves as well as on the responsiveness of the host. Metastasis does not appear as a merely random process. Both clinical and experimental studies revealed that the whole process can be described more appropriately in terms of stochastic, sequential, and selective events, each of which is controlled and influenced by a number of mechanisms. With regard to therapeutic intervention, a selective event offers more possibilities than a random one because it is governed by rules that can be exploited experimentally. Various impacts from experimental studies for the design of antimetastatic cancer treatment strategies were discussed. Sequential steps of the metastatic cascade could become new therapy targets. Conventional empirically derived treatment modalities should become flanked by methods aimed more specifically at critical steps of cancer spread in order to prevent progression of the disease. This is where basic research on mechanisms could make significant contributions to therapy planning in the future. Furthermore, possible negative effects of surgery, radiotherapy, and adjuvant chemotherapy or immunotherapy that could result in enhancement of metastatic progression need to be critically evaluated to limit them as much as possible.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of anaesthesia and surgery for benign disease of the upper urinary tract on circulating leucocyte subpopulations identified with monoclonal antibodies

Circulating lymphocyte subpopulations were monitored, using monoclonal antibodies and flow cytometry, in six patients undergoing surgery for benign disease of the upper urinary tract. A significant decrease in the total number of circulating lymphocytes was observed. This could be attributed to a significant decrease of T cells of both major subsets--the so-called T "helper" (Th) and T "suppressor/cytotoxic" (Ts) subpopulations. When the results of the T cell subsets were expressed as a ration (leu-3a+/leu-2a+, T "helper/suppressor") no significant change was noted. In contrast neither B cells nor natural killer (NK) and antibody dependent killer (K) cells were significantly affected. This selective loss of T cells from the circulation may be relevant to post operative infection and should be considered in the course of immunological monitoring.

Per- and postoperative monocyte and lymphocyte functions: effects of sera from patients operated under general or epidural anaesthesia

Effects on monocyte-mediated cytolysis and thymidine uptake in PHA-stimulated lymphocytes were studied with cells from healthy donors and sera from patients undergoing hip replacement under epidural- or general anaesthesia. Sera were sampled before induction of either epidural- or general anaesthesia (I), 15 min after induction of anaesthesia (II), during surgery 60-90 min after start of induction of anaesthesia (III), and the next morning at 8 o'clock (IV). Serum sample II from patients operated under general anaesthesia significantly depressed both monocyte cytolysis and thymidine uptake in lymphocytes. At sampling time III and IV the monocyte cytolysis was insignificantly reduced. There was no suppression of lymphocyte-thymidine uptake at these sampling times. The sera from patients operated under epidural anaesthesia did not influence the thymidine uptake in lymphocytes. However, sera drawn from epidural anaesthesia patients at sampling time IV significantly depressed the monocyte cytolysis (the sample was drawn the next morning 3-4 h after discontinuation of the epidural anaesthesia). We conclude that the depressive effect of surgery under general anaesthesia on monocyte cytolysis and lymphocyte proliferation is partly transferable by serum factors. The depressive effects on monocytes and lymphocytes of sera drawn 15 min after induction of general anaesthesia may be due to the effect of the induction of thiopentone.

Intradermal testing after anaphylactoid reaction to anaesthetic drugs: practical aspects of performance and interpretation

A detailed description of an intradermal test for the diagnosis of the drug responsible for acute anaphylactoid or anaphylactic reactions to anaesthetic drugs is presented. If intradermal testing is performed according to this protocol the drug responsible for the reaction can be determined in the majority of reactions.

Failure of epidural analgesia to modify postoperative depression of delayed hypersensitivity

Delayed hypersensitivity to four common antigens was assessed in 32 patients undergoing major abdominal surgery randomly allocated to either general anesthesia (fentanyl + O2/N2O + postoperative pain relief with systemic opiates) or general anaesthesia + epidural analgesia (local anaesthetics + morphine) continued for 72 h. Skin-test responses were performed 2 days before surgery and 1 day after surgery and compared to a similar retesting schedule in 16 comparable non-operative control patients. Cumulated mean skin-test responses increased from 1290 to 2330 mm2 (P less than 0.0001) during retesting in the non-operative control group. In contrast, mean skin-test responses in patients operated during general anaesthesia + systemic opiates for postoperative pain relief fell from 1422 to 1227 mm2 (P = 0.3) and in patients receiving epidural analgesia from 1228 to 890 mm2 (P = 0.06), without statistically significant differences between these two groups (P greater than 0.5). Thus, surgery leads to depression of delayed hypersensitivity and this impairment in immunofunction is not modified by an epidural analgesic regimen providing adequate pain relief.

Lymphocyte subsets in renal carcinoma--a sequential study using monoclonal antibodies

Using monoclonal antibodies in conjunction with flow cytometry, circulating lymphocyte subsets with distinct functions in the regulation of the immune response were enumerated in 32 patients with proven renal carcinoma. Analyses were performed at presentation and sequentially during the clinical course of the patients. Untreated patients with advanced disease had a deficit of T cells with the "helper/inducer" phenotype (Leu-3a+) and this resulted in abnormal T "helper/suppressor" (Leu-3a+/Leu-2a+) ratios. Following nephrectomy, performed in 26 patients, there was a significant increase in the number of T cells with the "helper/inducer" phenotype and a significant increase in T "H/S" ratios. Subsequent follow-up at a minimum of 2 months after nephrectomy showed that the increase in T cells with the "helper/inducer" phenotype was maintained (with the exception of 6 patients with disease progression) and was then accompanied by a significant increase of the T cell subset with the "suppressor/cytotoxic" phenotype (Leu-2a+). Pre-operative renal arterial embolisation resulted in an early transient lymphopenia. The response to embolisation combined with nephrectomy was little different when compared with nephrectomy alone. These observations represent a novel view of the immunosuppressive effects of renal carcinoma and their relation to anaemia and disease progression are discussed.

Cell-mediated immune suppression due to alfathesin in short-term anaesthesia

The immunosuppressive effects on cell-mediated immunity of alfathesin, when used as the sole agent for short-term anaesthesia, were investigated in ten women undergoing pregnancy termination. Cell-mediated immunity was evaluated by E rosette formation in peripheral blood (reflecting the percentage of T lymphocytes) and by proliferative responses to the mitogens concanavalin A and phyto-haemagglutinin in various concentrations. Measurements were made before alfathesin was administered, and again after 60 minutes, two days and seven days. Significant reductions in the percentage of E rosettes in peripheral blood and in mitogenic responses to concanavalin A were observed 60 minutes after administration of alfathesin. A model is proposed in which alfathesin binds to lymphocytic membrane receptors, thus affecting in vitro cell-mediated immune reactions.

Factors influencing nutritional assessment in abdominal trauma patients

Previous work has shown that an abdominal trauma index (ATI) based on anatomic severity of injury reliably predicts complications following abdominal trauma, whereas the Prognostic Nutritional Index (PNI) does not. This study was undertaken to reconcile the disparity between the PNI and ATI as predictors of postoperative morbidity and mortality. Twenty-four patients undergoing immediate laparotomy following acute abdominal trauma were evaluated. Their mean age was 32.8 years (range 18-59 years); 18 were men. All patients underwent nutritional assessment within 12 hours of surgery. A statistical comparison of blood replacement, operating time, ATI, and PNI was performed. The mean PNI was 51 and mean blood replacement was 12.5 units. Using linear regression the PNI and amount of blood replacement correlated significantly (r = 0..44, p less than 0.05). Operating time and ATI did not correlate with PNI. In conclusion, the PNI was more strongly influenced by blood loss than severity of intraperitoneal injury. For this reason it is relatively ineffective in predicting complications following trauma.

Effect of minor oral surgery on the reticuloendothelial system

In a study of the systemic effects following oral surgery, the left maxillary molars or maxillary and mandibular molars were extracted from young adult male CBA mice. The host response was assayed from peritoneal macrophage counts following prior intraperitoneal proteose peptone injection. These counts showed a reduction in macrophage accumulation to reach a peak by the 8th post-operative day with a subsequent recovery in functional reticuloendothelial activity by the 14th day. These data therefore suggested that minor oral surgical procedures, in common with major surgery, trauma, burn injury, hemorrhagic shock and widespread malignant disease, are followed by depression of reticulo-endothelial function, a feature that has implications for wound repair and resistance to both infection and malignant neoplasms.

Nutritional assessment and preliminary report on early support of the trauma patient

The high nitrogen demands imposed by severe trauma may quickly render the injured patient malnourished. Nutritional assessment of these patients is confused by tissue damage, shock, blood loss, operation, and anesthesia. Consequently, standard nutritional markers do not correlate well with immunocompetence and postoperative morbidity. For this reason we devised an abdominal trauma index (ATI) based on the anatomical severity of injury. The ATI is calculated by assigning a risk factor (1-5) to each organ injured and then multiplying this by a severity-of-injury estimate (1-5). The sum of the individual organ scores comprises the final ATI. The incidence of postlaparotomy complications is low (5%) with an ATI less than 15, intermediate (15%) with 15-25, and high (50%) with greater than 25. Having identified the high-risk trauma patient, we initiated a prospective randomized study to assess the cost-benefit of early nutritional support. Patients with an ATI greater than 15 were allocated to a control group (no supplemental nutrition during first five postoperative days) or enteral-fed group. The enteral group had a needle catheter jejunostomy (NCJ) placed at laparotomy. The constant infusion of an elemental diet (Vivonex HN) was begun at 18 hours postoperatively and advanced to 3,000 cc/day within 72 hours. To date 26 patients (14 control, 12 enteral) have been entered in this study. At one week, nitrogen balance in the control group (-12.9 to -11.1 g/day) continues to be negative compared to a positive trend (-12.2 to +3.3 g/day) in the fed group. In control patients serum albumin (3.54 +/- 0.16 to 3.19 +/- 0.15 g%) and transferrin (227 +/- 11 to 204 +/- 10 mg%) decrease while in the enteral patients albumin (3.27 +/- 0.11 to 3.34 +/- 0.15 g%) and transferrin (229 +/- 10 to 234 +/- 12 mg%) remain stable. Although the incidence of overall morbidity is similar, septic complications occurred in 29% (4/14) of the control group compared to none in the enteral group. Our experience suggests the following: (1) Anatomical severity of injury is a better predictor of postinjury septic morbidity than standard nutritional markers; (2) immediate postoperative feeding by NCJ is safe and feasible; and (3) early nutritional support decreases the incidence of septic complications in the severely injured patient.

The effects of surgery on the activity of neutrophil granule proteins

Activities of the neutrophil granule-associated proteins beta-glucuronidase, lysozyme and vitamin B12 binding protein were measured, serially, in the cells and serum of 10 patients undergoing total abdominal hysterectomy. The neutrophil leucocytosis which followed total abdominal hysterectomy was accompanied by a fall in the intraneutrophilic activities of all three granule-associated proteins. Intraneutrophilic lysozyme activity and intraneutrophilic vitamin B12 binding capacity were maximally reduced within 4 h of surgery and fell to 62 +/- 13% (mean +/- SEM) and 63 +/- 9% of their preoperative levels, respectively. This contrasted with the activity of intraneutrophilic beta-glucuronidase which was not maximally reduced until 24 h post-surgery when a fall to 80 +/- 6% of the preoperative level was observed. By the fifth postoperative day activities of the three intraneutrophilic granule proteins were increasing and approaching those observed preoperatively. Serum lysozyme and plasma unsaturated vitamin B12 binding capacity (UBBC) rose steadily following surgery and were significantly elevated by the fifth postoperative day. It is suggested that activation and in vivo degranulation of circulating neutrophils may be responsible for these changes in activity of neutrophil granule proteins following surgery.

Monocyte functions are depressed during and after surgery under general anaesthesia but not under epidural anaesthesia

Monocyte functions have been investigated in 18 patients undergoing total hip arthroplasty performed under either general anaesthesia or epidural anaesthesia. Serum cortisol increased significantly both per- and postoperatively in the general anaesthesia group compared to minor changes in the epidural group. The spreading of monocytes on plastic surfaces possibly reflects the phagocytic capacity of the cells. This spreading index of monocytes derived from patients operated under epidural anaesthesia and cultured in medium containing autologous serum showed a significant increase per- and postoperatively compared to the spreading index of monocytes from patients operated under general anaesthesia. This difference increased with increasing culture time. The ability of monocytes to induce lysis in malignant cells was reduced to 45% peroperatively in monocytes derived from patients operated under general anaesthesia and cultured in medium containing autologous serum. In the epidural group the lysis was nearly unchanged from the preoperative value, making the difference between the groups highly significant (P less than 0.01). On the first postoperative day, the difference between the groups was less pronounced. The differences in spreading index and cytolytic capacity were not seen when the monocytes were cultured in medium with pooled AB-serum, thus indicating a serum factor responsible for the monocyte depression when the patients were operated under general anaesthesia.

Barbiturate inhibition of lymphocyte function. Differing effects of various barbiturates used to induce coma

The present studies evaluated the effect of phenobarbital, pentobarbital, and thiopental at concentrations comparable to those attained during therapeutic barbiturate-induced coma, on in vitro mitogen-induced lymphocyte activation. Lymphocytes from normal volunteers were incubated for 72 hours in culture medium containing mitogen (phytohemagglutinin) and a range of concentrations of the barbiturates (5 to 833 microgram/ml). Three parameters of lymphocyte activation (mitogen-induced blast transformation, 3H-thymidine incorporation, and cell proliferation) were all suppressed by the barbiturates. The suppression was dose-dependent. The greatest suppression was caused by the short-acting barbiturate, thiopental. Lymphocyte responses were much less affected by the long-acting barbiturate, phenobarbital. The intermediate-acting barbiturate, pentobarbital, was also intermediate in its ability to inhibit lymphocyte activation. The two-to threefold difference between the effects of thiopental and pentobarbital on lymphocyte function may have direct clinical relevance, since it is primarily these two agents that are employed to induce therapeutic "barbiturate coma." Since lymphocyte suppression appears to be much more marked in the presence of thiopental, these observations support a role for the other barbiturates in programs of induced coma.

Anesthetic drugs accelerate the progression of postoperative metastases of mouse tumors

Experiments were made to investigate the effect of four anesthetic drugs that are commonly used in surgical practice on the postoperative growth of mouse tumors in syngeneic recipients. These experiments revealed that some of the anesthetics when applied for surgical excision of the local tumor, strongly accelerated postoperative progression of spontaneous lung metastases produced by the 3LL Lewis lung carcinoma and by the B16 melanoma. Some of the drugs caused the appearance of metastases in organs, such as the liver, in which spontaneous metastases are not usually produced by these tumors. A T10 sarcoma clone that does not produce detectable metastases in immune intact mice even following intravenous injection, did produce metastases when injected into animals treated with pentothal sodium.

The diagnosis of acute anaphylactoid reactions to anaesthetic drugs

Patients with a presumptive diagnosis of an acute anaphylactoid reaction to anaesthesia were investigated to determine the cause of the reaction and the drug responsible by intradermal testing, patch and prick testing, sequential complement measurement, passive transfer testing and challenge. The most valuable information was provided by intradermal testing and a diagnosis could be made in 150 of 165 patients. When analphylactoid reactions to anaesthetic drugs occur, intradermal testing one month after the reaction and sequential complement measurements in the immediate post reaction period will enable the diagnosis to be established in the majority of cases. Intradermal testing is of no value for trivial reactions or reactions to colloid solutions or contrast media.

Immunological aspects to severe bacterial sepsis

In spite of discovery of new antibiotics and regular progress in intensive care, mortality from severe bacterial sepsis remains high. In this review the importance of cellular and humoral immunity in the pathogenesis and the outcome of severe infection is delineated. Immunological evaluation of patients in Intensive Care Units should be performed almost routinely in order to detect "high risk" patients with acquired defect in host-defence mechanisms. For these patients in addition to nutritional care, passive or active immunotherapy will help to restore resistance to bacterial infection.

On the end results of surgical treatment of lung cancer patients depending on the type of anesthetic agent

The end results of therapy of 346 patients with lung tumors, treated with surgery alone, are compared, depending on the type of general anesthetic agent used. Anesthesia was induced with ether in 220 patients, halothane in 103, and neuroleptanalgesia in 23 cases. All the anesthetic agents were administered in a mixture with nitrous oxide. The basic characteristics of patients, who were divided on the basis of anesthetic agent, were identical. The results show that type of anesthesia during surgical treatment for lung tumor has an effect on the end results of therapy, and the best prognosis is ensured when halothane is used. Further analysis established that the end results of surgery with halothane anesthesia are improved, when partial resection rather than radical pneumonectomy is performed, at stage 2 of malignant disease and when metastases into regional lymph nodes are absent. Such improvement may be explained by stimulation of the hypothalamo-pituitary-adrenal system as well as a relatively lower degree of immunosuppression and development of conditions more adverse for implantation of circulating tumor cells than in the case of ether or neuroleptanalgetic anesthesia.

Cross-infection from contaminated anaesthetic equipment. A real hazard?

A definite relationship between the use of contaminated anaesthetic equipment and subsequent pulmonary infection remains to be established. There is however indirect and circumstantial evidence suggesting that cross-infection may occur, and further an increased susceptibility of surgical patients to pulmonary infections has been demonstrated. Decontamination should be recommended before the equipment is re-used. Pasteurisation may prove sufficient and this can be obtained employing a specially designed dish-washing machine.

Adverse reactions following fazadinium-thiopentone induction

Three cases of hypersensitivity to an anaesthetic induction with fazadinium and thiopentone are described. One reaction was fatal. Two patients had documented and the third presumptive previous exposure to thiopentone, and all had a history of allergy (skin rash) to penicillin. None of the patients had received fazadinium before. The possibility that fazadinium contributed to the severity of the reactions is conjectural.