Persistent inflammatory immunosuppression and catabolism syndrome (PICS): An understimated clinical problem in surgery

Abstract text (incl. references and figure legends)

Introduction: PICSis a new clinical picture, often misunderstood, but rather diffused in the surgical and critical areas. PICS is a very complex and varied syndrome, representing a real clinical challenge both for diagnosis and treatment. We wanted to bring to the attention the clinical presentation of PICS. Materials and methods: we collected three patients who fit criteria for PICS. To identify PICS it is necessary: ICU stay > 10 days, CRP > 150 mcg/dL, lymphocyte count<0,80x109/L, weight loss>10% during hospitalization or BMI<18, creatinine height index <80%, albumin level <3.0 g/dL, prealbumin level <10 mg/dL, RBP level <10 mcg/dL . The following intra-individual immunological variations were taken into account: lymphocyte count, C-reactive-protein (PCR), IL-6, IL-8, IL-10 and TNF-α, PCT, creatinine, albumin and pre-albumin, RBP, culture isolation. All these variable were measured longitudinally in this 3 patients Results: for all our patients the outcome was inauspicious. Two female and one male, mean age 44,45±5, mean ICU stay 38,33±16, surgical procedure of 3±1. We have whiteness a progressive and constant disruption of WBC and CRP, a rise of pro-inflammatory cytokines, no changes in anti-inflammatory cytokine. All these patients had a persistent catabolic and immunosuppressive state that lead to the development of several infections. Conclusion: abdominal infective syndrome was the trigger for PICS. Surgery, nutritional support and anti-infective drugs were unsuccessful. The patients experienced the so called indolent death. The clinical picture worsens constantly albeit small variations of bio-humoral parameters. We evidenced that no macro variation in the parameters evaluated has happened but the variations have been minimal. In our opinion, the use of IL and PCT is much more useful and meaningful than the use of CRP. We have noticed that in particular IL-8 has an important negative prognostic role.

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