Rankin J Scott, Glower Donald D, Teichmann Tracey L, Muhlbaier Lawrence H, Stratton Charles W
Department of Cardiac Surgery, Vanderbilt University, 2400 Patterson Street, Suite 103, Nashville, TN 37203, USA.
J Heart Valve Dis. 2005 Nov;14(6):783-91.
Pulmonary dysfunction/multiorgan failure (PD/MF), usually due to refractory pulmonary infection, is an important cause of mortality and morbidity after cardiac operations. Moreover, the incidence of PD/MF may be increasing due to the emergence of antibiotic-resistant pathogens.
Fifteen consecutive patients (median age 69 years) who were developing antibiotic-refractory PD/MF were administered 24 g per day intravenous immunoglobulin (IV-IgG; Carimune) for five days. Ten patients had undergone complex valve surgery, and five coronary bypass. Preoperatively, 93% of patients had significant comorbidity, 73% presented acutely, 53% were hypoalbuminemic and 47% had antecedent acute pulmonary derangement. Clinical variables were assessed by retrospective chart review for three days prior to (-3) the start of IV-IgG (day 0) and for five days afterwards (+5). A postoperative morbidity index (PMI) was generated as a weighted sum of: worsening lung infiltrates (I); leukocytosis (L); pulmonary dysfunction (P); ventilator requirement (V); septic shock (S); renal (R), gastrointestinal (G), or hepatic (H) dysfunction; thrombocytopenia (T); and delirium (D).
At day 0, all patients were refractory to major antibiotics, with morbidities of: 1-100%, L-93%, P-93%, V-60%, S-27%, R-67%, G-40%, H-13%, T-27%, and D-20%. Using regression analysis, IV-IgG administration was associated with a statistically significant fall in white blood count and improvement in PMI (p <0.006). Fourteen patients (93%) recovered uneventfully, and one patient (7%) died from progressive sepsis. No complications of IV-IgG therapy occurred.
Given the high predicted mortality of PD/MF patients, these data suggest that IV-IgG is a safe and efficacious adjunct to antibiotics in this setting. Further studies, including a randomized trial and investigation of immunomodulatory mechanisms, seem indicated.
肺功能障碍/多器官功能衰竭（PD/MF）通常由难治性肺部感染引起，是心脏手术后死亡率和发病率的重要原因。此外，由于抗生素耐药病原体的出现，PD/MF的发病率可能正在上升。
对15例连续发生抗生素难治性PD/MF的患者（中位年龄69岁），每天静脉注射免疫球蛋白（IV-IgG；卡立莫）24克，持续5天。10例患者接受了复杂瓣膜手术，5例接受了冠状动脉搭桥手术。术前，93%的患者有严重合并症，73%为急性发病，53%为低白蛋白血症，47%有既往急性肺功能紊乱。通过回顾性病历审查评估IV-IgG开始前3天（-3）（第0天）及之后5天（+5）的临床变量。生成术后发病率指数（PMI），作为以下各项加权总和：肺部浸润加重（I）；白细胞增多（L）；肺功能障碍（P）；呼吸机需求（V）；感染性休克（S）；肾脏（R）、胃肠道（G）或肝脏（H）功能障碍；血小板减少（T）；以及谵妄（D）。
在第0天，所有患者对主要抗生素均耐药，发病率分别为：I-100%，L-93%，P-93%，V-60%，S-27%，R-67%，G-40%，H-13%，T-27%，D-20%。通过回归分析，静脉注射免疫球蛋白与白细胞计数显著下降及PMI改善相关（p<0.006）。14例患者（93%）顺利康复，1例患者（7%）死于进行性脓毒症。未发生IV-IgG治疗的并发症。
鉴于PD/MF患者预计死亡率较高，这些数据表明在这种情况下，IV-IgG是抗生素的一种安全有效的辅助治疗方法。似乎需要进一步研究，包括随机试验和免疫调节机制的研究。
