Immunological Screening and Immunotherapy in Critically ill Patients with Abdominal Infections

170 Pages·2001·6.27 MB·English

by  G. Grass

Immunological Screening and Immunotherapy in Critically ill Patients
with Abdominal Infections
Springer
Berlin
Heidelberg
New York
Barcelona
Hong Kong
London
Milan
Paris
Singapore
Tokyo
E. FAIST (Ed.)
Immunological Screening
and Immunotherapy
in Critically ill Patients
with Abdominal Infections
With 41 Figures and 35 Tables
, Springer
FAIST, E., Professor Dr. med.
Chirurgische Universtitat der LMU Munchen
Klinikum GroBhadern
MarchioninistraBe 15
81377 Munchen
ClP data applied for
Immunological screening and immunotherapy in critically ill patients with abdominal infections; with
35 tables I Eugen Faist. -Berlin; Heidelberg; New York; Barcelona; Hong Kong; London; Mailand ;
Paris ; Singapore ; Tokyo : Springer, 2001
ISBN-13: 978-3-540-41148-2 e-ISBN-13: 978-3-642-59455-7
001: 10.1007/978-3-642-59455-7
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Preface
Over two decades an abundance of knowledge has been accumulated focus
ing on the understanding of the molecular and cellular pathomechanisms of
stressful conditions like systemic inflammation and sepsis.
We have learned that there is a clear correlation between the magnitude of
the inciting traumatic event and the degree of inflammatory dysbalance.
The immunoinflammatory disintegration comprises a simultaneous col
lapse of the otherwise very smoothly balanced pro- and antiinflammatory
vectors of cytokine regulation.
Most recently, we understood that it is predominantly the dysregulation of
antiinflammatory mediators that plays a pivotal role for the phenomenon of
trauma-induced depression or paralysis of cell-mediated immune responses.
The substantial intellectual and logistic investments of numerous investi
gators towards understanding the biology of sepsis inevitably lead us towards
a rewarding status in terms of reaching spheres of clinical relevance. From
the evolutionary collection of a multitude of ex-vivo and in-vivo immuno
mechanistic parameters, some were found to represent most significant bio
logical markers to support the clinician to characterize better the severity of
inflammatory illness and to predict outcome.
Chapter one of this book, authored by G. Grass and E.A.M. Neugebauer,
analyses elegantly our current knowledge on the assessment of the immuno
logical status in terms of risk and prognosis of sepsis.
Further on, many of us who have done research in the field of assessing
biochemical parameters agree that the availability of a strong, reliable and
pragmatic immunomonitoring system represents the crucial precondition to
develop reasonable and responsible modes of preventive and interventive
immunomodulatory therapeutic strategies. For the successful protection of
the host against progressive inflammatory dysregulation resulting in fatal
multiple organ dysfunction, adjunctive immunotherapy might strengthen our
armament of therapeutic interventions in the critically ill.
In chapter two, H. B. Reith and U. Mittelkotter describe their experience
with the value of biological markers of inflammation to characterize the
severity of abdominal sepsis which might result in a consecutive indication
for the therapeutic intervention with intravenous immunoglobulins.
As it is a major focus of this book to describe the association between
immunologic screening and immunotherapy in critically ill patients predom-
VI Preface
inantly following intraabdominal surgery and peritonitis, chapter three,
authored by M. Trautmann and P. M. Lepper, offers important information on
the underlying facets of microbiology as a crucial cornerstone of diagnosis
and therapy of intraabdominal infections.
In chapter four E. Hanisch and A. Encke extensively describe their work to
better characterize different degrees of inflammatory morbidity in patients
undergoing abdominal surgery using the definitions of SIRS and sepsis as
they have been suggested by the consensus conference of the American Col
lege of Chest Physicians and the Society of Critical Care Medicine.
Finally, in chapter five, H.G. Kress reflects about limitations, pitfalls and
flaws of therapeutic trials with immunotherapy. He is discussing the problems
with the heterogeneity of study populations, the difficult complex of primary
and surrogate endpoints as well as other crucial factors important for the val
ue of therapeutic studies, determinants that might be responsible for the fact
that our search for a magic bullet for treating inflammation and sepsis has so
far been unsuccessful. It is impossible to predict where the next breakthrough
will occur in the attempt to control an overwhelming inflammatory reactivi
ty and altered host immune responses.
I express my thanks to my colleagues for their contributions to this book.
I do hope that more frequent prevention of organ failure in patients with
abdominal infections will result from this information.
I am most indebted to the editorial staff of Springer-Verlag, especially Mr.
Thomas Gunther, for their willingness and enthusiastic support in preparing
this work. Finally, I would also like to thank Biotest Pharma, here Dr. Rein
hard Schweitzer, for the great effort to initiate and sponsor the creation and
production of this comprehensive text book.
Munich, January 2001 Prof. Dr. EUGEN FAIST, FACS
Ludwig-Maximilians-University Munich
Klinikum GroBhadern
Department of Surgery
Table of Contents
1 Risk and Prognosis of Sepsis - Current Methods on the Assessment
of the Immunological Status
G. GRASS and E.A.M. NEUGEBAUER .. . . . . . . . . . . . . . . . . . 1
2 Markers of Inflammation for Prognosis and Control of Therapeutic
Success in Patients with Abdominal Sepsis - Options for Using
Adjuvant Intravenous Immunoglobulins
H. B. REITH and U. MITTELKOTTER ................ 15
3 Microbiological Findings and Antiinfective Treatment Strategies
M. TRAUTMANN and P. M. LEPPER ............... 29
4 Intensive Care Management in Abdominal Surgical Patients
with Septical Complications
E. HANISCH and A. ENCKE ................... 71
5 The Doctor's Dilemma: The Assessment of Successful Adjunctive
Immunotherapy in Critically III Patients
H. G. KRESS 139
Subject Index 157
List of Contributors
ENCKE, A., Professor Dr. med.
Klinikum der Johann-Wolfgang-Goethe Univiversitat
Klinik ffir AUg.- u. GefcUkhirurgie
Theodor-Stern-Kai 7
60590 Frankfurt
FAIST, E., Professor Dr. med.
Chirurgische Universitat der LMU MUnchen
Klinikum GroBhadern
MarchioninistraBe 15
81377 MUnchen
GRASS, G., Dr. med.
Biochemical and Experimental Division II
Chirurgische Abteilung
Universitat Koln
Ostmerheimer StraBe 200
51109 Koln
HANISCH, M., Professor Dr. Dr. med.
Chirurgische Klinik
am Knappschaftskrankenhaus Dortmund
Wieckesweg 27
49309 Dortmund
KRESS, H.-G., Professor Dr. med.
Abt. fUr Anasthesie und Intensivmedizin B
AUg. Krankenhaus Wien
Wahringer-GUrteI18-20
A-I090 Wien
Osterreich
x List of Contributors
LEPPER, P. M.
Abt. fur Mikrobiologie und Hygiene
Universitat Ulm
SteinhOvel Str. 9
89075 Ulm
NEUGEBAUER, E.A.M., Professor Dr. med.
Biochemical and Experimental Division II
Chirurgische Abteilung
Universitat KOln
Ostmerheimer StraBe 200
51109 Koln
REITH, H. B., Professor Dr. med.
Chirurgische Abteilung
Universitatsklinik Wurzburg
Josef-Schneider-Str. 2
97080 Wurzburg
TRAUTMANN, M., Professor Dr. med.
Abt. fur Mikrobiologie und Hygiene
Universitat Ulm
Steinhovel Str. 9
89075 Ulm
CHAPTER 1
Risk and Prognosis of Sepsis
Current Methods on the Assessment
of the Immunological Status
G. GRASS and E.A.M. NEUGEBAUER
1.1
Introduction
Despite decades of research new therapeutic strategies have failed so far to
improve mortality of patients with systemic inflammatory response syndrome
(SIRS) and sepsis in controlled clinical trials. The reasons for this have been dis
cussed in symposia, workshops and a myriad of publications. There is agree
ment that beside relying on insufficient experimental data and wrong concepts
methodological shortcomings are common (Neugebauer et al.I998). Due to the
unsuccessful trials interest shifted from therapy to prophylaxis and/or very early
therapy of sepsis: "We should spend more time searching how to achieve an
accurate prognosis and less time searching for a magic bullet:' (Barclay 1995)
Measuring the immunestatus of patients should help to identify patients at risk
for up-coming prophylactic approaches or septic patients who may benefit from
immunomodulatory therapies.
The human immune system is a highly complex system of interacting cells,
tissues and mediators involving the whole body. Immune reactions occur locally
as well as systemically. Therefore the term "imunological status" of patients can
not be defined without relation to the disease and to the aim of categorizing dif
ferent disease states.
The expression "systemic inflammatory response syndrome" reflects the idea
that the disease formerly called sepsis or sepsis syndrome is independent of the
underlying cause. It has been assumed that SIRS is the result of the dysbalance
of pro-and anti-inflammatory forces (Bone 1996a). Compensatory anti-inflam
matory response (CARS) is assumed to lead to an increased susceptibility
to infection or anergy. Systemic spillover of the pro-inflammatory system leads
to apoptosis, organ dysfunction, thus septic shock. According to this paradigm
SIRS and sepsis are diseases of the immune system rather than simple effects
of a causative agent. Identification of these different immunestates may be
crucial for treatment of patients. When SIRS predominates anti-inflammatory
therapies may be useful, whereas agents such as granulocyte colony-stimulating
factor, interferon- gamma, and interleukin -13 can be used for stimulation of the
immunesystem in patients with CARS.