Influence of anesthesia on immune responses and its effect on vaccination in children: review of evidence

Pediatric influenza vaccination in the perioperative setting: A quality improvement project

INTRODUCTION/BACKGROUND

Unmet need for seasonal influenza vaccination administration to pediatric patients exists at national and local levels. Vaccination during the perioperative period remains controversial, though opportunity exists to meet vaccination need through perioperative programs. The initial SMART Aim of this quality improvement initiative was to establish and increase seasonal influenza vaccination rate in eligible patients during in person preoperative clinic visits in a pediatric perioperative surgical home (PSH) to 10%. Informed by each prior season's experience, we increased our SMART Aim target for vaccinations in seasons two and three to 15 and 18%, respectively.

METHODS

Following the Model for Improvement methodology, the PSH team developed and implemented a perioperative pediatric influenza vaccination program. Across three influenza seasons, key interventions included updates to organizational perioperative vaccination policy, obtaining material influenza vaccination supplies, development of EHR tools, PSH staff education, and communication with patient-families. Rate of eligible patients receiving influenza vaccination at their PSH clinic appointment was tracked over time. Influenza vaccination rates were reported monthly during Season 1, then weekly during seasons two and three. The balancing measure was same day surgery case cancellations related to influenza vaccination given at PSH clinic appointment. Statistical analysis methods utilized include Shewart's control chart and statistical process control (SPC) standards. Special cause variation was determined by eight or more consecutive data points above or below the centerline.

RESULTS

The influenza vaccination rates in each of the three influenza seasons exceeded vaccination rate goals of 10, 15, and 18%, respectively. A total of 695 vaccines have been administered since program inception. No same day surgical case cancellations were observed as balancing measure.

CONCLUSIONS

Over three consecutive influenza vaccination seasons, we safely established and met vaccination rate goals of 10, 15, and 18% to eligible patients during preoperative clinic visits within a pediatric PSH system. Through iterative PDSA cycles, we continue to identify opportunities for future improvement. This suggests that the perioperative period presents opportunity for seasonal influenza vaccination with potential program expansion to include routine vaccines of childhood.

Immunisation rates and predictors of undervaccination in infants with CHD

Vaccination coverage for infants with CHD is unknown, yet these patients are at high risk for morbidity and mortality associated with vaccine-preventable illnesses. We determined vaccination rates for this population and identified predictors of undervaccination. We prospectively enrolled infants with CHD born between 1 January, 2012 and 31 December, 2015, seen in a single-centre cardiology clinic between 15 February, 2016 and 28 February, 2017. We assessed vaccination during the first year of life. Subjects who by age 1 year received all routine immunisations recommended during the first 6 months of life were considered fully vaccinated. We also evaluated influenza vaccination during subjects' first eligible influenza season. We obtained immunisation histories from primary care providers and collected demographic and clinical data via a parent survey and chart review. We used multivariable logistic regression to identify predictors of undervaccination. Among 260 subjects, only 60% were fully vaccinated. Vaccination rates were lowest for influenza (64.6%), rotavirus (71.1%), and Haemophilus influenzae type b (79.3%). Cardiac surgery with cardiopulmonary bypass during the first year of life was associated with undervaccination (51.5% versus 76.4% fully vaccinated, adjusted odds ratio 2.1 [95% confidence interval 1.1-3.9]). Other predictors of undervaccination were out-of-state primary care (adjusted odds ratio 2.7 [1.5-4.9]), multiple comorbidities (≥2 versus 0-1, adjusted odds ratio 2.0 [1.1-3.6]), and hospitalisation for >25% of the first year of life (>25% versus ≤25%, adjusted odds ratio 2.1 [1.1-3.9]). Targeted quality improvement initiatives focused on improving vaccination coverage for these infants, especially surrounding cardiac surgery, are needed.

Beyond Influenza Vaccination: Expanding Infrastructure for Hospital-Based Pediatric COVID-19 Vaccine Delivery

Controlling the spread of severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), will rely on vaccination at increasing rates and in an equitable manner. The main reasons for under-vaccination are varied among different segments of the population and include vaccine hesitancy and lack of access. While vaccine hesitancy is complicated and requires long-term solutions, access can be enhanced through evidence-based delivery strategies that augment conventional approaches. Hospital-based COVID-19 vaccination programs hold particular promise in reaching populations with decreased vaccine access and those at higher risk for adverse outcomes from SARS-CoV-2 infection. Hospitals have the necessary equipment and storage capabilities to maintain cold chain requirements—a common challenge in the primary care setting—and can serve as a central distribution point for delivering vaccines to patients in diverse hospital locations, including inpatient units, emergency departments, urgent care centers, perioperative areas, and subspecialty clinics. They also have the capacity for mass-vaccination programs and other targeted outreach efforts. Hospital-based programs that have been successful in implementing influenza and other routine vaccinations can leverage existing infrastructure, such as electronic health record–related tools. With the possibility of COVID-19 becoming endemic, much like seasonal influenza, these programs will require flexibility as well as planning for long-term sustainability. This commentary highlights existing vaccine delivery to children in hospital-based settings, including key advantages and important challenges, and outlines how these systems could be expanded to include the COVID-19 vaccine delivery.

Perioperative Coronavirus Vaccination - Timing and Implications: A Guidance Document

Cardiothoracic surgical patients are at risk of increased coronavirus disease severity. Several important factors influence the administration of the coronavirus disease vaccine in the perioperative period. This guidance statement outlines current information regarding vaccine types, summarizes recommendations regarding appropriate timing of administration, and provides information regarding side effects in the perioperative period for cardiac and thoracic surgical patients.

Hypoxia-dependent signaling in perioperative and critical care medicine

A critical goal of patient management for anesthesiologists and intensivists is to maintain oxygen homeostasis in patients admitted to operation theaters and intensive care units. For this purpose, it is imperative to understand the strategies of the body against oxygen imbalance—especially oxygen deficiency (hypoxia). Adaptation to hypoxia and maintenance of oxygen homeostasis involve a wide range of responses that occur at different organizational levels in the body. These responses are greatly influenced by perioperative patient management including factors such as perioperative drugs. Herein, the influence of perioperative patient management on the body's response to oxygen imbalance was reviewed with a special emphasis on hypoxia-inducible factors (HIFs), transcription factors whose activity are regulated by the perturbation of oxygen metabolism. The 2019 Nobel Prize in Physiology or Medicine was awarded to three researchers who made outstanding achievements in this field. While previous studies have reported the effect of perioperatively used drugs on hypoxia-induced gene expression mediated by HIFs, this review focused on effects of subacute or chronic hypoxia changes in gene expression that are mediated by the transcriptional regulator HIFs. The clinical implications and perspectives of these findings also will be discussed. Understanding the basic biology of the transcription factor HIF can be informative for us since anesthesiologists manage patients during the perioperative period facing the imbalances the oxygen metabolism in organ and tissue. The clinical implications of hypoxia-dependent signaling in critical illness, including Coronavirus disease (COVID-19), in which disturbances in oxygen metabolism play a major role in its pathogenesis will also be discussed.

Implications of anesthesia and vaccination

The current COVID-19 pandemic has had a global impact on vaccination rates. Delays in routine healthcare and immunization have led to a rise in concerns about resurgence of vaccine-preventable diseases around the world. With the release and distribution of COVID-19 vaccines, plans to improve immunization rates need to be explored and implemented across disciplines. One approach would be the consideration of perioperative vaccinations; however, the effects of anesthesia and surgery on the immune response and complications associated with vaccination during the perioperative period are still poorly understood, and opinions are divided. To ascertain the value of a perioperative vaccination program, it is important to understand the basics of immunization and common vaccinations; the potential vaccine complications in the pediatric cohort; the implications of anesthesia and surgery on the immune response; and current recommendations. In addition, we believe it is important to discuss the logistics and feasibility of coordinating perioperative immunization should this become a regular opportunity.

Febrile convulsions during recovery after anesthesia in an infant with history of MMR vaccination: A case report

RATIONALE

Seizures are rare during the perioperative period; in most cases, there is a previous history of epilepsy or surgery-associated seizures. Febrile convulsions may occur when the body temperature rises above 38°C; this is the most common cause of seizures in children. Febrile convulsions after general anesthesia in the postanesthetic care unit (PACU) without a past or family history are rare. Some reviews suggest that since anesthesia changes immunity, elective surgery should be postponed three weeks after live vaccination.

PATIENT

A 12-month-old female with bilateral hearing loss underwent cochlear implantation under general anesthesia. She did not have any history of convulsions or developmental disorders. However, 1 week before surgery, measles-mumps-rubella (MMR) vaccination was given as a regular immunization.

DIAGNOSES

Forty minutes after arrival at the PACU, sudden generalized tonic-clonic movement occurred during recovery and the patient's measured body temperature exceeded 38.0°C.

INTERVENTIONS

Thiopental sodium was administered intravenously as an anticonvulsant, and the tonic-clonic movement stopped immediately. Endotracheal intubation was performed to secure the airway, and tepid massage and diclofenac β-dimethylaminoethanol administration were performed to lower the patient's body temperature.

OUTCOMES

There was no further fever and no seizures, and no other neurological deficits were observed until discharge.

LESSONS

The anesthesiologist should check the recent vaccination history even if the patient has not developed particular symptoms after vaccination. It is important to know that febrile convulsions may occur in patients who have recently received MMR vaccination.

Effects of oxycodone on immune function in patients undergoing radical resection of rectal cancer under general anesthesia

This study aims to explore the effect of oxycodone hydrochloride injection on the immune function of patients who underwent radical resection of rectal cancer under general anesthesia.Eighty patients were enrolled and randomly divided into group A and B (n = 40, each). All patients underwent general intravenous anesthesia. At the end of surgery, each patient in group A was injected with 5 mg (5 mL) of oxycodone hydrochloride, while 5 mg (5 mL) of morphine hydrochloride in group B. Venous blood was withdrawn in both groups at different time points. Changes in the numbers of T lymphocyte subsets and natural killer (NK) cells were determined by flow cytometry.First the numbers of T lymphocyte subsets and NK cells at T1, T2, T3, and T4 decreased in both groups, compared with those at T0, and the differences were statistically significant. Furthermore, the numbers reduced to a minimum at T2 and began to recover at T3. Second the differences between group A and B at T1, T2, T3, and T4 were statistically significant; and the numbers of T lymphocytes and NK cells were higher in group A than in group B at corresponding time points.Oxycodone hydrochloride and morphine hydrochloride both have inhibitory effects on immune function in patients undergoing radical resection of rectal cancer after surgery. However, oxycodone hydrochloride has a smaller effect compared to morphine hydrochloride.

Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications

Vaccine-preventable diseases (VPDs) such as measles and pertussis are becoming more common in the United States. This disturbing trend is driven by several factors, including the antivaccination movement, waning efficacy of certain vaccines, pathogen adaptation, and travel of individuals to and from areas where disease is endemic. The anesthesia-related manifestations of many VPDs involve airway complications, cardiovascular and respiratory compromise, and unusual neurologic and neuromuscular symptoms. In this article, we will review the presentation and management of 9 VPDs most relevant to anesthesiologists, intensivists, and other hospital-based clinicians: measles, mumps, rubella, pertussis, diphtheria, influenza, meningococcal disease, varicella, and poliomyelitis. Because many of the pathogens causing these diseases are spread by respiratory droplets and aerosols, appropriate transmission precautions, personal protective equipment, and immunizations necessary to protect clinicians and prevent nosocomial outbreaks are described.

Anesthesia for ORL surgery in children

ORL procedures are the most common operations in children – an optimal anesthetic management provides an uncomplicated, safe perioperative process with as little discomfort for the child as possible. Children at risk must already be identified preoperatively: the combination of ORL surgery, airway susceptibility and age below 3 years can increase the risk of perioperative respiratory adverse events. Postoperatively, it is important to prevent complications such as pain and PONV by dedicated prevention and treatment strategies, as well as to recognize and treat respiratory or circulatory complications competently. Interdisciplinary guidelines and agreements as well as the overall competence of the team have the potential to improve patient safety and outcome in children.

[Myocarditis exacerbation in a child undergoing inguinal herniopasty after viral infection]

INTRODUCTION

Immunosuppressive effects of general anaesthesia and surgery could have unexpected consequences in a child with recent infection. The incidence of myocarditis in childhood is unknown.

CASE OUTLINE

During general anaesthesia for inguinal hernia repair, a seven-year-old boy suddenly developed heart failure. Clinical presentation included hypotension, pulmonary oedema, drop in haemoglobin oxygen saturation, ST segment elevation and premature ventricular contractions. Haemodynamic stability and adequate oxygenation were achieved with dopamine and furosemide. Preoperative history, physical examination and complete blood count were unremarkable. Moderate cardiomegaly and pulmonary oedema were present on chest radiography. Diminished left ventricular contractility found on echocardiography increased troponin I and CK-MB levels suggested myocardial injury. Increased C-reactive protein with lymphocytosis suggested inflammation as its cause. Parents failed to report rubella 10 days before the operation. A clinical diagnosis of myocarditis as a complication of rubella was based on increased titer of IgM to rubella. With intravenous immunoglobulin, corticosteroids and symptomatic treatment for heart failure, his condition improved and ejection fraction reached 68% one month after operation.

CONCLUSION

In future, we need protocols with instructions for paediatric patients undergoing elective surgery and anaesthesia after viral infections.

Comparison of systemic Listeria monocytogenes infection in esophageally inoculated mice anesthetized with isoflurane or pentobarbital

In previous attempts to produce a murine model of gastrointestinal listeriosis, the authors observed that pentobarbital anesthesia greatly increased disease severity in mice that were esophageally inoculated with the bacterium Listeria monocytogenes. In this study, they sought to evaluate the severity of systemic infection in inoculated mice that were anesthetized with isoflurane, an inhalational agent that is safer than pentobarbital and more commonly used for rodent anesthesia. Compared with pentobarbital anesthesia, isoflurane anesthesia resulted in infections of lesser severity, similar to those observed in unanesthetized mice. A pilot study in which mice were anesthetized with isoflurane for 5, 10 or 20 min suggested that this effect was not related to the duration of anesthesia. These results show that isoflurane anesthesia administered for 5 to 20 min does not potentiate the severity of listeriosis infection in mice esophageally inoculated with L. monocytogenes.