Best practice & research. Clinical anaesthesiology
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Although individual cases have been reported in the literature, serious infections of the central nervous system (CNS) such as arachnoiditis, meningitis, and abscess following spinal or epidural anesthesia are rare. However, recent epidemiologic series from Europe suggest that the frequency of infectious complications associated with neuraxial techniques may be increasing. Importantly, while meningitis and epidural abscess are both complications of neuraxial block, the risk factors and causative organisms are disparate. ⋯ Conversely, meningitis follows dural puncture, and is typically caused by alpha-hemolytic streptococci, with the source of the organism the nasopharynx of the proceduralist. In order to reduce the risk of serious infection following neuraxial blockade, the clinician must be knowledgeable in the pathogenesis of CNS infections, patient selection, and use of meticulous aseptic technique. Finally, since delay in the diagnosis may result in morbidity and even death, it is crucial to be aware of the presenting signs and symptoms of meningitis and epidural abscess.
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Deep sternal wound infections (DSWI) continue to be a relatively uncommon event occurring in about 1%-2% of all patients undergoing cardiac surgery. However, the sheer number of cardiac surgery patients and the relatively high mortality associated with DSWIs makes them of clinical relevance. This review will describe the current incidence of DSWIs and their associated morbidity and mortality as well as risk factors for the development of this complication. The microbiology of DSWIs will be reviewed and strategies to prevent these complications will be discussed with a focus on interventions that may be undertaken by the clinical anesthesiologist.
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Best Pract Res Clin Anaesthesiol · Sep 2008
ReviewTransfusion-transmissible infections and transfusion-related immunomodulation.
The risk of acquiring a transfusion-transmitted infection has declined in recent years. However, after human immunodeficiency virus and hepatitis B and C virus transmission were successfully reduced, new pathogens are threatening the safety of the blood supply, especially in the face of rising numbers of immunocompromised transfusion recipients. ⋯ The precise pathomechanism still remains uncertain; however, its mostly deleterious effects--such as a higher incidence of postoperative or nosocomial infections--is increasingly accepted. Although transfusion-related immunomodulation is thought to be mediated mainly by donor white blood cells, the benefit of leukoreduction on overall mortality and on infectious complications is highly debatable.
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Surgical site infections remain a significant contributor to postoperative morbidity and mortality. It is estimated that 500,000 patients suffer from this complication annually. ⋯ The purpose of this review is to summarize the guiding principles of perioperative antibiotic administration including selection, timing, redosing, and discontinuation. In addition, special topics including likely organisms for classes of surgical procedures, endocarditis prophylaxis, and management strategies for patients with allergies will be reviewed.
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The perioperative management of immunosuppressed patients remains relatively unsophisticated. Rational management involves understanding the normal immune response to injury as modified by the preexisting or imposed abnormalities that immunosuppressed patients manifest on the basis of their disease and/or treatment. Patients with cancer, infected with human immunodeficiency virus, and having had an organ transplant are extreme examples of disordered immunity and it is important to understand the effects of their diseases and treatments. In the future, however, more appropriate management will require anticipation and appreciation of frequent preoperative immunotherapy, a more complete understanding of the immunological response to anesthesia and surgery, the ability to assess immune reserve and stratify risk within the context of that profile, and a better knowledge of the immunological effect of anesthetic agents.