Management of immune dysfunction after adult cardiac surgery

Abstract

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.