PERIOPERATIVE CARE OF THE IMMUNOCOMPROMISED PATIENT

ORGANS AND TISSUES OF THE IMMUNE SYSTEM The term lymphoid refers to the organs and tissues of the immune system that are involved in the growth, development, and dissemination of leukocytes (ie, a type of white blood cell [WBC]). Immune system cells and blood are closely related; both are produced in the bone marrow and both use the bloodstream for transportation.' The major components of the immime system are the bone marrow, thymus, peripheral lymphoid organs and tissues, and accessory lymphoid organs and tissues. Each plays a role in the development of B cells and T cells, the two major types of lymphocytes. - Bone marrow. Bone marrow contains stem cells that use the process of hematopoiesis to develop into two types of cellslymphocytes and phagocytes. - Thymus. In the thymus, T cells undergo "education," a process in which they learn to recognize other cells. There are several types of T cells with specific functions. Cytotoxic T cells are capable of killing infected somatic or tumor cells. - Peripheral lymphoid organs and tissues. Peripheral lymphoid organs and tissues consist of several structureslymph nodes, lymphatic vessels, and the spleen. Lymph nodes are small, oval-shaped structures located along a network of lymph channels that are most abundant in tiie neck, axilla, pelvis, and groin. These nodes help remove antigens that circulate in the blood and lymph fluid. Lymphatic vessels contain lymph fluid, consisting of lymphocytes, macrophages, and antigens, that is collected from body tissues as it seeps into the lymphatic vessels. Lymph fluid is transported to the lymph nodes where antigens are processed and killed. The lymph fluid then leaves the node through efferent lymphatic vessels, moves to larger lymph vessels, and finally empties into the superior vena cava. Lymph fluid usually travels through several chains of nodes that prevent organisms in peripheral areas from getting into the central areas.' The spleen is an immunological filter of the blood. It is made up of B cells, T cells, macrophages, dendritic cells, natural killer cells, and red blood cells. It has several functions. Phagocytes within the spleen engulf and break down worn out or damaged red blood cells. The spleen also filters and removes bacteria and other antigens. Interactions of splenic phagocytes with lymphocytes serve to initiate immune responses. The spleen also stores blood and platelets.' - Accessory lymphoid organs and tissues. The accessory lymphoid organs and tissues include the tonsils; adenoids; appendix; and Peyer's patches (ie, collections of lymphatic tissue within submucosa of the small intestine). The accessory lymphoid organs and tissues are located in areas that come in contact with food and air where microbial numbers may be high, and they remove foreign debris in the same manner as lymph nodes. IMMUNE SYSTEM FUNCTION The term immunity is defined as "the body's capacity to resist invading organisms and toxins, thereby preventing tissue and organ damage. The immune system recognizes, responds to, and eliminates antigens including bacteria, fungi, viruses, and parasites. It also preserves the body's intemal environment by scavenging dead or damaged cells and patrolling for antigens, which is characterized by a cascade of events. The immune response begins with microorganism invasion at the site of tissue damage. In response, basophils release heparin that causes histamine

and kinin to be produced. This results in vasodilation and increased capillary permeability of the vessels. Blood flow then increases to the affected area and fluid collects within it. Neutrophils flock to the site to engulf and destroy microorganisms from dying cells. The tissue regeneration and repair process then can begin. The immune system functions by three basic methods: the protective surface phenomenon, general host defenses, and specific immune responses. - The protective surface phenomenon. The protective surface phenomenon consists of physical, chemical, and mechanical barriers that work to prevent the entry of potentially harmful organisms. The skin and mucus membranes provide the first line of defense against microbial invasion by preventing attachment of organisms. Skin desquamation and low pH impede bacterial colonization. The enzyme lysozyme is an antibacterial substance found in tears, saliva, and divide and nasal secretions. Nasal hairs and turbulent air flow through the nostrils also filter out foreign maplasma cells terials. The nasal cavities produce secretions that produce and contain immunoglobulins that discourage microbe adherence. In the gastrointestinal (GI) tract, bacteria are mechanically removed by saliva, swallowing, peristalsis, and defecation. The stomachs low pH is bacteriocidal, eliminating most bacteria. The rest of the GI tract is protected by colonization resistance (ie, resident bacteria prevent other microorganisms from multiplying). - General host defenses. The general host defenses are nonspecific cellular responses to antigens that penetrate the skin or mucus membranes. For instance, the inflammatory response involves vascular and cellular changes, including the release of chemical substances such as heparin, histamine, and kinin. Polymorphonuclear leukocytes include: neutrophils that engulf, digest, and dispose of invaders through phagocytosis; eosinophils that multiply during allergic or parasitic disorders and also have phagocytic properties; and basophils and mast cells that have surface receptors for immunoglobin (Ig) E. When antigens are linked to the IgE complex, mediators are released that are characteristic of an allergic response. - Specific immune responses. Specific immune responses include humoral and cellmediated immunity. Humoral immunity involves B cells. Foreign antigens cause B cells to divide and differentiate into plasma cells. Each plasma cell produces and secretes large amounts of antigenspecific immunoglobulin into the bloodstream. The five types of immunoglobulin include IgA, IgG, and IgM, which guard against viral and bacterial invasion; IgD, which acts as an antigen receptor of B cells; and IgE, which causes allergic responses.' Immunoglobulins work as antitoxins by linking with toxins that bacteria produce by opsonizadon (ie, rendering microorganisms susceptible to phagocytosis); coating bacteria to make them targets for phagocytes; or linking to antigens, causing the immune system to produce and circulate enzymes. A time lag occurs after initial exposure to an antigen. The B cell recognizes the antigen, and a sequence of division, differentiation, and antibody formation begins. Two types of humeral responses occur, including a primary antibody response, which occurs four to 10 days after exposure when IgM is prevalent, and

a secondary response, which occurs when there is a repeat exposure to the same antigen, at which point memory cells produce antibodies that peak in one to two days
after re-exposure.

IMMUNE SYSTEM MALFUNCTION Several types of immune system malfunction may make a patient vulnerable during the surgical experience. These include hypersensitivity disorders, autoimmune disorders, and immunodeficiency. - Hypersensitivity disorders. Hypersensitivity disorders include those where immune function is exaggerated, misdirected misdirected, absent, or depressed. These are classified as types 1 to IV with some overlap. - The autoimmune disorders. The autoimmune disorders inelude marked or abnormal responses to one's own tissue. Autoimmunity leads to a sequence of tissue reactions and damage that produce systemic signs and symptoms. - Immunodeficiency. Immunodeficiency is caused by a variety of absent or depressed immune responses. There are 26 clinical immunodeficiency conditions including ataxiatelangiectasia, chronic granulomatous disease, common variable immunodeficiency, complement deficiencies, DiGeorge's syndrome, severe combined immunodeficiency disease, and X-linked infantile hypogammaglobulinemia. GENERAL POPULATIONS AT HIGH RISK FOR IMMUNE DYSFUNCTION Infants and geriatric adults are at high risk for immune dysfunction because their immune systems may be depressed or impaired. Other high risk populations include people who: abuse alcohol; are malnourished; are suffering from chronic pain; have undergone an organ transplantation procedure; have undergone a splenectomy, and; have cancer. - Infant. The immature immunological defense systems of infants increase their risk for immune dysfunction. The maternal immune system is part of the neonatal defense system, and infants rely on breast milk to provide phagocytes, B cells, T cells, and IgA. As a result, premature infants and infants who are not breast fed have a decreased ability to defend against bacterial toxins that can lead to necrotizing enterocolitis. - Geriatric adults. Immune systemfunction decreases with age, often losing some ability to distinguish self from non-self, therefore increasing the incidence of autoimmune diseases. The geriatric immune system also loses some ability to identify mutant cells, which leads to a variety of cancers. The B cells and T cells also may decrease in number and become less effective. Furthermore, the spleen and lymph nodes reduce in size slightly as the older adult ages. - People who abuse alcohol. Alcohol consumption compromises the function of several parts of the immune defense system. Heavy alcohol consumption (ie, more than 60 g per day) increases the risk of developing health care-associated infections. One glass of wine is equivalent to approximately 12 g of alcohol. - People who are malnourished. People who have poor nutrition also may be at risk. A malnourished person often has adepressed immune system and is susceptible to infection. - People suffering from chronic pain. Both surgery and pain negatively affect and can have harmful effects on immune system function via neuroendocrine pathways.

People who have undergone organ transplantation. Undergoing an organ transplantation causes a complex series of immunological processes to occur inflammation, immunity, tissue repair, and structural reinforcement of damaged tissues. Activation of biochemical cascades causes the immune system to control invading antigens and then promotes repair. People who have undergone spleneqomy. Patients who have imdergone a splenectomy may be at risk for a depressed immune system because macrophages in the spleen rid the blood of certain parasites and bacteria. The spleen contains lymphocytes, which release antibodies and weaken or kill bacteria, viruses, and other organisms that cause infection. When the spleen is removed, these cells may be fewer in number. People with cancer. Patients who have cancer and are taking chemotherapeutic agents or are undergoing radiation therapy have depressed immune systems because these treatments destroy or suppress all types of cells including immune system cells. In addition, patients taking chemotherapeutic agents often are given steroids, which further affect the immune system.

EFFECTS OF IMMUNE SYSTEM ON PATIENTS UNDERGOING SURGERY The immune system is the main defense against infection and is the mediator of the reparative process, providing cells to kill invader organisms. The immunological response works on the central nervous system and enhances systemic effects, increasing resistance to infection, minimizing tissue injury, and promoting tissue repair. Major surgery, trauma, burns, and sepsis all have significant inflammatory components; therefore, patients undergoing surgery may experience changes in immune, neuroendocrine, and metabolic functions triggered by the sympathetic nervous system. For many reasons, patients who are immunocompromised and are undergoing surgery are at higher risk than patients who are not immunocompromised. A person who is immunocompromised is missing some or many of the components that promote wound healing and prevent infection. Surgical patients who are immunocompromised are at risk because this normal activity may be depressed and be further diminished by the surgical process or anesthesia. - Use of steroids in perioperative patients. Cortisol and ACTH secretion normally is increased as a response to surgery. Usually, people secrete about 30 mg of cortisol each day. In response to minor surgery, however, a person's cortisol increases to approximately 50 mg. In response to major surgery, cortisol increases by two-thirds to approximately 75 mg to 100 mg. People who take steroids on a regular basis tend to have a suppressed hypothalamo-pituitaryadrenal axis, wich can impair the stress response. When a patient who takes steroids on a chronic or acute basis is admitted for elective or emergency surgery, administration of additional steroids may be required because the patient's already depressed immune system may not secrete the additional hormones needed to counteract elevated levels of ACTH and cortisol. - Replacement therapy. Normally, administration of high-dose steroids should be avoided because wound healing could be impaired, recovery delayed, and postoperative morbidity increased. - Hypoadrenal crisis. Adrenal insufficiency after major surgery can easily be confused with shock during the course of an immediate unstable postoperative period. It often is unrecognized because it is a rare complication of patients on replacement therapy.

Adrenal insufficiency can be overwhelming and, if unrecognized, may cause serious morbidity, or it can be fatal. NURSING CARE OF IMMUNOCOMPROMISED SURGICAL PATIENTS An intact immune system protects a perioperative patient from invading organisms and infection. Many diseases,disorders, and medications can impair the immune system, leaving the patient vulnerable during the perioperative period. Nurses, therefore, must have a basic knowledge of the immune system and must actively use the nursing process to protect their patients throughout the perioperative experience. - Assessment. An immunocompromised patient presents many challenges for a perioperative nurse. Care begins in the preoperative period with a complete and accurate assessment. The preoperative nurse should review the patient's medical history and physical examination results including the detailed history of immune system deficiencies. The nurse should note the disease process and document it accurately, including the on set and date of diagnosis. It is particularly important for perioperative nurses to obtain a thorough medication history for patients in highrisk groups. Patients taking immunosuppressive medications should have the following items monitored and documented in their medical record: weight, blood pressure; blood glucose level and electrolyte panel; hematocrit, complete blood cell (CBC) count, WBC count, and platelet count; liver and renal function test results; blood levels of certain medications; antibody titers for some medications; and chest x-ray results. - Nursing diagnoses. Several risks associated with the perioperative setting may be exaggerated in persons who are immunocompromised. Perioperative nurses should consider the following perioperative nursing diagnoses: infection, impaired skin integrity, ineffective thermoregulation, deficient or excess fluid volume, latex allergy, perioperative positioning injuries, chemical and electrical hazards - Nursing interventions. Postoperative wound infection is a serious and costly complication. It is paramount that perioperative nurses prevent contamination and infection in all patients but even more so in those who are immunocompromised. It is essential that perioperative nurses take precautions including extra vigilance related to sterile technique. Except in an emergency, health care providers should avoid inserting extra invasive lines, indwelling urinary catheters, and surgical drains.