VZL 2005, 74(3):115-124

Clinical, Microbiological and Immunological Aspects of Cardiosurgical Patients Care

Richard Kahlich1, Martin Střítecký1, Jan Krištof1, Branislav Škrovina1, Jan Pekárek2, Karel Barnet2, Ladislav Krajči3
1 Klinika anesteziologie a resuscitace Všeobecné fakultní nemocnice v Praze
2 Sevapharma, a. s., Praha
3 Centrum ambulantní zdravotní péče, Ústřední vojenská nemocnice, Praha

Je prezentována koncepce vyjádřená tezí "Diferenciace SIRS-sepse s vyvážením imunitních přístupů a zdrženlivé a cílené antibiotické politiky". Ve stadiu SIRS (systemic inflamatory response syndrome) simplex i dříve přistupujeme k monitorování celulární imunity výrazně implikované v patogenezi SIRS i sepse. Užíváme dostupné testy, jako je např. počet granulocytů a lymfocytů, subpopulace T-lymfocytů, IL-10 a prokalcitonin. Vedle některých adjuvantních imunomodulátorů aplikujeme běžně a co nejčasněji leukocytární dialyzát Immodin jako nabídku substrátů pro klíčové imunocyty ovlivňující harmonii pro- a antiimnflamatroních tendencí. Uvádíme perakutní MOF při hyperinflamatorním čistém SIRS, prolongovaný SIRS s obleněnou zpětnou regulací a oddálený MOF provázený infekcí při nadměrném CARS (compensatory antiinflamatory response syndrome). Zdrženlivá a cílená antibiotická politika aplikovaná při absenci infekce i v přítomnosti zánětových markerů omezila vedle jiných komplikací mnohotvárnou selekci podmíněných patogenů včetně vývoje k rezistenci. V tom vidíme důvod, proč relativně převládal infekcí nekomplikovaný čistý SIRS se svou úplnou samostatnou vývojovou linií. Jeho incidence činila 0,5 až 1,3 % oproti sepsi s pouhým 0,1 %. Tento příznivý efekt v sestavách našich 4599 kardiochirurgických pacientů vykládáme globálním působením zdrženlivé politiky a včasné imunomodulace. Výsledky motivují k ověření navržené koncepce v kontrolovaných studiích a v dalších směrech chirurgie, např. v traumatologii, a u řady jiných kriticky nemocných.

Keywords: Diferenciace SIRS-sepse; Zdrženlivá ATB politika; Celulární imunita; Imunomodulace

Our conception can be summarized as follows: "Differentiation of SIRS - sepsis with balancing of the immune approaches and a reserved and a target antibiotic policy". Cellular immunity which plays a key role in the pathogenesis of both sepsis and SIRS should be monitored starting with the SIRS simplex level or even earlier. Accessible tests such as a granulocyte and lymphocyte count, T-lymphocyte subpopulation, IL-10 and procalcitonin may be sufficient. Apart from some adjuvant immunomodulators, we use commonly and as early as possible use the leucocyte dialysate Immodin as substrata for key immunocytes to influence the harmony of pro- and anti-inflammatory tendencies. We present peracute MOF during hyper inflammatory clear SIRS, prolonged SIRS with impaired back-regulation and delayed MOF accompanied by infection during excessive CARS. A reserved as well as a target antibiotic policy used in the absence of infection even though inflammation markers were present, reduced, among other complications, the selection of unwanted pathogens and antibiotic resistance. It is here where we find a reason for the relative prevalence of a clear SIRS without infection with its own independent line of development. Its incidence was 0.5-1.3 % in comparison with sepsis being only 0.1 %. We believe that this favourable effect on our 4599 cardiac surgery patiens is due to a global effect of a rational antibiotic policy and of early immunomodulation. These results of our pilot study motivate to test the proposed conception in controlled studies and in other surgical fields, for example, in traumatology and in many critically ill patiens.

Keywords: Differentiation of SIRS-sepsis; Reserved ATB policy; Cellular immunity; Immunomodulation

Received: July 21, 2004; Published: December 1, 2005  Show citation

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Kahlich, R., Střítecký, M., Krištof, J., Škrovina, B., Pekárek, J., Barnet, K., & Krajči, L. (2005). Clinical, Microbiological and Immunological Aspects of Cardiosurgical Patients Care. Vojenské Zdravotnické Listy, 74(3-4), 115-124
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