Postoperative systemic inflammatory dysregulation and corticosteroids: a narrative review

Bain, Chris; Myles, Paul S.; Corcoran, Tomás; Dieleman, Jan M.

doi:10.1111/anae.15896

Cited by 42 publications

(20 citation statements)

References 139 publications

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“…Surgical trauma and postoperative inflammatory response have been implicated in the pathophysiology of PONV and reported as factors for PONV 44,46 . Studies designed to measure the magnitude of the inflammatory response and the specific impact of suppressing the inflammatory response are needed.…”

Section: Discussionmentioning

confidence: 99%

Nausea and Vomiting After Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis

Syed,

Baghdadi,

Muhly

et al. 2024

JBJS Reviews

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Background: Postoperative nausea and vomiting (PONV) affects patient satisfaction, health care costs, and hospital stay by complicating the postoperative recovery period after adolescent idiopathic scoliosis (AIS) spinal fusion surgery. Our goal was to identify recommendations for optimal management of PONV in AIS patients undergoing posterior spinal fusion (PSF). Methods: We performed a systematic review in June 2022, searching the PubMed and Embase electronic databases using search terms “(Adolescent idiopathic scoliosis) AND (Postoperative) AND (Nausea) AND (Vomiting).” Three authors reviewed the 402 abstracts identified from January 1991 to June 2022. Studies that included adolescents or young adults (<21 years) with AIS undergoing PSF were selected for full-text review by consensus. We identified 34 studies reporting on incidence of PONV. Only 6 studies examined PONV as the primary outcome, whereas remaining were reported PONV as a secondary outcome. Journal of Bone and Joint Surgery Grades of recommendation were assigned to potential interventions or clinical practice influencing incidence of PONV with respect to operative period (preoperative, intraoperative, and postoperative period) on the basis that potential guidelines/interventions for PONV can be targeted at those periods. Results: A total of 11 factors were graded, 5 of which were related to intervention and 6 were clinical practice-related. Eight factors could be classified into the operative period—1 in the intraoperative period and 7 in the postoperative period, whereas the remaining 3 recommendations had overlapping periods. The majority of grades of recommendations given were inconclusive or conflicting. The statement that neuraxial and postoperative systemic-only opioid therapy have a similar incidence of PONV was supported by good (Grade A) evidence. There was fair (Grade B) and poor evidence (Grade C) to avoid opioid antagonists and nonopioid local analgesia using wound catheters as PONV-reducing measures. Conclusion: Although outcomes after spinal fusion for AIS have been studied extensively, the literature on PONV outcomes is scarce and incomplete. PONV is most commonly included as a secondary outcome in studies related to pain management. This study is the first to specifically identify evidence and recommendations for interventions or clinical practice that influence PONV in AIS patients undergoing PSF. Most interventions and clinical practices have conflicting or limited data to support them, whereas others have low-level evidence as to whether the intervention/clinical practice influences the incidence of PONV. We have identified the need for expanded research using PONV as a primary outcome in patients with AIS undergoing spinal fusion surgery.

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Section: Discussionmentioning

confidence: 99%

Nausea and Vomiting After Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis

Syed,

Baghdadi,

Muhly

et al. 2024

JBJS Reviews

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“…Such discovery may facilitate improved prediction [47] and understanding of how immune modifying interventions [5,48] may be utilised to better target patients at high perioperative risk.…”

Section: Discussionmentioning

confidence: 99%

“…Inflammation after major abdominal surgery is essential and balanced by pro-and anti-inflammatory processes within the innate and adaptive immune systems, stimulating natural repair and healing [5][6][7]. However, dysregulated hyperinflammation and/or immunosuppression may increase the risk of postoperative complications and organ dysfunction and contribute to poorer quality of recovery, persistent disability, or death [2,[8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Postoperative systemic inflammation after major abdominal surgery: patient‐centred outcomes

et al. 2023

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SummaryPostoperative systemic inflammation is strongly associated with surgical outcomes, but its relationship with patient‐centred outcomes is largely unknown. Detection of excessive inflammation and patient and surgical factors associated with adverse patient‐centred outcomes should inform preventative treatment options to be evaluated in clinical trials and current clinical care. This retrospective cohort study analysed prospectively collected data from 3000 high‐risk, elective, major abdominal surgery patients in the restrictive vs. liberal fluid therapy for major abdominal surgery (RELIEF) trial from 47 centres in seven countries from May 2013 to September 2016. The co‐primary endpoints were persistent disability or death up to 90 days after surgery, and quality of recovery using a 15‐item quality of recovery score at days 3 and 30. Secondary endpoints included: 90‐day and 1‐year all‐cause mortality; septic complications; acute kidney injury; unplanned admission to intensive care/high dependency unit; and total intensive care unit and hospital stays. Patients were assigned into quartiles of maximum postoperative C‐reactive protein concentration up to day 3, after multiple imputations of missing values. The lowest (reference) group, quartile 1, C‐reactive protein ≤ 85 mg.l‐1, was compared with three inflammation groups: quartile 2 > 85 mg.l‐1 to 140 mg.l‐1; quartile 3 > 140 mg.l‐1 to 200 mg.l‐1; and quartile 4 > 200 mg.l‐1 to 587 mg.l‐1. Greater postoperative systemic inflammation had a higher adjusted risk ratio (95%CI) of persistent disability or death up to 90 days after surgery, quartile 4 vs. quartile 1 being 1.76 (1.31–2.36), p < 0.001. Increased inflammation was associated with increasing decline in risk‐adjusted estimated medians (95%CI) for quality of recovery, the quartile 4 to quartile 1 difference being ‐14.4 (‐17.38 to ‐10.71), p < 0.001 on day 3, and ‐5.94 (‐8.92 to ‐2.95), p < 0.001 on day 30. Marked postoperative systemic inflammation was associated with increased risk of complications, poor quality of recovery and persistent disability or death up to 90 days after surgery.

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“…This was recently described as 'postoperative systemic inflammatory dysregulation', defined on the basis of exaggerated increases in circulating concentrations of C-reactive protein (CRP). 16 CRP is an acute phase protein that is primarily synthesised in the liver following exposure to the dominant postoperative inflammatory cytokine, interleukin-6 (IL-6). 17 Increases in IL-6 in turn are proportional to the degree of tissue injury during surgery and the subsequent burden of damage and pathogen-associated molecular patterns.…”

Section: Introductionmentioning

confidence: 99%

Inflammation risk before cardiac surgery and the treatment effect of intraoperative dexamethasone

Toner,

Corcoran,

Vlaskovsky

et al. 2023

Anaesth Intensive Care

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Patients who exhibit high systemic inflammation after cardiac surgery may benefit most from pre-emptive anti-inflammatory treatments. In this secondary analysis ( n = 813) of the randomised, double-blind Intraoperative High-Dose Dexamethasone for Cardiac Surgery trial, we set out to develop an inflammation risk prediction model and assess whether patients at higher risk benefit from a single intraoperative dose of dexamethasone (1 mg/kg). Inflammation risk before surgery was quantified from a linear regression model developed in the placebo arm, relating preoperatively available covariates to peak postoperative C-reactive protein. The primary endpoint was the interaction between inflammation risk and the peak postoperative C-reactive protein reduction associated with dexamethasone treatment. The impact of dexamethasone on the main clinical outcome (a composite of death, myocardial infarction, stroke, renal failure, or respiratory failure within 30 days) was also explored in relation to inflammation risk. Preoperatively available covariates explained a minority of peak postoperative C-reactive protein variation and were not suitable for clinical application (R2 = 0.058, P = 0.012); C-reactive protein before surgery (excluded above 10 mg/L) was the most predictive covariate ( P < 0.001). The anti-inflammatory effect of dexamethasone increased as the inflammation risk increased (–0.689 mg/L per unit predicted peak C-reactive protein, P = 0.002 for interaction). No treatment-effect heterogeneity was detected for the main clinical outcome ( P = 0.167 for interaction). Overall, risk predictions from a model of inflammation after cardiac surgery were associated with the degree of peak postoperative C-reactive protein reduction derived from dexamethasone treatment. Future work should explore the impact of this phenomenon on clinical outcomes in larger surgical populations.

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Postoperative systemic inflammatory dysregulation and corticosteroids: a narrative review

Cited by 42 publications

References 139 publications

Nausea and Vomiting After Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis

Nausea and Vomiting After Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis

Postoperative systemic inflammation after major abdominal surgery: patient‐centred outcomes

Inflammation risk before cardiac surgery and the treatment effect of intraoperative dexamethasone

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