Seminars in ANESTHESIA, PERIOPERATIVE MEDICINE AND PAIN Vol 19, No 2 June 2000 Immunosuppression: The Basics Marie Csete T HOUSANDS of patients undergo solid organ transplantation each year, obligating them to undergo life-long immunosuppressive treatment. The 1997 United Network of Organ Sharing data base reported a total of 8,844 liver and 4,091 kidney transplants as well as 1,053 pancreas, 2,352 heart, and 1,450 lung grafts. These data do not include living related transplants, which are in- creasing in frequency because of donor organ shortages, and they do not include marrow grafts. In addition, powerful immunosuppressive drugs are used to treat a variety of disorders including collagen vascular diseases and infla _nynatory bowel disease. Nonetheless, the mechanisms underlying the therapeutic efficacy of immunosuppressive agents are not generally part of anesthesiology training. The purpose of this review is to present the scientific underpinnings of immunosuppressive therapy and to highlight specific issues in both acute and chronic administration of immunosup- pressive agents that impact anesthesia practice. Optimal care of immunosuppressed patients im- plies knowledge of particular problems associated with their drug therapy. opment and/or fatal infections. Probably the most important feature of anesthesia care in immuno- suppressed patients is attention to infection control. It is prudent to take the time and effort to create a sterile field for line placement, particularly central line placement. In addition, nasal intubation may lead to transient bacteremia, thus, oral intubation is preferable during general anesthesia. Infection control also mandates that antibiotics and antiviral drugs be continued on schedule during surgical procedures. In particular, gancyclovir is adminis- tered repeatedly to many transplant recipients. No specific interactions with anesthetics have been reported for gancyclovir. Immunosuppressive Therapy in the OR and Perioperative Period A major problem in immunosuppressive therapy has been the marked interindividnal variation in pharmacological profiles. After transplantation, drug level monitoring is used to establish the ap- propriate individual dosing regimen for cyclospor- ine or tacrolimus, which protect the patient from GENERAL PRINCIPLES Infection Control Immunosuppression presents an inherent diffi- culty: Subtherapeutic doses lead to graft rejection, but acceptable therapeutic doses (or overly aggres- sive immunosuppression) can lead to tumor devel- From Anesthesiology Research Labs, University of Michi- gan, Ann Arbor, M1. Address reprint requests to Marie Csete, MD, University of Michigan, Anesthesiology Research Labs, 1150 W Medical Center Dr, Ann Arbor, MI 48109-0615. Copyright 9 2000 by W.B. Saunders Company 0277-0326/00/1902-0001510.00/0 doi: 10.1053/sa.2000.6786 Seminars in Anesthesia, Perioperative Medicine and Pain, Vol 19, No 2 (June), 2000: pp 61-66 61