C-Reactive Protein Kinetics After Major Surgery

Surgery alters parameters of vitamin D status and other laboratory results

Fracture liaison services often perform laboratory testing, but these results may be altered by surgery. In 40 hip arthroplasty patients, many laboratory parameters of bone health relevance were reduced by 8-22% on the first post-operative day. Laboratory results obtained in the immediate post-surgery interval do not reliably ascertain baseline status.

INTRODUCTION

As secondary causes of osteoporosis are common, fracture liaison services often perform laboratory testing in the immediate post-fracture interval. We hypothesized that laboratory results obtained shortly after surgery may not accurately ascertain baseline status. If true, such alterations might confound subsequent fracture prevention efforts.

METHODS

Patients undergoing elective total hip arthroplasty were studied as a surrogate for hip fracture patients. Blood and urine were obtained 2 weeks before surgery, before anesthetic induction, on post-operative day one, and 6 weeks after surgery. Serum total and free 25-hydroxyvitamin D (25(OH)D), vitamin D-binding protein (DBP), calcium, creatinine, albumin (Alb), alkaline phosphatase (ALP), plasma hemoglobin (Hgb) and urinary DBP/creatinine ratio (UDBP/Cr) were measured.

RESULTS

Forty volunteers (28 women; 12 men) with mean age of 65.7 [8.7] years were studied. Laboratory results were stable from 2 weeks before to the day of surgery. On the first day after surgery, total 25(OH)D, DBP, calcium, creatinine, ALP, and Alb declined 8-22% (p < 0.0001); free 25(OH)D and Hgb declined by 8 and 15% (p < 0.01), respectively; and UDBP/Cr increased 32% (p < 0.01). Using a 25(OH)D <30 ng/mL threshold, vitamin D inadequacy prevalence increased from 38% before surgery to 68% the day after (p < 0.001). All laboratory values returned to baseline at 6 weeks after surgery.

CONCLUSIONS

Laboratory values are reduced immediately following elective total hip arthroplasty. Testing at that time does not accurately ascertain baseline status and may lead to elevated estimates of vitamin D inadequacy, incorrect interventions, and misallocation of healthcare resources.

Serum Calprotectin Expression as a Diagnostic Marker for Sepsis in Postoperative Intensive Care Unit Patients

The research was performed to explore the diagnosis value of dynamic serum calprotectin (SC) expression for sepsis in postoperative intensive care unit patients. One hundred sixty-three patients who met the inclusion criteria served as the study group. All cases in the study group were further divided into the sepsis subgroup (51 cases) and the nonsepsis subgroup (112 cases). Fifty healthy volunteers served as the control group. The levels of SC and other laboratory indexes including complete blood counts, leukocytes, the immature-to-total-neutrophil ratio, procalcitonin (PCT), C-reactive protein, and blood lactate were detected, cytokines [interleukin (IL)-2, IL-6, and interferon-γ] released by neutrophils were also determined. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Sequential Organ Failure Assessment score were calculated. The factors related to prognosis were analyzed with multivariate logistic regression analysis. The diagnostic accuracies of ΔSC [the differences of SC levels between postoperative day (POD) 1 and POD 2, 3, 5, 7] and ΔPCT (the differences of PCT levels between POD 1 and POD 2, 3, 5, 7) on sepsis were compared with other markers for sepsis. The levels of SC and cytokines were markedly increased on POD 1, 2, 3, 5, and 7 in the study group compared with the control group (P < 0.05 or P < 0.01). The same results were found in the sepsis subgroup compared with the nonsepsis subgroup (P < 0.05 or P < 0.01). Significant positive correlations between SC and cytokines were confirmed in patients of the study group (P < 0.05 or P < 0.01). APACHE II scores and the levels of SC and PCT on POD 1 were the variables significantly associated with sepsis. The diagnostic accuracies of ΔSC_1-3 (sensitivity 87%, specificity 89%) and ΔPCT_1-3 (sensitivity 89%, specificity 90%) for sepsis were greater than other ΔSCs and ΔPCTs. It appears that the dynamic changes in SC are of the predictive values for septic patients after major surgeries.

The Clinical Challenge of Sepsis Identification and Monitoring

Jean-Louis Vincent outlines why combinations of biomarkers will be central to the future of sepsis diagnosis.

Simple blood and urinary parameters measured at ICU admission may sign for AKI development in the early postoperative period: a retrospective, exploratory study

Recent studies have suggested that some blood physicochemical and urinary biochemical parameters have a standardized behavior during acute kidney injury (AKI) development. The changes in these parameters frequently begin to occur before significant rises in serum creatinine (sCr) and may help in identifying patients with more subtle decreases in glomerular filtration rate (GFR). Surgical patients have an increased risk of AKI but renal impairment is usually not evident at ICU admission. We hypothesized that the surgical patients who have AKI diagnosed in the early postoperative period have an impaired GFR since ICU admission, indirectly inferred by alterations in these blood physicochemical and urinary biochemical parameters even in the presence of a still normal sCr. We retrospectively evaluated 112 surgical patients who were categorized according to AKI development during the first 3 ICU days. Twenty-eight patients developed AKI, most of them in the first day (D1) after ICU admission (D0). AKI patients had, at D0, lower serum pH and albumin, higher C - reactive protein (CRP), lower urine sodium (NaU) and fractional excretion of urea (FEUr). Fractional excretion of potassium (FEK) was high in both groups at D0 but remained high in the subsequent days only in AKI patients. Very low CRP and high serum albumin, high NaU and FEUr values at ICU admission had a significant negative predictive value for AKI. We concluded that some easily assessed parameters in blood and urine may help to identify patients with indirect signs of increased inflammatory response and decreased GFR at ICU admission, which could help to predict the risk of postoperative AKI development.

Markedly raised levels of C-reactive protein are associated with culture-proven sepsis or necrotising enterocolitis in extremely preterm neonates

AIM

A serious inflammatory process is suspected when C-reactive protein (CRP) is very high, and we established the causes and outcomes when CRP was >100 mg/L in neonates.

METHODS

We retrospectively reviewed all 277 episodes where CRP exceeded 100 mg/L between January 2007 and December 2011 at a tertiary neonatal unit.

RESULTS

Of the 6025 neonates admitted during the study period, 258 had CRP >100 mg/L at least once. The overall mortality rate was 44/258 (17%); 36 died within 7 days of CRP >100 mg/L, and 34 were extremely preterm infants. CRP exceeded 100 mg/L in 106 infants within the first 3 days of life - 74 term, 25 preterm and seven extremely preterm - with no infection identified in 81%. In contrast, infections were found in 87% of the 171 episodes from day four of life - 129 extremely preterm, 23 preterm and 19 term - predominantly coagulase-negative staphylococcus sepsis and necrotising enterocolitis.

CONCLUSION

Markedly elevated CRP in the first 3 days of life was most likely to affect term neonates (74/106) with no infectious cause (81%). However, CRP >100 mg/L from the fourth day of life was most likely to affect extremely preterm neonates (129/171) and have an infectious cause (87%).

Correlation of ischemia-modified albumin with SOFA and APACHE II scores in preoperative patients with colorectal cancer

Purpose. Critical illnesses are assessed according to the sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation (APACHE) II. Circulating ischemia-modified albumin (IMA) is a biomarker generated under ischemic and oxidative conditions and may reflect disease severity in preoperative patients. This study investigated the correlations of IMA with SOFA and APACHE II scores in inpatients admitted for colorectal surgery. Methods. We examined 27 patients with advanced colorectal cancers (mean age 69 years, men/women = 15/12). Correlations between SOFA and APACHE II scores in addition to preoperative serum IMA and C-reactive protein (CRP) levels were analyzed. Results. The mean IMA level was 0.5 AU, and the median CRP level was 0.6 mg/dL. Median scores for SOFA and APACHE II were 2 and 12 points, respectively. Significant positive correlations between IMA and SOFA (r = 0.45, P < 0.05) and IMA and APACHE II (r = 0.45, P < 0.05) were identified which remained significant in confounder-adjusted analyses. In contrast, weak correlations were observed between CRP and the SOFA and APACHE II scores. Conclusions. The positive correlations between IMA and both SOFA and APACHE II scores suggest that serum IMA measurements reflect the severity of systemic failure in patients admitted for colorectal surgery in the preoperative phase.