Preoperative assesment of the immunocompromised patient

The IFSD Score-A Practical Prognostic Model for Invasive Fungal Spondylodiscitis

Objectives: Invasive fungal spondylodiscitis (IFSD) is rare and could be lethal in certain circumstances. The previous literature revealed limited data concerning its outcomes. This study aimed to establish a risk-scoring system to predict the one-year mortality rate of this disease. Methods: A total of 53 patients from a multi-centered database in Taiwan were included in this study. All the clinicopathological and laboratory data were retrospectively analyzed. Variables strongly related to one-year mortality were identified using a multivariate Cox proportional hazards model. A receiver operating characteristic (ROC) curve was used to express the performance of our IFSD scoring model. Results: Five strong predictors were included in the IFSD score: predisposing immunocompromised state, the initial presentation of either radiculopathy or myelopathy, initial laboratory findings of WBC > 12.0 or <0.4 103/µL, hemoglobin < 8 g/dL, and evidence of candidemia. One-year mortality rates for patients with IFSD scores of 0, 1, 2, 3, and 4 were 0%, 16.7%, 56.3%, 72.7%, and 100%, respectively. The area under the curve of the ROC curve was 0.823. Conclusions: We developed a practical scoring model with easily obtained demographic, clinical, and laboratory parameters to predict the probability of one-year mortality in patients with IFSD. However, more large-scale and international validations would be necessary before this scoring model is commonly used.

Surgical Antimicrobial Prophylaxis in Neonates and Children with Special High-Risk Conditions: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs), which are a potential complications in surgical procedures, are associated with prolonged hospital stays and increased postoperative mortality rates, and they also have a significant economic impact on health systems. Data in literature regarding risk factors for SSIs in pediatric age are scarce, with consequent difficulties in the management of SSI prophylaxis and with antibiotic prescribing attitudes in the various surgical procedures that often tend to follow individual opinions. The lack of pediatric studies is even more evident when we consider surgeries performed in subjects with underlying conditions that may pose an increased risk of complications. In order to respond to this shortcoming, we developed a consensus document to define optimal surgical antimicrobial prophylaxis (SAP) in neonates and children with specific high-risk conditions. These included the following: (1) colonization by methicillin-resistant Staphylococcus aureus (MRSA) and by multidrug resistant (MDR) bacteria other than MRSA; (2) allergy to first-line antibiotics; (3) immunosuppression; (4) splenectomy; (5) comorbidity; (6) ongoing antibiotic therapy or prophylaxis; (7) coexisting infection at another site; (8) previous surgery in the last month; and (9) presurgery hospitalization lasting more than 2 weeks. This work, made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies, represents, in our opinion, the most up-to-date and comprehensive collection of recommendations relating to behaviors to be undertaken in a perioperative site in the presence of specific categories of patients at high-risk of complications during surgery. The application of uniform and shared protocols in these high-risk categories will improve surgical practice with a reduction in SSIs and consequent rationalization of resources and costs, as well as being able to limit the phenomenon of antimicrobial resistance.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Intraoperative Acute Respiratory Failure in an Immunocompromised Patient with Human Metapneumovirus

Patient: Male, 31

Final Diagnosis: Pneumonia from Human Metapneumovirus pulmonary infection

Symptoms: Cough • fatigue

Medication: —

Clinical Procedure: Hernia repair

Specialty: Anesthesiology

Effects of dexmedetomidine on inflammatory factors, T lymphocyte subsets and expression of NF-κB in peripheral blood mononuclear cells in patients receiving radical surgery of colon carcinoma

The effects of dexmedetomidine on inflammatory factors, T lymphocyte subsets and expression of nuclear factor-κB (NF-κB) in peripheral blood mononuclear cells in patients receiving radical surgery of colon carcinoma were investigated. A total of 141 patients receiving radical surgery of colon carcinoma from January 2014 to April 2017 were divided into two groups randomly. The patients in the treatment group were given dexmedetomidine, while the patients in the control group were treated with saline. Results showed that there were no significant differences in preoperative levels of NF-κB, sICAM-1 and IL-8 between the two groups. However, the above three indexes of the groups were all significantly increased at 0.5 and 24 h after operation, and the results showed that the control group had a higher degree of increase (P<0.05). It was also found that the changes in levels of IL-6 and CRP in patients were the same as those of the above three indexes; in other words, the degree of the increase in the control group was significantly higher than that in the treatment group after operation. Moreover, it was found that there was little difference in the preoperative Ramsay score of patients between the two groups. The scores at 0.5 and 12 h after operation in the treatment group were significantly higher than those in the control group (P<0.05). It was also found that the intraoperative and postoperative dosages of fentanyl in the treatment group were significantly less than those in the control group (P<0.05). We can conclude that the application of dexmedetomidine during anesthesia in patients receiving radical operation of colon carcinoma has a better clinical treatment effect, which can reduce the secretion of inflammatory factors, decrease the inhibition of immunity and reduce the use of fentanyl.

Patients with immunodeficiency

Patients presenting in an immunocompromised state merit special consideration when being evaluated for fitness to undergo surgery. A variety of immunodeficient conditions and their respective therapies, including human immunodeficiency virus, cancer, and transplantation, exert numerous systemic effects that may lead to multiorgan dysfunction. Understanding the potential impact of these disease manifestations, and their proper evaluation, is essential in achieving optimal perioperative outcomes for these patients.