Neutrophil function in surgical patients: two inhibitors of granulocyte chemotaxis associated with sepsis.

Two hundred fifty-four surgical patients were studied of whom 69% had a poor clinical outcome which correlated with skin test anergy and decreased polymorphonuclear neutrophil (PMN) chemotaxis (CTX). Patients demonstrating decreased PMN chemotaxis of less than 115 ± 1.0 μm (normal chemotaxis ± 95% confidence limits equaled 128.4 ± 4.4 μm) and skin test anergy (A) had a rate of sepsis equal to 66% and mortality of 37% compared to no sepsis or mortality in patients with normal CTX and normal skin test response. Of 170 A patients, 94% demonstrated decreased autologous PMN CTX. One hundred eleven sera from this pool were tested and all were found to decrease normal heterologous PMN CTX. This chemotactic inhibiting activity was due to two inhibitors circulating in sera from patients with anergy. One inhibitor was found in all sera and has pI = 6.2, s_20,w = 5.3, and MW = 110,000. The other was found only in anergic sera and has pI = 4.6, s_20,w = 9.4, MW = 310,000. The data suggest that the decreased PMN CTX observed in anergy is due to the de novo appearance of the larger PMN CTX inhibitor and that decreased PMN CTX and skin test anergy correlate highly with increased sepsis and mortality in the surgical patient.     

In vivo neutrophil delivery to inflammatory sites in surgical patients. Correlation with in vitro neutrophil chemotaxis and adherence

We examined the interrelationships between leukocyte adherence (ADH), polymorphonuclear neutrophil (PMN) chemotaxis (CTX), and PMN delivery to an inflammatory focus in hospitalized patients. Patients included 25 men and 17 women, with a mean age of 62.8 years, who were admitted for major elective surgery. The patients were studied preoperatively and on the second and seventh postoperative days. Leukocyte adherence increased on the second postoperative day (82.3%, P less than .05) and remained elevated on the seventh postoperative day (81.6%). Polymorphonuclear neutrophil chemotaxis decreased significantly on the second postoperative day (3.4 to 2.9 cm, P less than .05), but returned to normal by the seventh postoperative day. The PMN delivery to skin-window chambers decreased markedly on the second postoperative day (1.28 million cells, P less than .05) with a further decrease on the seventh postoperative day (0.82 million cells). There was no correlation between in vitro PMN CTX and in vivo cell delivery. We conclude that major surgery leads to increased ADH, decreased PMN CTX, and diminished PMN delivery to areas of inflammation. However, a single measure of PMN function such as in vitro PMN CTX does not, alone, reflect in vivo PMN delivery to areas of inflammation.     

Neutrophil chemotaxis and neutrophil elastase in the aortic wall in patients with abdominal aortic aneurysms.

To test the hypothesis that elastin-derived peptides (EDP) from human aortic tissue may be chemotactic for inflammatory cells, we studied the chemotaxis of neutrophils and monocytes to EDP derived from abdominal aortic aneurysm (AAA), aortic occlusive disease (AOD), and control aortas. In addition, we determined if neutrophils deliver neutrophil elastase to the aorta in vivo by staining for neutrophil elastase (NE) throughout the course of abdominal aortic aneurysms with the monoclonal antibody to human NE. EDP from AAA, AOD, and control tissue demonstrated significant chemotactic activity for both neutrophils and monocytes. All neutrophils had a greater attraction to EDP from AAA tissue compared to AOD and control aorta. Neutrophils from AAA patients were more attracted to EDP of AAA tissue than were neutrophils of AOD or control patients attracted to their respective aortic EDP. Neutrophil elastase stained positive in the adventitia and thrombus throughout the course of the aneurysm, but was not found in the intima, media, or plaque of the aorta.     

Neutrophil chemotaxis in patients with burns

In a group of 22 patients with second and third degree burns, seven were found to have impaired chemotaxis. The chemotactic defect was present from two to 68 days and eventually became normal. The impairment was found to be due to a primary transient defect in polymorphonuclear leukocytes and not to an inhibitor or inactivator in the serum.     

Neutrophil function in surgical patients. Relationship to adequate bacterial defenses

Chemotaxis under agarose and the beta-glucosaminidase enzyme-release assay (BGERA) were evaluated for assessing neutrophil function in 44 patients in a surgical intensive care unit (SICU). The 27 patients shown to be angeric to delayed-type hypersensitivity skin tests at entry to the SICU had decreased neutrophil chemotaxis of 2.6 +/- 0.2 cm (mean +/- SEM) and a decreased BGERA result of 22.4% +/- 1.6%. Major sepsis developed in 59% of them, and 44% died. The ten relatively anergic patients (reacting to one antigen) had a normal neutrophil chemotactic response of 3.0 +/- 0.2 cm and a decreased BGERA result of 20.9% +/- 1.6%. Sepsis developed in 30% of them, and 20% died. The seven reactive patients (reacting to two or more antigens) had a neutrophil chemotaxis of 3.7 +/- 0.3 cm and a BGERA result of 18.9% +/- 1.7%. None had sepsis or died. The agarose method correlated best with the delayed-type hypersensitivity response. The BGERA results did not correlate with neutrophil chemotaxis and were not helpful in gauging neutrophil function.     

The association of impaired neutrophil chemotaxis with postoperative surgical sepsis

Postoperative sepsis remains a major problem in current surgical practice. This study assesses the predictive role of neutrophil chemotaxis in the development of sepsis in surgical patients. Neutrophil chemotaxis was measured in 30 cancer patients undergoing gastrointestinal surgery and in 26 healthy age and sex-matched controls. Neutrophil chemotaxis was significantly reduced (P less than 0.02) in the patients (mean 79.2 micron +/- 2.7 s.e.m.) compared with the controls (mean 86.8 micron +/- 1.9 s.e.m.). In the entire patient group neutrophil chemotaxis did not change to any appreciable extent following surgery. However, in the seven patients who developed postoperative septic complications, chemotaxis, which was similar to control levels in the pre-operative stage, declined significantly following surgery. Pre-operative values for the septic group of patients are 92.4 micron +/- 4.02 s.e.m.. These declined to 73.4 micron +/- 3.15 s.e.m. (P less than 0.05) and to 68.2 micron +/- 2.89 s.e.m. (P less than 0.05), 5-8 days (early) and 10-14 days (late) postoperatively respectively. Neutrophil chemotaxis in the non-septic group of patients did not alter over this same period. The data suggest that the onset of postoperative sepsis in patients is accompanied by impairment of chemotactic properties in their neutrophils. However, it is also evident that measurement of this variable in patients before operation does not help to define an 'at risk' group for the development of postoperative sepsis.     

Inhibition of neutrophil chemotaxis by plasma of burned patients: effect of blood transfusion practice

Incubation of normal human neutrophils with plasma from burned patients markedly reduced the ability of the cells to respond to a chemotactic stimulus in vitro. Previous transfusion of the patients with packed red blood cells did not alter the inhibited locomotion of neutrophils, whereas transfusion with normal plasma alone attenuated or even abolished the inhibitory activity. The finding provides direct evidence for the involvement of circulating suppressive factors in neutrophil chemotaxis, rendering burned patients more susceptible to infections. In addition, it stresses the relevance of plasma transfusion in clinical management and infection control following thermal injury.     

Chemokine regulation of neutrophil function in surgical inflammation

BACKGROUND: Morbidity and even mortality correlate closely with major injury that causes a systemic inflammatory response. Cytokines and bioactive molecules present at the inflammatory site induce this response and regulate neutrophil proinflammatory responses. The CXC chemokines, important for neutrophil recruitment and activation, include interleukin 8 (IL-8), granulocyte chemotactic protein 2 (GCP-2), and epithelial cell-derived neutrophil attractant 78 (ENA-78). They induce neutrophil responses via 2 cell-surface receptors, CXCR-1 and CXCR-2. All 3 chemokines bind CXCR-2 with high affinity. Only IL-8 and GCP-2 bind CXCR-1 with high affinity. HYPOTHESIS: The CXC chemokines regulate neutrophil responses differently. METHODS: Pretreatment of neutrophils from healthy volunteers with IL-8, GCP-2, or ENA-78; measured IL-8-induced migration; and tumor necrosis factor alpha (TNF-alpha)-induced peroxide production. RESULTS: Flow cytometry and radioligand binding data indicate that IL-8, GCP-2, and ENA-78 equivalently reduced CXCR-1 and CXCR-2 cell surface expression by 34% to 54%. All treatments decreased affinity of both receptors 1.5- to 2-fold. However, only IL-8 pretreatment inhibited chemotaxis to 10-nmol/L IL-8 (mean +/- SE inhibition, 62%+/-6%). Although IL-8 and GCP-2, but not ENA-78, suppressed TNF-alpha-induced oxidant production (mean +/- SE inhibition, 42%+/-8% and 40%+/-23%, respectively), only GCP-2 inhibited the oxidative response to complement fragment C5a, and to the bacterial cell wall peptide N-formyl-methionyl-leucyl-phenylalanine. CONCLUSIONS: The CXC chemokines regulate neutrophil proinflammatory functions differently. A thorough understanding of mechanisms for modulating neutrophil responses in inflammation will aid the development of interventions that reduce morbidity and mortality associated with severe trauma and sepsis.     

Peritoneal neutrophil chemotaxis is impaired in biliary obstruction.

Previous studies have shown impaired reticuloendothelial function in biliary obstruction. The chemotactic response of polymorphonuclear leukocytes from peripheral blood and peritoneal fluid of jaundiced rats (Group 1) was compared to that of sham operated controls (Group 2) and normal rats (Group 3). Male Sprague-Dawley rats underwent bile duct ligation or sham celiotomy. Studies were performed from 1 to 3 weeks after surgery. Mean serum bilirubin was 6.8 mg percent in Group 1 and normal in Groups 2 and 3. Peritoneal neutrophils were induced by intraperitoneal injection of 10 ml of 10 percent peptone broth 16 hours before the study, harvested from peritoneal fluid and peripheral blood, and isolated on Ficoll-Hypaque. F-met-leu-phe (FMLP) chemoattractant (10(-7) M) was used to induce migration of neutrophils across 3 mu filters. The filters were removed, mounted on slides, stained, and counts averaged for five oil immersion fields for each of three wells. Data were expressed as number of neutrophils per oil immersion field. Peritoneal neutrophil chemotaxis was significantly decreased in Group 1 (10.3 +/- 8.1) compared with Groups 2 (17.0 +/- 7.3) and 3 (20.2 +/- 6.4). A similar trend was noted in polymorphonuclear leukocytes from peripheral blood (Group 1: 13.1 +/- 7.8, Group 2: 18.2 +/- 6.7, Group 3: 17.4 +/- 5.9; P = 0.1). This impairment in neutrophil chemotaxis may contribute to the high rate of septic complications observed in the jaundiced host.     

Effects of ascorbate on leucocytes: Part III. In vitro and in vivo stimulation of abnormal neutrophil motility by ascorbate

Abnormal in vitro neutrophil motility was found in 10 patients with recurrent bacterial infection. The defect appeared to be primary in 3 patients, secondary to hyperimmunoglobulinaemia E in 2 patients and secondary to bacterial infection in 5 patients. In 7 patients impaired polymorphonuclear leucocyte (PMN) motility was the only detectable abnormality; defective lymphocyte function was found in 2 patients and 1 had a total IgA deficiency. Increased random motility and migration to endotoxin-activated serum (EAS) and partially purified C5a was observed when patients' neutrophils were incubated with 5 x 10(-2)M calcium ascorbate or 10(-1)M sodium ascorbate in the presence of 5% autologous serum in vitro. Six of the patients, 4 children and 2 adults, were given oral ascorbate, 1 g daily for children and 3 g daily for adults, and tests of neutrophil migration were performed at monthly intervals thereafter. Improved neutrophil motility was observed in all patients and this correlated with clinical improvement in 5 of the 6.     

Effect of fluticasone propionate on neutrophil chemotaxis, superoxide generation, and extracellular proteolytic activity in vitro.

BACKGROUND--Corticosteroids are widely used in the treatment of many inflammatory conditions but the exact mode of action on neutrophil function is uncertain. Fluticasone propionate is a new topically active synthetic steroid which can be measured in body fluids and which undergoes first pass metabolism. METHODS--The effects of fluticasone propionate on the function of neutrophils isolated from normal, healthy control subjects and on the chemotactic activity of sputum sol phase were assessed. RESULTS--Preincubation of neutrophils with fluticasone propionate reduced the chemotactic response to 10(-8) mol/l F-Met-Leu-Phe (FMLP) and to a 1:5 dilution of sputum sol phase in a dose dependent manner. Furthermore, when fluticasone propionate was added to sputum from eight patients with stable chronic obstructive bronchitis the chemotactic activity of a 1:5 dilution of the sol phase fell from a mean (SE) value of 22.2 (1.21) cells/field to 19.6 (0.89), 17.1 (0.74), and 11.9 (0.6) cells field at 1 mumol/l, 10 mumol/l, and 100 mumol/l, respectively. In further experiments fluticasone propionate preincubated with neutrophils inhibited fibronectin degradation by resting cells and by cells stimulated by FMLP (15.2% inhibition of resting cells, 5.1% inhibition of stimulated cells with 1 mumol/l fluticasone propionate, 24% and 18.7% inhibition respectively at 100 mumol/l fluticasone propionate. Fluticasone propionate had no effect on generation of superoxide anion by resting or stimulated cells. CONCLUSIONS--These results indicate that fluticasone propionate has a direct suppressive effect on several aspects of neutrophil function and may suggest a role for this agent in the modulation of neutrophil mediated damage to connective tissue.     

Delayed hypersensitivity and neutrophil chemotaxis: effect of trauma

To investigate alterations in host defense produced by trauma, skin testing with five standard recall antigens was done on admission and weekly on 53 patients with blunt trauma and seven with penetrating missile injuries, who then were classified as normal (N), 2 or more positive responses; relatively anergic (RA), one positive response; or anergic (A), no response. Neutrophil chemotaxis was tested 145 times in 32 patients. Degree of injury was assessed by assigning one point to pelvic fracture, long-bone fracture, head, chest, or abdominal injury, to a maximum of five. The A and RA patients had greater trauma, 3 vs. 1.6 for N, and a significantly increased rate of sepsis (p less than 0.005) and mortality (p less than 0.05). Incidence of anergy depended upon age and extent of trauma. Neutrophil chemotaxis in A and RA patients was significantly (p less than 0.001) worse at 96.7 +/- 2.4 mu and 99.8 +/- 1.7 mu compared to N, 113.2 +/- 1.7 mu, and controls 121 +/- 4 mu. With recovery, chemotaxis returned to normal. It is concluded that failure of delayed hypersensitivity responses follows trauma, is related to the severity of injury and age of patient, and is associated with an abnormality of neutrophil chemotaxis and increased rate of sepsis.     

Inhibition of the neutrophil oxidative response by propofol: preserved in vivo function despite in vitro inhibition

BACKGROUND AND OBJECTIVE: Propofol has been shown to inhibit a variety of functions of neutrophils in vitro, but there is a lack of in vivo data. To analyse the effects of propofol on neutrophil function in vivo we chose to investigate cataract surgery since it represents a small surgical procedure with minimal immunomodulatory effects induced by surgery. We sought to analyse any immunosuppressive effects of propofol after short-term administration in vivo in comparison to local anaesthesia as well as to in vitro effects of propofol. METHODS: The study was designed as an open randomized trial enrolling 20 patients undergoing general or local anaesthesia. The neutrophil oxidative response and propofol plasma concentration were assessed prior, during and after anaesthesia. Neutrophil function was determined flow cytometrically based on dihydrorhodamine 123 oxidation. RESULTS: Propofol concentrations which yielded a marked suppression in vitro did not alter the neutrophil oxidative response during cataract surgery in vivo. However, after local anaesthesia the neutrophil oxidative response declined to 37%, compared to the control response prior to anaesthesia. CONCLUSIONS: Although we could detect the well established suppression of neutrophil function by propofol in vitro it was not evident in vivo. This may be due to compensating effects on neutrophil function during surgery in vivo. The decline in the neutrophil oxidative response in the local anaesthesia group might be due to increased stress and catecholamine concentrations or a direct interaction of local anaesthetics with neutrophil intracellular signalling.     

Prolactin suppression of leukocyte chemotaxis in vitro.

Leukocyte chemotaxis in vitro was studied for cells from patients with pituitary adenomas. Leukocytes obtained preoperatively from two of three patients with elevated serum prolactin levels demonstrated chemotaxic alterations described in other malignant disease. Statistically significant suppression of chemotaxis occurred in the leukocytes of four of 12 specimens from normal donors at concentrations of 1000 ng/ml, and in four of eight specimens at 2000 ng/ml of prolactin in preincubation media. Thus prolactin concentration may influence the motility of leukocytes. The variable neoplastic behavior of morphologically similar pituitary adenomas may, in part, reflect a neurohormonally altered host response to the presence of these lesions.     

Insulin infusion improves neutrophil function in diabetic cardiac surgery patients.

Diabetic patients are at increased risk of wound infection after major surgery, but the effect of perioperative glucose control on postoperative wound infection rates after surgery is uncertain. We tested the effect of an insulin infusion on perioperative neutrophil function in diabetic patients scheduled for coronary artery bypass surgery. Participants (n = 26) were randomly allocated to receive either aggressive insulin therapy (AIT) or standard insulin therapy (SIT) during surgery. Blood was drawn for neutrophil testing before surgery, 1 h after the completion of cardiopulmonary bypass, and on the first postoperative day. Neutrophil phagocytic activity decreased to 75% of baseline activity in the AIT group and to 47% of baseline activity in the SIT group (P < 0.05 between groups). No important differences in neutrophil antibody-dependent cell cytotoxicity were found. This study documents a potentially beneficial effect of continuous insulin therapy in diabetic patients who require major surgery. IMPLICATIONS: A continuous insulin infusion and glucose control during surgery improves white cell function in diabetic patients and may increase resistance to infection after surgery.     

Abnormal in vitro immunoglobulin synthesis in surgical patients.

Blood mononuclear cells from surgical patients produce large amounts of IgG in vitro. This synthesis is not increased by stimulation with pokeweed mitogen. To determine if this abnormal pattern of IgG synthesis extended to other immunoglobulin classes, surgical patients were stratified according to delayed-type hypersensitivity responses as reactive or anergic. Healthy personnel were studied as controls. Mononuclear cells were cultured without or with pokeweed mitogen, and IgG, IgM, and IgA were measured in supernatants. Unstimulated IgG and IgA synthesis was increased in surgical patients, especially in those with reduced delayed-type hypersensitivity responses. Synthesis of IgM was normal or low. With mitogen stimulation, IgG synthesis was increased in control and reactive subjects, but not in anergic subjects. For IgM, mitogen stimulation increased synthesis to a less than normal level in all patients. For IgA, synthesis was increased in all groups.