An increasing proportion of people today have inherited, acquired, or induced immunodeficiencies [1]. The term “immunocompromised” refers to an immune system in which the ability to resist or fight infectious agents is impaired [2]. Common examples are those with cancer, autoimmune or inflammatory diseases, HIV, sickle cell disease, and patients with organ or bone marrow transplantation [1]. Infants and geriatric adults also commonly have depressed immune systems [2]. Rare fungal, bacterial, and viral infections are encountered in immunocompromised patients more often than in the general population [1]. Those with an immunocompromised status are at a higher risk for adverse perioperative events [2].
Immunocompromised patients have an increased risk for hypothermia, which can affect the postoperative wound healing processes and lead to infection [2]. When a patient becomes hypothermic, the capacity for the body to produce new cells for tissue repair becomes depressed [2]. For a patient who is already immunocompromised, this further increases the risk for infection [2]. It is critically important to prevent perioperative hypothermia in this population, and thus the surgical team should assess the patient’s risk factors and monitor the patient’s temperature repeatedly [2]. Warming devices (e.g. forced-air temperature-regulating devices and IV and irrigation fluid warming devices) should be used when feasible during the surgical process. Postoperatively, warm blankets should be applied immediately [2].
Surgical site infection (SSI) is also a significant issue in immunocompromised patients [3]. The reported rate of SSI in immunocompromised transplant patients is up to 27% [3]. Commonly used practices, like antimicrobial prophylaxis, are inefficient in preventing SSI in immunocompromised patients [3]. Furthermore, misuse of antibiotics has led to increased rates of multi-drug resistant bacteria that could be deadly for this group [3]. In 2016, the World Health Organization released guidelines on SSI prevention [3]. The use of negative pressure wound therapy (NPWT) was suggested for high-risk immunocompromised patients [3]. It was proposed that when NPWT is applied to the surgical incisional wound with closed suture, the rate of SSI is reduced [3].
Moreover, some medications impair wound healing, an effect that is enhanced in the immunocompromised population [3]. Oncological patients undergoing surgery while in chemotherapy with VEGF inhibitors (e.g. bevacizumab) may be exposed to a higher risk of SSI [3]. Data from two randomized trials analyzed the influence of bevacizumab on wound healing in surgical procedures [3]. The authors found a complication rate of 3.4% when bevacizumab was administered more than 28 days after surgery and a complication rate of 13% in patients who underwent surgery during chemotherapy treatment [3]. In immunocompromised patients about to undergo elective surgery, pausing or switching certain immunosuppressants is recommended [1]. For example, mammalian target of rapamycin (mTOR) inhibitors, which slow wound healing, can be switched to a less antiproliferative and antiangiogenic immunosuppressant such as a calcineurin inhibitor [1].
References
- Graeb, C., & Jauch, K. (2008). Surgery in immunocompromised patients. Journal of British Surgery, 95(1), 1-3. doi:10.1002/bjs.6096
- Neil, J. (2007). Perioperative care of the immunocompromised patient. AORN Journal, 85(3), 544-560. doi:10.1016/S0001-2092(07)60126-4
- Coccolini, F., Improta, M., Cicuttin, E. etc. (2021). Surgical site infection prevention and management in immunocompromised patients: a systematic review of the literature. World Journal of Emergency Surgery, 16(1), 1-13. doi:10.1186/s13017-021-00375-y
