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CARDIOVASCULAR ANESTHESIA

Myocardial Ischemia and Cytokine Response Are Associated with Subsequent Onset of Infections After Noncardiac Surgery

Claudia D. Spies, MD^*, Hartmut Kern, MD^*, Torsten Schröder, MD^*, Michael Sander, MD^*, Henning Sepold, MD^*, Philip Lang, MD^*, Karl Stangl, MD, Steffen Behrens, MD, Pranav Sinha, MD, Walter Schaffartzik, MD^||, Klaus-Dieter Wernecke, PhD^¶, Wolfgang J. Kox, MD, PhD^*, and Uday Jain, MSIT, PhD, MD^#

Departments of *Anesthesiology and Intensive Care Medicine and Cardiology and Institute of Clinical Chemistry and Pathological Biochemistry, University Hospital Charité, Campus Charité Mitte, Humboldt-University, Berlin, Germany; Department of Cardiology, University Hospital Benjamin Franklin, Free University, Berlin, Germany; ||Department of Anesthesiology and Intensive Care Medicine, Unfallkrankenhaus Berlin-Marzahn, Berlin, Germany; ¶Department of Medical Biometry, Humboldt University Berlin, Germany; and #Department of Anesthesiology, Stanford University School of Medicine Partner, SFA Medical Group, Hillsborough, California

Address correspondence and reprint requests to Prof. Dr. med. Claudia D. Spies, Klinik für Anaesthesiologie und Operative Intensivmedizin, Universitätsklinik Charité, Campus Charité Mitte, Humboldt-Universität zu Berlin, Schumannstr. 20/21, 10117 Berlin, Germany. Address e-mail to claudia.spies{at}charite.de

Postoperative myocardial ischemia (POMI) is prevalent among patients after major noncardiac surgery. Surgery, as well as POMI, may modulate the immune system, potentially worsening patient outcome. We sought to investigate the modulation of soluble interleukin (IL)-6 and IL-10 by POMI and its association with increased postoperative infection rates. Two-hundred-three patients undergoing elective major abdominal, vascular, and orthopedic surgery participated in this prospective observational study. Perioperative management was standardized. Hemodynamic variables were kept within 20% of baseline. POMI was assessed by Holter electrocardiography starting at least 8 h before the induction of anesthesia and continued until 96 h after surgery. Twelve-lead electrocardiograms, cardiac enzymes, and immune variables were obtained at the time of admission to the hospital, before surgery, before the induction of anesthesia, after surgery, at the time of admission to the intensive care unit, and 6, 12, 18, 24, 36, 48, 72, 96, 120, 144, and 168 h after surgery. Infections were diagnosed according to the Centers for Disease Control criteria. The incidence of POMI was 27%, and the majority of cases (76%) occurred within the first 24 h after surgery. IL-6 and IL-10 levels significantly increased during surgery but did not differ between the POMI and Non-POMI groups. However, in the subset of patients who developed severe infections or sepsis (n = 47) a median of 3 days (range, 1–8 days) after surgery, the intraoperative increases of IL-6 and IL-10 in the POMI group were, respectively, 3 and 10 times higher compared with the increase in the Non-POMI group. By using a multifactorial analysis in these patients with severe infections, the type of surgical trauma was associated with an increased IL-6 response, whereas the increase in IL-10 was attributed to POMI. These findings suggest that immediate cytokine responses due to POMI and type of surgery might be relevant for the later onset of severe infections and sepsis.

IMPLICATIONS: Postoperative myocardial ischemia (POMI) occurred in 27% of patients after major noncardiac surgery. This was associated with an immediate augmented cytokine response in the first 12 h after surgery in patients who developed severe infections or sepsis 3 days later. POMI was associated with an increased interleukin (IL)-10 response, whereas IL-6 was associated with the type of surgery.

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