General Management of Immunosuppressed Patients

Abstract

Advances in the therapy and management of malignancies and immunologic diseases, together with improved survival of patients with various transplanted organs, have added to the number of patients with profound derangements of the immune system. For the same reasons the number of immunocompromised patients with medical, surgical, or neurologic conditions requiring the expertise and facilities of intensive care treatment has increased within recent years. This group of patients is particularly susceptible to an adverse outcome in case of serious illness. Thus, a thorough understanding of any host defense impairment, diagnostic dilemmas, therapeutic approaches, and possible preventive strategies is essential for an effective treatment. Impairment of the immune system either by a predisposing disease state or by chemotherapy may change the typical clinical pattern of a disease. For example, patients with neutropenia and infection exhibit less fever and less striking physical findings of infection (e.g., local heat, swelling, adenopathy, exudate) than are ordinarily encountered in non-immunosuppressed patients with similar disorders. Furthermore, standard diagnostic tools, such as laboratory and serologic studies, often give inadequate results in such patients; this which may complicate differential diagnostic possibilities and therapeutic strategies. In addition, in transplanted patients or those with autoimmune diseases, the medical or surgical treatment of the condition requiring intensive care treatment may conflict with cytotoxic chemotherapy or other immunosuppressive therapeutic regimens of the primary disease. In the same patients immunosuppressive drugs often interfere with those commonly used in intensive care treatment, causing side effects and complications. Overall, although substantial progress has been made in our understanding of the mechanisms causing a derangement of the host’s immune response, the treatment of such patients remains an intensive care challenge with a high death rate. Detailed discussion of each problem is beyond the scope of this chapter. The goal here is to supply information on those problems commonly encountered in the treatment of immuncompromised patients in the intensive care unit.