Centennial Medical Center, Nashville, Tenn, USA.
J Thorac Cardiovasc Surg. 2011 Sep;142(3):575-80. doi: 10.1016/j.jtcvs.2011.04.042. Epub 2011 Jul 2.
Pulmonary dysfunction/multiorgan failure syndrome is an important cause of mortality and morbidity after cardiac operations. In this series, results of immune augmentation were assessed in patients experiencing pulmonary dysfunction/multiorgan failure syndrome after cardiac surgery.
Since 2002, 44 consecutive patients with primary antibiotic-refractory pulmonary dysfunction/multiorgan failure syndrome were treated with intravenous immunoglobulin (0.3 g/kg × 5 days; 1.5 g/kg total dose). Thirty patients had undergone complex valve or aortic surgery, and 14 patients had coronary bypass. Median age was 66 years, and risk profiles were especially high preoperatively. Clinical variables were assessed for 3 days prior (-3) to beginning intravenous immunoglobulin (on day 0) and for 5 days afterward (+5). A postoperative morbidity index was generated as a weighted sum of all relevant clinical variables. By using each patient as his or her own control, the therapeutic effect of intravenous immunoglobulin was assessed with linear regression of postoperative morbidity index over time with a spline and a knot at day 0, coincident with beginning intravenous immunoglobulin.
At day 0, all patients were deteriorating clinically and refractory to major antibiotics. Overall morbidity was high, and immunoglobulin-G levels, obtained in the last 14 patients, were consistently low. By using linear regression of postoperative morbidity index over time, intravenous immunoglobulin administration was associated with significant improvement in clinical status (P < .0001). A total of 42 of 44 patients (95%) recovered uneventfully to hospital discharge. No significant complications of intravenous immunoglobulin therapy occurred.
This experience suggests that management of immune dysfunction with intravenous immunoglobulin is safe and effective for treatment of primary pulmonary dysfunction/multiorgan failure syndrome after cardiac surgery. Expanded application seems indicated.
肺功能障碍/多器官衰竭综合征是心脏手术后患者死亡率和发病率升高的一个重要原因。在本系列研究中，我们评估了免疫增强在经历心脏手术后发生肺功能障碍/多器官衰竭综合征的患者中的疗效。
自 2002 年以来，我们对 44 例原发性抗生素耐药性肺功能障碍/多器官衰竭综合征患者进行了静脉免疫球蛋白治疗（0.3 g/kg×5 天；总剂量 1.5 g/kg）。30 例患者接受了复杂的瓣膜或主动脉手术，14 例患者接受了冠状动脉旁路移植术。患者的中位年龄为 66 岁，术前风险状况尤其高。我们评估了 3 天前（-3）开始静脉免疫球蛋白治疗前（第 0 天）和治疗后 5 天内（+5）的临床变量。通过对所有相关临床变量进行加权求和，生成了术后发病率指数。通过使用每位患者自身作为对照，采用样条和节点在第 0 天（即开始静脉免疫球蛋白治疗时）的时间对术后发病率指数进行线性回归，评估静脉免疫球蛋白的治疗效果。
在第 0 天，所有患者的临床状况均在恶化，且对主要抗生素耐药。总体发病率较高，最后 14 例患者的免疫球蛋白-G 水平持续较低。通过对术后发病率指数随时间的线性回归，静脉免疫球蛋白的使用与临床状况的显著改善相关（P<0.0001）。44 例患者中有 42 例（95%）成功康复出院，无静脉免疫球蛋白治疗的严重并发症发生。
本研究经验提示，静脉免疫球蛋白治疗免疫功能障碍对于心脏手术后原发性肺功能障碍/多器官衰竭综合征的治疗是安全有效的。似乎有必要扩大其应用。
