Published ahead of print on May 25, 2006, doi:10.1164/rccm.200506-907OC
© 2006 American Thoracic Society doi: 10.1164/rccm.200506-907OC
Intervention at the Level of the Neuroendocrine–Immune Axis and Postoperative Pneumonia Rate in Long-term AlcoholicsDepartment of Anesthesiology and Intensive Care Medicine, Institute of Laboratory Medicine and Pathobiochemistry, and Institute of Medical Biometry, Campus Charité Mitte and Campus Virchow Klinikum; Institute of Medical Immunology, Campus Charité Mitte; Department of Otorhinolaryngology and Head and Neck Surgery, Campus Charité Mitte, Campus Virchow Klinikum, and Campus Benjamin Franklin; Clinic and Polyclinic for Oral and Maxillofacial Surgery and Plastic Surgery, Campus Virchow Klinikum; and Department of Maxillofacial and Plastic Surgery, Campus Benjamin Franklin, Charité–University Medicine Berlin, Berlin, Germany; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; and Center for Drug and Alcohol Programs, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina Correspondence and requests for reprints should be addressed to Claudia Spies, M.D., Department of Anesthesiology and Intensive Care Medicine, and Emergency Medicine and Pain Therapy, Charité–University Medicine Berlin, Campus Charité Virchow Klinikum and Campus Charité Mitte, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail: claudia.spies{at}charite.de Rationale: Postoperative pneumonia is three to four times more frequent in patients with alcohol use disorders followed by prolonged intensive care unit (ICU) stay. Long-term alcohol use leads to an altered perioperative hypothalamus–pituitary–adrenal (HPA) axis and immunity. Objectives: The aim of this study was to evaluate HPA intervention with low-dose ethanol, morphine, or ketoconazole on the neuroendocrine–immune axis and development of postoperative pneumonia in long-term alcoholic patients. Methods: In this randomized, double-blind controlled study, 122 consecutive patients undergoing elective surgery for aerodigestive tract cancer were included. Long-term alcohol use was defined as consuming at least 60 g of ethanol daily and fulfilling the Diagnostic and Statistical Manual of Mental Disorders IV criteria for either alcohol abuse or dependence. Nonalcoholic patients were included but only as a descriptive control. Perioperative intervention with low-dose ethanol (0.5 g/kg body weight per day), morphine (15 µg/kg body weight per hour), ketoconazole (200 mg four times daily), and placebo was started on the morning before surgery and continued for 3 d after surgery. Blood samples to analyze the neuroendocrine–immune axis were obtained on the morning before intervention and on Days 1, 3, and 7 after surgery. Measurements and Main Results: In long-term alcoholic patients, all interventions decreased postoperative hypercortisolism and prevented impairment of the cytotoxic T-lymphocyte type 1:type 2 ratio. All interventions decreased the pneumonia rate from 39% to a median of 5.7% and shortened intensive care unit stay by 9 d (median) compared with the placebo-treated long-term alcoholic patients. Conclusions: Intervention at the level of the HPA axis altered the immune response to surgical stress. This resulted in decreased postoperative pneumonia rates and shortened intensive care unit stay in long-term alcoholic patients.
Key Words: aerodigestive tract cancer • alcohol use disorder • cortisol • pneumonia • T-cell–mediated immunity This article has been cited by other articles:
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