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Ansari MA, Das S, Rai G, Singh PK, Lahan S, Tyagi A, Alamer E, Dar SA. Low monocytic HLA-DR expression in critically ill patients of sepsis: An indicator for antimicrobial and/or immunomodulatory intervention. Transpl Immunol 2023; 81:101942. [PMID: 37866671 DOI: 10.1016/j.trim.2023.101942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Sepsis is a result of suppressed host immune response which leads to fatal multi-organ dysfunctionality. Low frequency of active monocytes or reduced expression of human leukocyte antigen (HLA)-DR on monocytes shows the suppressed immune response in sepsis patients. One of the well-studied markers in patients with sepsis is procalcitonin (PCT). The role of monocytic (m) HLA-DR expression has been monitored in sepsis and is being considered a marker of the severity of interim immuno-depression in these patients. The study describes the impact of HLA-DR expression on monocytes quantitatively using flow cytometry. METHODS In this prospective study, we quantified monocytes and their HLA-DR expression in 20 patients of sepsis admitted to the Intensive Care Unit (ICU). Serum levels of PCT and interleukin (IL)-6 production were also measured in these patients, and the results were compared with those in healthy controls. RESULTS Monocyte frequency calculated was higher in sepsis patients as compared to healthy controls, however, HLA-DR expressing monocytes were significantly reduced as was the mean fluorescence intensity (MFI) of HLA-DR. Contrastingly, IL-6 and PCT levels were significantly high in sepsis than controls. The results suggest that low HLA-DR expression, combined with PCT, is a better prognostic parameter in the early phase of sepsis. CONCLUSION Poor recovery of mHLA-DR may serve as an early guide for clinicians to assess the prognosis of sepsis patients and consider immunomodulatory therapy in its management.
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Affiliation(s)
- Mohammad Ahmad Ansari
- Department of Microbiology, University College of Medical Sciences (University of Delhi) & GTB Hospital, Delhi 110095, India
| | - Shukla Das
- Department of Microbiology, University College of Medical Sciences (University of Delhi) & GTB Hospital, Delhi 110095, India.
| | - Gargi Rai
- Department of Microbiology, University College of Medical Sciences (University of Delhi) & GTB Hospital, Delhi 110095, India
| | - Praveen Kumar Singh
- Department of Microbiology, University College of Medical Sciences (University of Delhi) & GTB Hospital, Delhi 110095, India
| | - Shubham Lahan
- University College of Medical Sciences (University of Delhi) & GTB Hospital, Delhi 110095, India
| | - Asha Tyagi
- Department of Anesthesiology and Critical Care, University College of Medical Sciences (University of Delhi) & GTB Hospital, Delhi 110095, India
| | - Edrous Alamer
- Department of Medical Laboratory Technology, College of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia
| | - Sajad Ahmad Dar
- Department of Microbiology, University College of Medical Sciences (University of Delhi) & GTB Hospital, Delhi 110095, India; Research and Scientific Studies Unit, College of Nursing, Jazan University, Jazan 45142, Saudi Arabia.
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The Procalcitonin-guided Antibiotics in Respiratory Infections (PARI) project in general practice – a study protocol. BMC PRIMARY CARE 2022; 23:43. [PMID: 35279069 PMCID: PMC8917812 DOI: 10.1186/s12875-022-01646-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 02/23/2022] [Indexed: 11/19/2022]
Abstract
Background Antibiotic resistance is a global health challenge and the close correlation between antibiotic use and the development of resistance makes it essential to maintain a rational use of antibiotics. Most antibiotics are prescribed in general practice against acute respiratory tract infections (ARTI), even though most of these infections are of viral etiology. Thus, a safe method to substantially reduce unnecessary use of antibiotics in general practice is needed. Procalcitonin (PCT) is a precursor protein with very low circulating levels in the blood under physiological conditions. However, in response serious bacterial infection the level of PCT in the blood may increase significantly. Until recently, quantitative analyses of PCT was performed in hospital laboratories, impeding the implementation of PCT in primary care. Our aim is to determine whether it is possible to lower the use of antibiotics in patients presenting with symptoms of ARTI, without significantly prolonging the period of illness, by using a newly released PCT point-of-care test in general practice. Methods The Procalcitonin-Guided Antibiotics in Respiratory Infections (PARI) study is a randomized, single-blinded, non-inferiority, multi-practice intervention study comparing a PCT-group to a control group. Patients (N = 508) will be randomly assigned 1:1 to standard care or to the PCT group. The primary outcomes the duration of illness and symptoms from ARTI measured with the Acute Respiratory Tract Infection Questionnaire. Secondary outcomes include (1) Number of participants in each trial arm exposed to antibiotic treatment at index consultation (day 1) and within 30 days, (2) Number of participants in each trial arm with side effects from antibiotic treatment within 14 days, (3) Number of participants in each trial arm with re-consultations within 30 days, (4) Number of participants in each trial arm admitted to hospital (including diagnosis and mortality) within 30 days, (5) Characterization of biomarker (CRP and PCT) level at index consultation. Tertiary outcomes include patient and general practitioner satisfaction with the use of the PCT point-of-care test, and long-term follow-up. Discussion To our knowledge, this is the first study to examine a PCT point-of-care test in general practice with the aim of reducing the use of antibiotics in patients with symptoms of ARTI. Results of this study may prove important in targeting antibiotic treatment only to those patients who need it, thus contributing to limiting the spread of antibiotic resistance. Trial registration ClinicalTrials.gov Identifier: NCT04216277, date of registration: 2. of January 2020.
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Post-operative kinetics of C-reactive protein to distinguish between bacterial infection and systemic inflammation in infants after cardiopulmonary bypass surgery: the early and the late period. Cardiol Young 2022; 32:904-911. [PMID: 34365991 DOI: 10.1017/s1047951121003231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Differentiation between post-operative inflammation and bacterial infection remains an important issue in infants following congenital heart surgery. We primarily assessed kinetics and predictive value of C-reactive protein for bacterial infection in the early (days 0-4) and late (days 5-28) period after cardiopulmonary bypass surgery. Secondary objectives were frequency, type, and timing of post-operative infection related to the risk adjustment for congenital heart surgery score. METHODS This 3-year single-centre retrospective cohort study in a paediatric cardiac ICU analysed 191 infants accounting for 235 episodes of CPBP surgery. Primary outcome was kinetics of CRP in the first 28 days after CPBP surgery in infected and non-infected patients. RESULTS We observed 22 infectious episodes in the early and 34 in the late post-operative period. CRP kinetics in the early post-operative period did not accurately differentiate between infected and non-infected patients. In the late post-operative period, infected infants displayed significantly higher CRP values with a median of 7.91 (1.64-22.02) and 6.92 mg/dl (1.92-19.65) on days 2 and 3 compared to 4.02 (1.99-15.9) and 3.72 mg/dl (1.08-9.72) in the non-infection group. Combining CRP on days 2 and 3 after suspicion of infection revealed a cut-off of 9.47 mg/L with an acceptable predictive accuracy of 76%. CONCLUSIONS In neonates and infants, CRP kinetics is not useful to predict infection in the first 72 hours after CPBP surgery due to the inflammatory response. However, in the late post-operative period, CRP is a valuable adjunctive diagnostic test in conjunction with clinical presentation and microbiological diagnostics.
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Tang YH, Jeng MJ, Wang HH, Tsao PC, Chen WY, Lee YS. Risk factors and predictive markers for early and late-onset neonatal bacteremic sepsis in preterm and term infants. J Chin Med Assoc 2022; 85:507-513. [PMID: 34966164 DOI: 10.1097/jcma.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The early detection and prediction of bacteremic sepsis in preterm and term neonates remains a challenging task because of their nonspecific clinical presentations. We aimed to investigate the risk factors associated with bacteremia and find the cutoff values of predictive markers to achieve accurate diagnosis of neonatal bacteremic sepsis. METHODS Not-doing-well preterm and term neonates with suspected sepsis were retrospectively enrolled between January 2015 and December 2017 in Taipei Veterans General Hospital. Blood culture, hemogram, serum procalcitonin (PCT), and C-reactive protein (CRP) were drawn at the onset of clinical signs and symptoms. All cases were divided to either early-onset or late-onset groups according to postpartum age. Nonparametric statistic, logistic regression, and receiver operating characteristic analysis were performed to evaluate the risk factors and cutoff values for predicting bacteremia. RESULTS A total of 169 suspected sepsis episodes were analyzed, 68.0% of which had cardiopulmonary dysfunction and 19.5% had perinatal stress. The early-onset group had 123 (72.8%) patients, 4 of which had bacteremia and 119 had nonbacteremia conditions. The late-onset group had 46 (27.2%) patients, 8 of which had bacteremia and 38 had nonbacteremia conditions. Gestational age, birth body weight, Apgar score at 5 minutes, serum PCT, CRP, and platelet (PLT) count in the early-onset group and white blood cell (WBC) count in the late-onset group were substantially different between the patients with bacteremia and nonbacteremia conditions. PCT greater than 27 µg/L (adjusted odd ratio [aOR], 21.6; 95% CI, 1.1-435.1) and thrombocytopenia less than 100 × 109/L (aOR, 38.6; 95% CI, 1.4-1030.3) were predictive markers for bacteremia in the early-onset group. CONCLUSION Early- and late-onset neonatal sepsis had different risk factors and predictive markers of bacteremia. PCT and PLT count in the early-onset group and WBC count in the late-onset group were accurate diagnostic serum markers for neonatal bacteremic sepsis.
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Affiliation(s)
- Yi-Hsuan Tang
- Division of Pediatric Immunology and Nephrology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Neonatology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hsin-Hui Wang
- Division of Pediatric Immunology and Nephrology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Pediatrics, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Pei-Chen Tsao
- Division of Neonatology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Physiology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Wei-Yu Chen
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Neonatology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Sheng Lee
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Neonatology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Dardashti A, Sterner N, Fisher J, Thelaus L, Nilsson J, Linder A, Zindovic I. Impact of cardiopulmonary bypass and surgical complexity on plasma soluble urokinase-type plasminogen activator receptor levels after cardiac surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 81:634-640. [PMID: 34657538 DOI: 10.1080/00365513.2021.1990395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Circulating soluble urokinase plasminogen activator receptor (suPAR) is a marker of inflammation with prognostic value for elevated risk of morbidity and mortality. It has not yet been shown how the inflammatory process induced by cardiac surgery affects suPAR concentrations postoperatively. METHODS In a prospective observational study, plasma suPAR levels were measured in 30 patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), pre-, peri, post-operatively, and 3-5 days after surgery. Fifteen patients underwent coronary artery bypass grafting (CABG) and 15 underwent complex procedures with longer CPB duration. Concentrations of suPAR at each time point were compared to the preoperative levels and compared between the two groups. RESULTS In both groups, plasma suPAR concentrations were significantly higher on the first postoperative day (3.27 (interquartile range (IQR) 2.75-3.86) µg/L compared to baseline (2.62 (1.98-3.86)) µg/L, p < .001. There were no significant differences in suPAR concentrations between the groups at any time point. Preoperatively, the median suPAR concentration was 2.57 (2.01-3.60) µg/L in the CABG group versus 2.67 (1.89-3.97) µg/L in the complex group (p = .567). At ICU arrival 2.48 (2.34-3.23) µg/L versus 2.73 (2.28-3.44) µg/L in CABG and complex patients, respectively (p = .914). There was no difference in suPAR concentrations between the groups on postoperative day 1 (3.34 (2.89-3.89) versus 3.19 (2.57-3.62) p = .967) or 3-5 days after surgery (2.72 (1.98-3.16) versus 2.96 (2.39-4.28) p = .085. CONCLUSIONS After a transient rise on the first postoperative day, the suPAR levels returned to the preoperative levels by the third postoperative day. There was no significant difference in suPAR levels between the routine CABG and complex group with longer CPB time.
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Affiliation(s)
- Alain Dardashti
- Department of Cardiothoracic Surgery, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Niklas Sterner
- Department of Cardiothoracic Surgery, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Jane Fisher
- Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Faculty of Medicine, Lund, Sweden
| | - Louise Thelaus
- Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Faculty of Medicine, Lund, Sweden
| | - Johan Nilsson
- Department of Cardiothoracic Surgery, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Adam Linder
- Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Faculty of Medicine, Lund, Sweden
| | - Igor Zindovic
- Department of Cardiothoracic Surgery, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
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Farias JS, Villarreal EG, Dhargalkar J, Kleinhans A, Flores S, Loomba RS. C-reactive protein and procalcitonin after congenital heart surgery utilizing cardiopulmonary bypass: When should we be worried? J Card Surg 2021; 36:4301-4307. [PMID: 34455653 DOI: 10.1111/jocs.15952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/22/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION To assess the efficacy of C-reactive protein (CRP) and procalcitonin (PCT) at identifying infection in children after congenital heart surgery (CHS) with cardiopulmonary bypass (CPB). MATERIALS AND METHODS Systematic review of the literature was conducted to identify studies with data regarding CRP and/or PCT after CHS with CPB. The primary variables identified to be characterized were CRP and PCT at different timepoints. The main inclusion criteria were children who underwent CHS with CPB. Subset analyses for those with and without documented infection were conducted in similar fashion. A p value of less than .05 was considered statistically significant. RESULTS A total of 21 studies were included for CRP with 1655 patients and a total of 9 studies were included for PCT with 882 patients. CRP peaked on postoperative Day 2. A significant difference was noted in those with infection only on postoperative Day 4 with a level of 53.60 mg/L in those with documented infection versus 29.68 mg/L in those without. PCT peaked on postoperative Day 2. A significant difference was noted in those with infection on postoperative Days 1, 2, and 3 with a level of 12.9 ng/ml in those with documented infection versus 5.6 ng/ml in those without. CONCLUSIONS Both CRP and PCT increase after CHS with CPB and peak on postoperative day 2. PCT has a greater statistically significant difference in those with documented infection when compared to CRP and a PCT of greater than 5.6 ng/ml should raise suspicion for infection.
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Affiliation(s)
- Juan S Farias
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Enrique G Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Janhavi Dhargalkar
- Department of Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Alicia Kleinhans
- Section of Critical Care and Cardiology, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor School of Medicine, Houston, Texas, USA
| | - Saul Flores
- Section of Critical Care and Cardiology, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor School of Medicine, Houston, Texas, USA
| | - Rohit S Loomba
- Department of Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA.,Department of Pediatric Critical Care, Advocate Children's Hospital, Oak Lawn, Illinois, USA
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Prognostic Value of Procalcitonin for Morbidity and Mortality in Patients after Cardiac Surgery. Cardiol Res Pract 2021; 2021:1542551. [PMID: 34350035 PMCID: PMC8328725 DOI: 10.1155/2021/1542551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/03/2021] [Accepted: 07/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background The increased serum procalcitonin (PCT) level in cardiac patients is known as a sign of postoperative complications. Objective Considering the importance of predicting the incidence of both complications and mortality caused by coronary artery bypass graft (CABG) surgery, this study was conducted to determine the serum PCT level and its relationship with one-year morbidity and mortality among CABG patients. Methods This descriptive-analytical study was performed on 100 patients who underwent CABG surgery in Vali-e-Asr Hospital of Birjand, Iran. They were selected by a census sampling method from March 2014 to March 2015. The Elecsys BRAHMS PCT kit (Roche Company) was then used to measure the patients' serum PCT level. The required data were collected using the patients' medical records and telephone interviews with the patient or his/her relatives by passing one year from their discharge. The outcomes of this study comprised of mortality and morbidity causes (e.g., dysrhythmia, infection, and stroke). The data were then analyzed in SPSS version 16 by Mann–Whitney, chi-squared, and Fisher exact tests. Results The postoperative serum PCT level is significantly correlated with sternum wound infection (p=0.001), packed cells (PC) transfusion (p=0.003), and death (p=0.003). In addition, a significant relationship was found between dyslipidemia and hypertension and early mortality rate in patients with high levels of PCT. Of note, risk-adjusted death did not differ significantly between the serum PCT levels after one year (RR, 0.068; 95% CI 0.008–0.566). Conclusion Higher PCT serum levels in CABG patients are associated with the increased early mortality rate, sternum wound infection, and PC transfusion. Additionally, the other factors associated with mortality in the patients under study included dyslipidemia and hypertension.
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Cosenza M, Sacchi S, Pozzi S. Cytokine Release Syndrome Associated with T-Cell-Based Therapies for Hematological Malignancies: Pathophysiology, Clinical Presentation, and Treatment. Int J Mol Sci 2021; 22:ijms22147652. [PMID: 34299273 PMCID: PMC8305850 DOI: 10.3390/ijms22147652] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 01/08/2023] Open
Abstract
Cytokines are a broad group of small regulatory proteins with many biological functions involved in regulating the hematopoietic and immune systems. However, in pathological conditions, hyperactivation of the cytokine network constitutes the fundamental event in cytokine release syndrome (CRS). During the last few decades, the development of therapeutic monoclonal antibodies and T-cell therapies has rapidly evolved, and CRS can be a serious adverse event related to these treatments. CRS is a set of toxic adverse events that can be observed during infection or following the administration of antibodies for therapeutic purposes and, more recently, during T-cell-engaging therapies. CRS is triggered by on-target effects induced by binding of chimeric antigen receptor (CAR) T cells or bispecific antibody to its antigen and by subsequent activation of bystander immune and non-immune cells. CRS is associated with high circulating concentrations of several pro-inflammatory cytokines, including interleukins, interferons, tumor necrosis factors, colony-stimulating factors, and transforming growth factors. Recently, considerable developments have been achieved with regard to preventing and controlling CRS, but it remains an unmet clinical need. This review comprehensively summarizes the pathophysiology, clinical presentation, and treatment of CRS caused by T-cell-engaging therapies utilized in the treatment of hematological malignancies.
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Effects of sugammadex on postoperative respiratory management in children with congenital heart disease: a randomized controlled study. Biomed Pharmacother 2020; 127:110180. [PMID: 32353822 DOI: 10.1016/j.biopha.2020.110180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/07/2020] [Accepted: 04/17/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early extubation can reduce pulmonary complications in children undergoing cardiac surgery. The aim of this study is to evaluate the effects of sugammadex for postoperative respiratory management in children with congenital heart disease. METHODS Sixty children with congenital heart disease undergoing elective cardiac surgery were divided into group S and group C (30 children in each group). When post tetanic twitches count (PTC) = 1-2 and train-of-four (TOF) = 0, the children in group S received sugammadex4 mg/kg for reversal of neuromuscular block at the end of surgery, and the children in group C received the same volume of normal saline. The recovery time to TOF of 0.9, the mechanical ventilation and extubation times were recorded. On the other side, the hemodynamic parameters before and 5 min after administration, and side effects were also recorded. The levels of C-reactive protein (CRP) and procalcitonin (PCT) before and 24 h after surgery were measured. RESULTS The recovery time to TOF of 0.9 and extubation time were significantly shorter in the group S than in the group C (4.2 ± 1.4 vs 108.2 ± 26.7 min, 66.3 ± 6.5 vs 171.6 ± 23.1 min, respectively, P < 0.01). The CRP and PCT levels were found to be increased in both groups at postoperative 24 h than before surgery. Further, the levels of PCT and CRP at postoperative 24 h were lower in group S when compared to group C (median, 7 vs 17.5 mg/ml, 1.76 vs 5.22 ng/ml, respectively, P < 0.05). There were no statistical differences observed between the two groups (P> 0.05) with respect to side effects. CONCLUSION Sugammadex is rapid and effective in reversing rocuronium-induced neuromuscular block, and significantly reduces the extubation time and the release of postoperative CRP and PCT in children with congenital heart diseases.
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Procalcitonin versus C-reactive protein: review of kinetics and performance for diagnosis of neonatal sepsis. J Perinatol 2019; 39:893-903. [PMID: 30926891 DOI: 10.1038/s41372-019-0363-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/03/2019] [Accepted: 03/08/2019] [Indexed: 11/08/2022]
Abstract
Procalcitonin (PCT) and C-reactive protein (CRP) are commonly used biomarkers, but their diagnostic advantage for neonatal early-onset (EOS) or late-onset (LOS) sepsis is controversial. In a comprehensive literature review we found significant heterogeneity between studies in sample timing, cut-off values, consideration of blood culture results for sepsis classification, and definition of EOS versus LOS. We identified 39 studies directly comparing PCT with CRP, but only four in very low birth weight (VLBW) neonates. The mean sensitivity for EOS, LOS, and EOS + LOS was 73.6%, 88.9%, and 76.5% for PCT, compared to 65.6%, 77.4%, and 66.4% for CRP, respectively. Mean specificity of PCT and CRP was 82.8% versus 82.7% for EOS, 75.6% versus 81.7% for LOS, and 80.4% versus 91.3% for EOS + LOS. More studies directly comparing both biomarkers for EOS and LOS, especially in extremely and very-low-birth-weight infants, are needed to determine their clinical value for guidance of antibiotic therapy in neonatal sepsis.
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Huang JS, Chen Q, Chen LW, Kuo YR, Hong ZN, Cao H. Changes in the levels of inflammatory markers after transthoracic device closure of ventricular septal defects in pediatric patients. J Cardiothorac Surg 2019; 14:70. [PMID: 30961628 PMCID: PMC6454635 DOI: 10.1186/s13019-019-0900-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/01/2019] [Indexed: 12/28/2022] Open
Abstract
Background Transthoracic device closure of ventricular septal defect (VSD) is widely used in the clinic, especially in China. Changes in inflammatory marker levels after transthoracic device closure of VSD in pediatric patients have not been reported. Methods We retrospectively collected clinical data for 85 pediatric patients in our hospital from September 2017 to January 2018. The patients were divided into two groups according to treatment (device group vs. surgical group). The clinical and experimental data from the two groups were statistically analyzed. Results Clinical outcomes were good in all patients without any fatal complications. Similar increasing trends in inflammatory markers (white blood cell (WBC) count, procalcitonin (PCT), C-reactive protein (CRP), and interleukin-6 (IL-6)) were found in the two groups, both of which showed noticeable systemic inflammatory responses. In addition, no significant difference in the postoperative levels of inflammatory markers was observed between these two groups. Conclusions Although transthoracic device closure of VSD seems to be less traumatic and involves a quicker recovery, it also induces a systemic inflammatory response as measured by WBC count and PCT, CRP and IL-6 levels, and the altered trends in inflammatory markers were similar to those of conventional surgery under CPB.
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Affiliation(s)
- Jiang-Shan Huang
- Department of Cardiac Surgery, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, the Daoshan road 18, Gulou District, Fuzhou, 350001, People's Republic of China
| | - Qiang Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Yur-Ren Kuo
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, 100 TzYou 1st Rd, Kaohsiung City, 80756, Taiwan
| | - Zhi-Nuan Hong
- Department of Cardiac Surgery, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, the Daoshan road 18, Gulou District, Fuzhou, 350001, People's Republic of China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, the Daoshan road 18, Gulou District, Fuzhou, 350001, People's Republic of China.
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Xu H, Sun Y, Zhang S. The Relationship Between Neutrophil to Lymphocyte Ratio and Clinical Outcome in Pediatric Patients After Cardiopulmonary Bypass Surgery: A Retrospective Study. Front Pediatr 2019; 7:308. [PMID: 31417881 PMCID: PMC6684771 DOI: 10.3389/fped.2019.00308] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/09/2019] [Indexed: 12/22/2022] Open
Abstract
Background: The aim of this study was to investigate the prognostic role of the neutrophil to lymphocyte ratio (NLR) in pediatric patients undergoing open-heart surgery with cardiopulmonary bypass (CPB). Methods: A retrospective cohort study of 61 pediatric patients who underwent CPB in the First Affiliated Hospital of Nanjing Medical University from January 2017 to October 2018 was conducted. All perioperative clinical data, including neutrophil count, lymphocyte count, and C-reactive protein (CRP), were collected retrospectively. The prognostic value of NLR and its association with extubation time, duration of intensive care unit (ICU) stay and in-hospital stay were analyzed. Results: Neutrophil count, NLR, and CRP were significantly increased post-operative compared with pre-operative (p < 0.05). The increased post-operative levels of NLR were significantly associated with longer extubation time, as well as prolonged post-operative cardiac ICU stay (p < 0.05). Multivariate linear regression analysis revealed that elevated NLR displayed a significant independent association with extubation time and the duration of an ICU stay. Conclusion: Increased post-operative NLR followed by cardiac surgery with CPB in pediatric patients was associated with longer extubation time and a longer duration of an ICU stay.
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Affiliation(s)
- Hao Xu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yanxin Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sibi Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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13
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Lanziotti VS, Póvoa P, Soares M, Silva JRLE, Barbosa AP, Salluh JIF. Use of biomarkers in pediatric sepsis: literature review. Rev Bras Ter Intensiva 2017; 28:472-482. [PMID: 28099644 PMCID: PMC5225923 DOI: 10.5935/0103-507x.20160080] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/09/2016] [Indexed: 12/17/2022] Open
Abstract
Despite advances in recent years, sepsis is still a leading cause of
hospitalization and mortality in infants and children. The presence of
biomarkers during the response to an infectious insult makes it possible to use
such biomarkers in screening, diagnosis, prognosis (risk stratification),
monitoring of therapeutic response, and rational use of antibiotics (for
example, the determination of adequate treatment length). Studies of biomarkers
in sepsis in children are still relatively scarce. This review addresses the use
of biomarkers in sepsis in pediatric patients with emphasis on C-reactive
protein, procalcitonin, interleukins 6, 8, and 18, human neutrophil gelatinase,
and proadrenomedullin. Assessment of these biomarkers may be useful in the
management of pediatric sepsis.
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Affiliation(s)
- Vanessa Soares Lanziotti
- Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil.,Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | - Pedro Póvoa
- NOVA Medical School, Universidade Nova de Lisboa - Lisboa, Portugal.,Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal
| | - Márcio Soares
- Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil
| | | | - Arnaldo Prata Barbosa
- Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil.,Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal
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14
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Sariego-Jamardo A, Rey C, Medina A, Mayordomo-Colunga J, Concha-Torre A, Prieto B, Vivanco-Allende A. C-reactive protein, procalcitonin and interleukin-6 kinetics in pediatric postoperative patients. J Crit Care 2017; 41:119-123. [PMID: 28514716 DOI: 10.1016/j.jcrc.2017.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/04/2017] [Accepted: 05/10/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Andrea Sariego-Jamardo
- Paediatric Department, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain.
| | - Corsino Rey
- University of Oviedo, Oviedo, Spain; Pediatric Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Alberto Medina
- Pediatric Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Juan Mayordomo-Colunga
- Pediatric Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Andrés Concha-Torre
- Pediatric Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Belén Prieto
- Department of Biochemistry, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ana Vivanco-Allende
- Pediatric Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
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15
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Pérez SB, Rodríguez-Fanjul J, García IJ, Hernando JM, Iriondo Sanz M. Procalcitonin Is a Better Biomarker than C-Reactive Protein in Newborns Undergoing Cardiac Surgery: The PROKINECA Study. Biomark Insights 2016; 11:123-129. [PMID: 27840575 PMCID: PMC5096765 DOI: 10.4137/bmi.s40658] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/26/2016] [Accepted: 10/05/2016] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To assess the kinetics of procalcitonin (PCT) and C-reactive protein (CRP) in newborns after cardiothoracic surgery (CS), with and without cardiopulmonary bypass, and to assess whether PCT was better than CRP in identifying sepsis in the first 72 hours after CS. PATIENTS AND METHODS This is a prospective study of newborns admitted to the neonatal intensive care unit after CS. INTERVENTIONS PCT and CRP were sequentially drawn 2 hours before surgery and at 0, 12, 24, 48, and 72 hours after surgery. RESULTS A total of 65 patients were recruited, of which 14 were excluded because of complications. We compared the kinetics of PCT and CRP after CS in bypass and non-bypass groups without sepsis; there were no differences in the PCT values at any time (24 hours, P = 0.564; 48 hours, P = 0.117; 72 hours, P = 0.076). Thirty-five patients needed bypass, of whom four were septic (11.4%). Significant differences were detected in the PCT values on comparing the septic group to the nonseptic group at 48 hours after cardiopulmonary bypass (P = 0.018). No differences were detected in the CRP values in these groups. A suitable cutoff for sepsis diagnosis at 48 hours following bypass would be 5 ng/mL, with optimal area under the curve of 0.867 (confidence interval 0.709–0.958), P < 0.0001, and sensitivity and specificity of 87.5% (29.6–99.7) and 72.6% (53.5–86.4), respectively. CONCLUSION This is a preliminary study but PCT seems to be a good biomarker in newborns after CS. Values over 5 ng/mL at 48 hours after CS should alert physicians to the high risk of sepsis in these patients.
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Affiliation(s)
- Sara Bobillo Pérez
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Javier Rodríguez-Fanjul
- Neonatal Intensive Care Unit Service, Hospital de Sant Joan de Déu Maternal, Fetal and Neonatology Center Barcelona (BCNatal), University of Barcelona, Barcelona, Spain
| | - Iolanda Jordan García
- Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, Paediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, CIBERESP, Barcelona, Spain
| | - Julio Moreno Hernando
- Neonatal Intensive Care Unit Service, Hospital de Sant Joan de Déu Maternal, Fetal and Neonatology Center Barcelona (BCNatal), University of Barcelona, Barcelona, Spain
| | - Martín Iriondo Sanz
- Neonatal Intensive Care Unit Service, Hospital de Sant Joan de Déu Maternal, Fetal and Neonatology Center Barcelona (BCNatal), University of Barcelona, Barcelona, Spain
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16
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Macrina F, Tritapepe L, Pompei F, Sciangula A, Evangelista E, Toscano F, Criniti A, Brancaccio G, Puddu PE. Procalcitonin is useful whereas C-reactive protein is not, to predict complications following coronary artery bypass surgery. Perfusion 2016; 20:169-75. [PMID: 16038389 DOI: 10.1191/0267659105pf800oa] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: The respective value of procalcitonin (PCT) and C-reactive protein (CRP) as markers of postoperative complications after coronary bypass surgery is unclear. Therefore, complications during one week after surgery were studied to evaluate the predictive role of PCT and CRP changes during the immediate postoperative period. Methods: Thirty-two patients, in whom an uneventful immediate postoperative course was anticipated, were prospectively enrolled and followed-up to the 7th postoperative day. At the end of the follow-up, patients were divided into two groups. Group A were patients with an uncomplicated postoperative course and Group B were patients with a complicated postoperative course. Results: Serum samples were drawn for PCT and CRP determination after induction of anesthesia (baseline), at the end of surgery and daily until postoperative day 2. Baseline serum PCT concentrations were 0.119 ± 0.09 and 0.209 ± 0.21 ng/mL in Groups A and B, respectively (NS). Serum PCT concentration increased compared with baseline in both groups during the first two days after surgery. The increase in serum PCT concentration was significantly greater in Group B than A patients ( p<0.0002). Considering a perioperative abnormal cut-off value of > 0.5 ng/mL, there were none in Group A versus 57% in Group B ( p<0.0001). Baseline serum CRP concentrations were 1.449 ± 1.30 and 1.589 ± 1.35 ng/mL in Groups A and B, respectively (NS). After surgery, CRP increased significantly compared with baseline in both groups. When changes in time-varying variables were included in a logistic model, complications were predicted by changes (between baseline and end of surgery values) of PCT (coefficient=9.410; t=2.18) and heart rate (coefficient=0.075; t=1.57), whereas changes of CRP, white blood cells, mean blood and central venous pressures did not contribute statistically. The model constant was -4.827 (t= -2.43) and the ROC curve area was 0.8971. Thus, absolute PCT changes of 0.20, 0.40 and 0.60 ng/mL carry an approximate risk of 5, 26 and 69%, respectively, of postoperative complications in the time frame of this study. Conclusions: A postoperative serum PCT concentration of >0.5 ng/mL is highly suggestive of a postoperative complication. CRP changes do not contribute to predictive information.
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Affiliation(s)
- Francesco Macrina
- Dipartimento del Cuore e dei Grossi Vasi Attilio Reale, Università degli Studi La Sapienza, Rome, Italy
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17
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Chakravarti SB, Reformina DA, Lee TM, Malhotra SP, Mosca RS, Bhatla P. Procalcitonin as a biomarker of bacterial infection in pediatric patients after congenital heart surgery. Ann Pediatr Cardiol 2016; 9:115-9. [PMID: 27212844 PMCID: PMC4867794 DOI: 10.4103/0974-2069.180665] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Bacterial infection (BI) after congenital heart surgery (CHS) is associated with increased morbidity and is difficult to differentiate from systemic inflammatory response syndrome caused by cardiopulmonary bypass (CPB). Procalcitonin (PCT) has emerged as a reliable biomarker of BI in various populations. Aim: To determine the optimal PCT threshold to identify BI among children suspected of having infection following CPB. Setting and Design: Single-center retrospective observational study. Materials and Methods: Medical records of all the patients admitted between January 2013 and April 2015 were reviewed. Patients in the age range of 0-21 years of age who underwent CHS requiring CPB in whom PCT was drawn between postoperative days 0-8 due to suspicion of infection were included. Statistical Analysis: The Wilcoxon rank-sum test was used for nonparametric variables. The diagnostic performance of PCT was evaluated using a receiver operating characteristic (ROC) curve. Results: Ninety-eight patients were included. The median age was 2 months (25th and 75th interquartile of 0.1-7.5 months). Eleven patients were included in the BI group. The median PCT for the BI group (3.42 ng/mL, 25th and 75th interquartile of 2.34-5.67) was significantly higher than the median PCT for the noninfected group (0.8 ng/mL, 25th and 75th interquartile 0.38-3.39), P = 0.028. The PCT level that yielded the best compromise between the sensitivity (81.8%) and specificity (66.7%) was 2 ng/mL with an area under the ROC curve of 0.742. Conclusion: A PCT less than 2 ng/mL makes BI unlikely in children suspected of infection after CHS.
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Affiliation(s)
- Sujata B Chakravarti
- Department of Pediatrics, Division of Cardiology, New York University Langone Medical Center, New York, New York, USA
| | - Diane A Reformina
- Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York, USA
| | - Timothy M Lee
- Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York, USA
| | - Sunil P Malhotra
- Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York, USA
| | - Ralph S Mosca
- Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York, USA
| | - Puneet Bhatla
- Department of Pediatrics, Division of Cardiology, New York University Langone Medical Center, New York, New York, USA
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18
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Fontela PS, Lacroix J. Procalcitonin: Is This the Promised Biomarker for Critically Ill Patients? J Pediatr Intensive Care 2016; 5:162-171. [PMID: 31110901 DOI: 10.1055/s-0036-1583279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/19/2015] [Indexed: 12/23/2022] Open
Abstract
Objective Procalcitonin (PCT) has been increasingly used in the critical care setting to determine the presence of bacterial infection and also to guide antibiotic therapy. We reviewed PCT's physiologic role, as well as its clinical utility for the management of pediatric critically ill patients. Findings PCT is a precursor of the hormone calcitonin. Its production is induced by inflammatory conditions, especially bacterial infections. Literature shows that PCT is a moderately reliable diagnostic test for severe bacterial infection in children. Synthesis of available adult studies suggests that the use of PCT-based algorithms to support medical decision making reduces antibiotic exposure without compromising safety in critically ill patients. However, no study has addressed the usefulness and safety of PCT to guide antibiotic therapy in severely ill children. In pediatric patients with acute lower respiratory tract infections, the use of PCT-based algorithms also led to a safe decrease in antibiotic treatment duration. Conclusion PCT has demonstrated clinical utility in the pediatric critical care setting when used for the diagnosis of bacterial infections and to guide antibiotic use in children with acute lower respiratory tract infections. However, more research is needed in critically ill children to determine the utility of PCT-driven antibiotic therapy in this population.
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Affiliation(s)
- Patricia S Fontela
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
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19
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Prevention of infectious complications after heart surgery in children: procalcitonin-guided strategy. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 11:140-4. [PMID: 26336411 PMCID: PMC4283869 DOI: 10.5114/kitp.2014.43840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 04/30/2014] [Accepted: 05/21/2014] [Indexed: 11/18/2022]
Abstract
Introduction Infectious complications remain a significant problem of modern cardiac surgery. New prevention strategies, based on the pathogenesis of such complications occurring after cardiopulmonary bypass (CPB) procedures, should be evaluated. Aim of the study To evaluate the effectiveness of a procalcitonin (PCT)-guided strategy involving the use of IgM-enriched intravenous immunoglobulins (IVIGs) in children with congenital heart disease with systemic inflammation during the early postoperative period. Material and methods Sixty consecutive patients aged 25 (21-30) months who underwent cardiac surgery with CPB and had blood PCT levels > 2 ng/mL on the 1st postoperative day were enrolled in this single-center prospective randomized clinical trial. The patients were randomized into two groups, comparable in terms of the severity of their initial condition, age, and CPB time. IgM-enriched IVIGs (Pentaglobin, Biotest Pharma GmbH, Germany) were administered during the first 3 postoperative days (5 mL/kg each day) in the study group (n = 30) in addition to the standard treatment, which was also provided to the control group (n = 30). The data are presented as medians with 25-75th percentiles; they were compared by the Mann-Whitney U-test, and p values of < 0.05 were considered as statistically significant. Results Postoperatively, 1/30 (3.3%) patients in the study group and 8/30 (26.7%) in the control group suffered from infectious complications (study group: urinary tract infection [UTI] – 1; control group: pneumonia – 4, pneumonia and sepsis – 2, peritonitis with multiorgan failure – 1, UTI – 1), p = 0.03. The length of hospital stay in the study group was shorter than in the control group: 19 (16-23) days vs. 24 (19-29) days, p = 0.002, as was the length of intensive care unit (ICU) stay: 3 (2-4) days vs. 4 (2-8) days, p = 0.03. Conclusions High PCT levels on the 1st postoperative day are associated with an increased risk of infectious complications after cardiac surgery. Early administration of IgM-enriched IVIGs can prevent the development of infectious complications.
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20
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Dhillon S, Yu X, Cheypesh A, Ross DB, Li J. Comparison of Profiles of Perioperative Serum C-Reactive Protein Levels in Neonates Undergoing the Norwood Procedure or Arterial Switch Operation. CONGENIT HEART DIS 2014; 10:226-33. [DOI: 10.1111/chd.12195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Santokh Dhillon
- Division of Pediatric Cardiology; Department of Pediatrics; Stollery Children's Hospital; University of Alberta; Edmonton Alberta Canada
| | - Xiaoyang Yu
- Division of Pediatric Cardiology; Department of Pediatrics; Stollery Children's Hospital; University of Alberta; Edmonton Alberta Canada
| | - Andriy Cheypesh
- Division of Pediatric Cardiology; Department of Pediatrics; Stollery Children's Hospital; University of Alberta; Edmonton Alberta Canada
| | - David B. Ross
- Division of Cardiac Surgery; Department of Surgery; Stollery Children's Hospital; University of Alberta; Edmonton Alberta Canada
| | - Jia Li
- Division of Pediatric Cardiology; Department of Pediatrics; Stollery Children's Hospital; University of Alberta; Edmonton Alberta Canada
- Clinical Physiology Research Center; Capital Institute of Pediatrics; Beijing China
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21
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Jaworski R, Haponiuk I, Irga-Jaworska N, Chojnicki M, Steffens M, Szofer-Sendrowska A, Zielinski J, Juscinski J. Kinetics of C-reactive protein in children with congenital heart diseases in the early period after cardiosurgical treatment with extracorporeal circulation. Adv Med Sci 2014; 59:19-22. [PMID: 24797968 DOI: 10.1016/j.advms.2013.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 06/12/2013] [Indexed: 01/20/2023]
Abstract
PURPOSE The aim of the study was to assess postoperative C-reactive protein (CRP) serum kinetics in children without clinical signs of infection after atrial and ventricular septal defects closure in terms of extracorporeal circulation (ECC). MATERIAL/METHODS Fifty-two patients met inclusion criteria and were divided into 2 groups: group A (antibiotic prophylaxis with cefazolin given up to 48 h postoperatively) and group B (antibiotic prophylaxis with amoxicillin and clavunic acid given more than 48 h postoperatively). The CRP was measured perioperatively in both groups. The CRP evaluation was the part of routine lab-tests during perioperative period, without any modification of the typical perioperative strategy. In the postoperative period CRP was measured after 24h, 48 h, 72 h and 96 h in both groups. RESULTS There were no differences between CRP levels between both groups of patients. The peak CRP values were observed after 48 h after the operation in ECC in both groups and decreased in the next postoperative days. CONCLUSIONS In children with congenital heart defects undergoing cardiosurgical treatment with the use of ECC the assessing CRP values in the first postoperative day remains questionable. The maximum peak CRP value after operation with ECC can be much higher than the reference values without infection complications. Single CRP assessment in early postoperative period in these groups of children can lead to over-diagnosis of infections and antibiotics abuse.
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Affiliation(s)
- Radoslaw Jaworski
- Department of Pediatric Cardiac Surgery, Mikolaj Kopernik Pomeranian Centre of Traumatology in Gdansk, Gdansk, Poland.
| | - Ireneusz Haponiuk
- Department of Pediatric Cardiac Surgery, Mikolaj Kopernik Pomeranian Centre of Traumatology in Gdansk, Gdansk, Poland
| | - Ninela Irga-Jaworska
- Department of Pediatric, Hematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Maciej Chojnicki
- Department of Pediatric Cardiac Surgery, Mikolaj Kopernik Pomeranian Centre of Traumatology in Gdansk, Gdansk, Poland
| | - Mariusz Steffens
- Department of Pediatric Cardiac Surgery, Mikolaj Kopernik Pomeranian Centre of Traumatology in Gdansk, Gdansk, Poland
| | - Aneta Szofer-Sendrowska
- Department of Pediatric Cardiac Surgery, Mikolaj Kopernik Pomeranian Centre of Traumatology in Gdansk, Gdansk, Poland
| | - Jacek Zielinski
- Department of Surgical Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Jacek Juscinski
- Department of Pediatric Cardiac Surgery, Mikolaj Kopernik Pomeranian Centre of Traumatology in Gdansk, Gdansk, Poland
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22
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Xu Z, Zhang M, Zhu L, Gong X, Li J. Elevated Plasma B-type Natriuretic Peptide and C-reactive Protein Levels in Children with Restrictive Right Ventricular Physiology Following Tetralogy of Fallot Repair. CONGENIT HEART DIS 2014; 9:521-8. [DOI: 10.1111/chd.12166] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Zhuoming Xu
- Cardiac Intensive Care Unit; Shanghai Children's Medical Center; School of Medicine; Shanghai Jiao Tong University; Shanghai China
| | - Mingjie Zhang
- Cardiac Intensive Care Unit; Shanghai Children's Medical Center; School of Medicine; Shanghai Jiao Tong University; Shanghai China
| | - Limin Zhu
- Cardiac Intensive Care Unit; Shanghai Children's Medical Center; School of Medicine; Shanghai Jiao Tong University; Shanghai China
| | - Xiaolei Gong
- Cardiac Intensive Care Unit; Shanghai Children's Medical Center; School of Medicine; Shanghai Jiao Tong University; Shanghai China
| | - Jia Li
- Department of Pediatrics; University of Alberta; Edmonton Alberta Canada
- Clinical Physiology Research Center; Capital Institute of Pedatrics; Beijing China
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23
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Kinetics of procalcitonin and C-reactive protein and the relationship to postoperative infection in young infants undergoing cardiovascular surgery. Pediatr Res 2013; 74:413-9. [PMID: 23863853 PMCID: PMC3955993 DOI: 10.1038/pr.2013.124] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 03/09/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The utility of procalcitonin (PCT) and C-reactive protein (CRP) as infectious biomarkers following infant cardiothoracic surgery is not well defined. METHODS We designed a prospective cohort study to evaluate PCT and CRP after infant cardiothoracic surgery. PCT and CRP were drawn preoperatively and 24/72 h postoperation or daily in delayed sternal closure patients. Presence of infection within 10 d of surgery, vasoactive-inotropic scores at 24 and 72 h, and length of intubation, intensive care unit stay, and hospital stay were documented. RESULTS PCT and CRP were elevated at 24 h. PCT then decreased while CRP increased in patients undergoing delayed sternal closure or cardiopulmonary bypass. In the delayed sternal closure group, PCT was significantly higher on postoperative days 2-5 in patients who ultimately developed infection. Higher PCT was independently associated with increased vasoactive-inotropic score at 72 h. CRP did not correlate with infection or postoperative support. CONCLUSION PCT rises after cardiothoracic surgery in infants but decreases by 72 h while CRP remains elevated. Sternal closure may affect CRP but not PCT. PCT is independently associated with circulatory support requirements at 72 h postoperation and with development of infection. PCT may have greater utility as a biomarker in this population.
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Abstract
Appreciating the complexity and evolving pathophysiology after palliation of CHD is critical to improving the outcome. Despite a growing patient population because of greater survival over the years, detailed data on the long-term outcomes of these patients is surprisingly sparse. The establishment in 2001 of the Pediatric Heart Network by the National Heart, Lung and Blood Institute has provided a collaborative multicenter platform to conduct large trials in CHD and to characterize outcomes. This chapter has emphasized how CHD care spans the continuum from fetal life to adulthood. Current research efforts aspire to better characterize short-term and long-term outcomes, continue advancement of technologies to better diagnose and treat CHD, and to elucidate the role of genetics and biomarkers in predicting outcome. Focused studies on variations in perioperative practice and quality will help us provide better clinical outcomes for CHD survivors.
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Abstract
Over the past two decades, the body of literature on the clinical usefulness of procalcitonin (PCT) in adults has grown rapidly. Although this approach has led to increased insight, it has also prompted debate regarding its potential use in diagnosis and management of severe infection. Clinicians, however, are less familiar with the use of PCT in pediatric populations. In this review, we examine PCT as a marker of severe clinical pediatric conditions including its role in systemic inflammation, infection, and sepsis.
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26
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Abstract
Fever in the postoperative period in children undergoing surgery for congenital heart disease is fairly common and tends to cause anxiety to both the surgeon and the patient. Such fever is associated with the metabolic response to trauma, systemic response to the cardiopulmonary bypass, hypothermia, presence of drainage tubes, drugs, blood transfusion as well as infections. Establishing the diagnosis requires proper assessment of the patient with focused history, targeted physical examination and judicious use of investigations with the knowledge of the common causes.
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Affiliation(s)
- Ajay K Gupta
- Department of Critical Care Medicine, Fortis Escorts Heart Institute, Okhla, New Delhi, India
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27
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Yu X, Larsen B, Rutledge J, West L, Ross DB, Rebeyka IM, Buchholz H, Li J. The profile of the systemic inflammatory response in children undergoing ventricular assist device support. Interact Cardiovasc Thorac Surg 2012; 15:426-31. [PMID: 22617505 DOI: 10.1093/icvts/ivs206] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Serum C-reactive protein (CRP) has been used as a systemic inflammatory response (SIR) marker in the critical ill, including children after cardiopulmonary bypass surgery. Ventricular assist devices (VAD) have been increasingly used as a bridge support to heart transplantation in children. We aimed to examine the profiles of CRP in children receiving VAD support. METHODS Charts of 13 children receiving Berlin Heart EXCOR(®) from 2005 to 2009 were reviewed. The data obtained prior to and during VAD support included: CRP, white blood cells, inotropes and steroid use, VAD mode and duration of VAD support. Ten patients received left VAD (LVAD) and 3 biventricular VAD (BiVAD). RESULTS The median duration of VAD support was 59 days (ranged 3-678 days). Pre-VAD CRP was 35 ± 51 mg/l and increased to 109 ± 59 mg/l on days 1-3 after the VAD implantation (P = 0.01), then gradually decreased to 28 ± 28 mg/l by 4 months and normalized by 5 months (P < 0.0001). CRP was higher in BiVAD than in LVAD patients throughout the study period (P = 0.003). CRP positively correlated with the doses of the epinephrine and norepinephrine and the monocyte counts, and negatively correlated with the lymphocyte count. The lymphocyte count was 2.5 ± 0.4 x 10(9)/l prior to implantation, and decreased to 2.1 ± 1.3 x 10(9)/l on days 1-3 (P = 0.5) and then to 0.6 ± 0.1 x 10(9)/l by 6 months (P = 0.08). It tended to be lower in BiVAD patients (P = 0.06). CONCLUSIONS SIR exists in children prior to VAD support. VAD implantation is associated with a significant and prolonged increase in CRP and a decrease in lymphocyte count, indicating a suppressed immune function, being more pronounced in BiVAD patients.
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Affiliation(s)
- Xiaoyang Yu
- Division of Pediatric Cardiology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
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Yu X, Larsen B, Urschel S, Cheung PY, Ross DB, Rebeyka I, West L, Li J. The profile of inflammatory and metabolic response in children undergoing heart transplantation. Clin Transplant 2011; 26:E137-42. [PMID: 22168310 DOI: 10.1111/j.1399-0012.2011.01566.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Inflammatory and metabolic response is an important factor to determine clinical outcomes. However, it remains unknown in children undergoing heart transplantation (HTx). We examined the perioperative changes in the inflammatory and metabolic response markers C-reactive protein (CRP) and prealbumin (PA) in 38 heart-transplanted children. Data obtained prior to and within one month after HTx included CRP, PA, total and differential white blood cell counts, doses of inotropes and immunosuppressants, cultures of blood and body fluids, duration of cardiopulmonary bypass (CPB), aortic cross clamp and donor heart ischemia, and days in the intensive care unit (ICU) and hospital. CRP was 32±49 mg/L before HTx, increased to 130±55 mg/L on postoperative day 1-2, and decreased to 21±31 mg/L by one month after HTx. PA was 0.15±0.06 g/L before HTx, decreased to 0.12±0.03 g/L on postoperative day 1-2, and then gradually increased to 0.21±0.10 g/L by one month after HTx. Postoperative CRP positively correlated with epinephrine dosage and CPB duration. PA positively correlated with age. In conclusion, inflammatory and metabolic response is present before HTx and acutely intensified after HTx. It may be mainly influenced by CPB duration and cardiovascular function status.
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Affiliation(s)
- Xiaoyang Yu
- Division of Pediatric Cardiology, Stollery Children's Hospital, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Bektas F, Soyuncu S, Gunduz I, Basarici I, Akbas H, Eken C. The Value of Procalcitonin, a Novel Inflammatory Marker, in the Diagnosis of Myocardial Infarction and Evaluation of Acute Coronary Syndrome Patients. J Emerg Med 2011; 41:524-30. [DOI: 10.1016/j.jemermed.2010.05.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 02/22/2010] [Accepted: 05/19/2010] [Indexed: 11/30/2022]
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Nahum E, Schiller O, Livni G, Bitan S, Ashkenazi S, Dagan O. Procalcitonin level as an aid for the diagnosis of bacterial infections following pediatric cardiac surgery. J Crit Care 2011; 27:220.e11-6. [PMID: 21958983 DOI: 10.1016/j.jcrc.2011.07.076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 07/06/2011] [Accepted: 07/17/2011] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of the present study was to determine if blood procalcitonin can serve as an aid to differentiate between bacterial and nonbacterial cause of fever in children after cardiac surgery. MATERIALS AND METHODS A nested case-control study of children who underwent open cardiac surgery in critical care units of fourth-level pediatric hospital was performed. Blood samples for procalcitonin level were collected 1 day before operation; 1 hour postoperation; on postoperative days 1, 2, and 5; and on the day of fever, when it occurred. RESULTS Of 665 children who underwent cardiac bypass surgery, 126 had a febrile episode postoperatively, 47 children with a proven bacterial infection and 79 without bacterial infection. Among the 68 children in whom fever developed within the first 5 postoperative days, procalcitonin level at fever day was significantly higher in those with bacterial infection (n = 16) than in those without infection (n = 52). Similarly, among the 58 children in whom fever developed after day 5 postoperation, a significant difference was found in procalcitonin level at fever day between those with (n = 31) and without (n = 27) bacterial infection. CONCLUSION During the critical early and late periods after cardiac surgery in children, procalcitonin level may help to differentiate patients with bacterial infection from patients in whom the fever is secondary to nonbacterial infectious causes.
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Affiliation(s)
- Elhanan Nahum
- Pediatric Critical Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 49202, Israel.
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C-reactive protein in the diagnosis of postoperative infection in pediatric patients: a prospective observational study of 103 patients. J Pediatr Surg 2011; 46:1726-31. [PMID: 21929981 DOI: 10.1016/j.jpedsurg.2011.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Revised: 02/10/2011] [Accepted: 03/13/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND Surgical stress elicits a systemic inflammatory response syndrome that contributes to the development of septic complications. C-reactive protein (CRP) is an acute phase protein released in inflammatory states. To analyze the usefulness of CRP as a marker of infection in surgical pediatric patients, we analyzed its kinetics in these patients in comparison with usual markers, such temperature, leukocytes, or fibrinogen. METHODS One hundred three pediatric patients undergoing major surgery were enrolled consecutively in this observational study. C-reactive protein, leukocytes, neutrophils, platelets, fibrinogen, glycemia, and temperature were determined daily after surgery. Patients were classified as infected or not infected. Sensitivity, specificity, positive predictive value, negative predictive value, efficiency, precocity, positive likelihood ratio, and number of subjects to be treated were calculated. RESULTS Peak in CRP was detected at 48 ± 24 hours. C-reactive protein was higher in the infected group from the first day, with significant differences between groups from the second day. Best cutoff for detecting infection was increases in CRP of 11 mg/dL in 48 hours, with a sensitivity of 87%, specificity of 89%, precocity of 1.7 days (0.82-2.54), number of subjects to be treated of 1.7 (1.4-2.6), and positive likelihood ratio of 7.9. Application of other markers alone or in combination did not surpass the sensitivity, specificity, or precocity for increases in CRP of 11 mg/dL in 48 hours. CONCLUSIONS Increases of CRP constitute an easy and cheap prognostic alert system and may be used to establish strategies aimed to detect infection in surgical pediatric patients.
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Procalcitonin as a marker of bacterial infection in children undergoing cardiac surgery with cardiopulmonary bypass. Cardiol Young 2011; 21:392-9. [PMID: 21385512 DOI: 10.1017/s104795111100014x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Owing to systemic inflammatory response syndrome, the diagnosis of post-operative infection after cardiopulmonary bypass is difficult to assess in children with the usual clinical and biological tools. Procalcitonin could be informative in this context. METHODS Retrospective study in a paediatric intensive care unit. Blood samples were collected as soon as infection was clinically suspected and a second assay was performed 24 hours later. Using referenced criteria, children were retrospectively classified into two groups: infected and non-infected. RESULTS Out of the 95 children included, 14 were infected. Before the third post-operative day, procalcitonin median concentration was significantly higher in the infected group than in the non-infected group - 20.24 nanograms per millilitre with a 25th and 75th interquartile of 15.52-35.71 versus 0.72 nanograms per millilitre with a 25th and 75th interquartile of 0.28 to 5.44 (p = 0.008). The area under the receiver operating characteristic curve was 0.89 with 95% confidence intervals from 0.80 to 0.97. The best cut-off value to differentiate infected children from healthy children was 13 nanograms per millilitre with 100% sensitivity - 95% confidence intervals from 51 to 100 - and 85% specificity - 95% confidence intervals from 72 to 91. After the third post-operative day, procalcitonin was not significantly higher in infected children - 2 nanograms per millilitre with a 25th and 75th interquartile of 0.18 to 12.42 versus 0.37 nanograms per millilitre with a 25th and 75th interquartile of 0.24 to 1.32 (p = 0.26). The area under the receiver operating characteristic curve was 0.62 with 95% confidence intervals from 0.47 to 0.77. A procalcitonin value of 0.38 nanograms per millilitre provided a sensitivity of 70% with 95% confidence intervals from 39 to 89 for a specificity of 52% with 95% confidence intervals from 34 to 68. After the third post-operative day, a second assay at a 24-hour interval can improve the sensitivity of the test. CONCLUSIONS Procalcitonin seems to be a discriminating marker of bacterial infection during the post-operative days following cardiopulmonary bypass in children.
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Time course of C-reactive protein and inflammatory mediators after neonatal surgery. J Pediatr 2011; 159:121-6. [PMID: 21419426 DOI: 10.1016/j.jpeds.2010.12.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 11/08/2010] [Accepted: 12/30/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To characterize the perioperative course of C-reactive protein (CRP) and inflammatory mediators in neonates ≤44 weeks' corrected gestational age. STUDY DESIGN Prospective study of CRP and inflammatory mediators interleukin (IL)-1β, IL-6, IL-8, IL-10, and tumor necrosis factor-α in 55 neonates undergoing thoracic or abdominal surgery. RESULTS In the absence of infection, CRP increased after surgery, peaking on post-operative day 2. The perioperative patterns of CRP differed by diagnosis and inflammatory state. Surgery alone did not cause an increase in CRP because in 13 of 55 infants (24%), CRP remained <1.0 mg/dL at all time points. For thoracic procedures, patent ductus arteriosus ligation showed the least post-operative increase in CRP, and patients undergoing repair of congenital diaphragmatic hernia or tracheoesophageal fistula had a greater response. Abdominal procedures with low CRP response included repair of imperforate anus and pyloric stenosis, while gastroschisis repair and bowel reanastomosis after necrotizing enterocolitis were accompanied by a robust CRP response. IL-6 concentrations peaked on post-operative day 1 and correlated with the post-operative day 2 CRP peak (r=0.398, P=.004). The additional inflammatory mediators measured were not informative. CONCLUSIONS The range and time course of perioperative CRP differ by diagnosis. Serial measurements may be more informative than CRP magnitude.
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Nahum E, Livni G, Schiller O, Bitan S, Ashkenazi S, Dagan O. Role of C-reactive protein velocity in the diagnosis of early bacterial infections in children after cardiac surgery. J Intensive Care Med 2011; 27:191-6. [PMID: 21561990 DOI: 10.1177/0885066610396642] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fever after cardiac surgery in children may be due to bacterial infection or noninfectious origin like systemic inflammatory response syndrome (SIRS) secondary to bypass procedure. A marker to distinguish bacterial from nonbacterial fever in these conditions is clinically important. The purpose of our study was to evaluate, in the early postcardiac surgery period, whether serial measurement of C-reactive protein (CRP) and its change over time (CRP velocity) can assist in detecting bacterial infection. A series of consecutive children who underwent cardiac surgery with bypass were tested for serum levels of CRP at several points up to 5 days postoperatively and during febrile episodes (>38.0°C). Findings were compared among febrile patients with proven bacterial infection (FWI group; sepsis, pneumonia, urinary tract infection, deep wound infection), febrile patients without bacterial infection (FNI group), and patients without fever (NF group). In all, 121 children were enrolled in the study, 31 in the FWI group, 42 in the FNI group, and 48 patients in the NF group. Ages ranged from 4 days to 17.8 years (median 19.0, mean 46 ± 56 months). There was no significant difference among the groups in mean CRP level before surgery, 1 hour, and 18 hours after. A highly significant interaction was found in the change in CRP over time by FWI group compared with FNI group (P < .001). Mean CRP velocity ([fCRP - 18hCRP]/[fever time (days) - 0.75 day]) was significantly higher in the infectious group (4.0 ± 4.2 mg/dL per d) than in the fever-only group (0.60 ± 1.6 mg/dL per d; P < .001). A CRP velocity of 4 mg/dL per d had a positive predictive value (PPV) of 85.7% for bacterial infection with 95.2% specificity. Serial measurements of CRP/CRP velocity after cardiac surgery in children may assist clinicians in differentiating postoperative fever due to bacterial infection from fever due to noninfectious origin.
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Affiliation(s)
- Elhanan Nahum
- Pediatric Critical Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
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Crespo-Marcos D, Rey-Galán C, López-Herce-Cid J, Crespo-Hernández M, Concha-Torre A, Pérez-Solís D. [Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery]. An Pediatr (Barc) 2011; 73:162-8. [PMID: 20621577 DOI: 10.1016/j.anpedi.2010.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 05/17/2010] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES The systemic inflammatory response syndrome developed after cardiac surgery impedes the detection of complications. The aim of our study was to examine the behaviour of C-reactive protein (CRP) and procalcitonin (PCT), as well as to evaluate its relationship with severity and to analyse its usefulness in the identification of complications. METHODS A total of 59 children who underwent cardiac surgery with cardiopulmonary bypass were prospectively studied. CRP and PCT were determined after surgery and at 24, 48 and 72 hours. The relationships between both parameters and the clinical severity were analysed (evaluated with PRISM and TISS scoring systems), as well as with the incidence of complications (infectious and haemodynamics). RESULTS Serum concentrations of CRP and PCT increased in the first 24 hours after surgery, with a gradual decrease over the following days. There was no association between CRP and severity or development of complications. A moderate correlation was observed between PCT after surgery, at 24 and 48 hours, and PRISM (r=0.548; 0.434 and 0.446) and a low correlation between PCT and TISS. When studying the identification of complications, we obtained cut-off values of PCT>0.17ng/ml (Ss 73.3%; Sp 72.2%) and PCT>1.98ng/ml (Ss 57.1%; Sp 87%) immediately and 48 hours after surgery. No differences were found in CPR and PCT levels among patients with infectious and haemodynamics complications. CONCLUSIONS CPR does not correlate with the severity or the incidence of complications after paediatric cardiac surgery. PCT correlates with clinical severity and may be able to detect post-surgical complications.
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Abstract
Sepsis is a clinical syndrome defined by physiologic changes indicative of systemic inflammation, which are likely attributable to documented or suspected infection. Septic shock is the progression of those physiologic changes to the extent that delivery of oxygen and metabolic substrate to tissues is compromised. Biomarkers have the potential to diagnose, monitor, stratify and predict outcome in these syndromes. C-reactive protein is elevated in inflammatory and infectious conditions and has long been used as a biomarker indicating infection. Procalcitonin has more recently been shown to better distinguish infection from inflammation. Newer candidate biomarkers for infection include IL-18 and CD64. Lactate facilitates the diagnosis of septic shock and the monitoring of its progression. Multiple stratification biomarkers based on genome-wide expression profiling are under active investigation and present exciting future possibilities.
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Affiliation(s)
- Stephen W Standage
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Allan CK, Newburger JW, McGrath E, Elder J, Psoinos C, Laussen PC, del Nido PJ, Wypij D, McGowan FX. The relationship between inflammatory activation and clinical outcome after infant cardiopulmonary bypass. Anesth Analg 2010; 111:1244-51. [PMID: 20829561 DOI: 10.1213/ane.0b013e3181f333aa] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) induces a systemic inflammatory response. The magnitude and consequences in infants remain unclear. We assessed the relationship between inflammatory state and clinical outcomes in infants undergoing CPB. METHODS Plasma concentrations of interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor α, IL-1β, and C-reactive protein (CRP) were measured pre-CPB and immediately post-CPB, and at 6, 12, and 24 hours post-CPB in infants ≤9 months old. Perioperative clinical data were collected prospectively. RESULTS Diagnoses of 93 patients included transposition of the great arteries (40), tetralogy of Fallot (28), ventricular septal defect (21), truncus arteriosus (2), and complete atrioventricular canal (2). The median age was 37 days (range = 2 to 264). Pre-CPB IL-6 and CRP were higher in younger infants but were not associated with postoperative inflammatory mediator concentrations or measured clinical outcomes. IL-6 increased post-CPB (median 3.2 pg/mL pre-CPB, 24.2 post-CPB, 95.4 at 6 hours, and 90.3 at 24 hours; all P < 0.001). CRP increased post-CPB, peaking at 24 hours (median 27.5 at 24 hours, 0.3 pre-CPB; P < 0.001). IL-10 and IL-8 increased immediately post-CPB. After adjusting for age and diagnosis, postoperative IL-6 and IL-8 correlated with intensive care unit length of stay and postoperative blood product administration and, for IL-8, 24-hour lactate. CONCLUSIONS Greater preoperative cytokine and CRP production in younger infants did not correlate with postoperative outcomes; correlation between postoperative inflammatory mediator production and clinical course was statistically significant but clinically modest. We conclude that in infants undergoing low-to-moderate-complexity cardiac surgery in a single high-volume center, the contribution of inflammatory mediator production to postoperative morbidity is relatively limited.
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Affiliation(s)
- Catherine K Allan
- Department of Cardiology, Children's Hospital, Boston, MA 02115, USA.
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Prat C, Ricart P, Ruyra X, Domínguez J, Morillas J, Blanco S, Tomasa T, Torres T, Cámara L, Molinos S, Ausina V. Serum concentrations of procalcitonin after cardiac surgery. J Card Surg 2009; 23:627-32. [PMID: 19016986 DOI: 10.1111/j.1540-8191.2008.00658.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Monitoring of complications in patients undergoing cardiac surgery may be difficult because cardiopulmonary bypass (CPB) can lead to a systemic inflammatory response syndrome because of exposure of blood to nonphysiological surfaces. The purpose of the study was to establish the baseline levels of procalcitonin (PCT) after cardiac surgery in our population in order to analyze a possible induction of the inflammatory response that might interfere with the diagnosis of infection by PCT. METHODS Serum samples from patients undergoing coronary artery bypass grafting or valve replacement were collected at the time of admission to intensive care unit, after surgery as well as in the first and second postoperative days. Patients were followed for the development of postoperative complications. PCT levels were measured by immunoluminometric assay. RESULTS The mean PCT values were significantly higher in the first postoperative day in all the groups except the control group. No increased PCT levels were found related neither to duration of CPB, nor to time of aortic clamping. Only patients who presented complications had significantly increased PCT values immediately after surgery (p = 0.004), in the first postoperative day (p < 0.0001), and in the second postoperative day (p < 0.0001) with respect to those who recovered uneventfully. CONCLUSIONS A slight and transient increase in PCT levels was observed in the first postoperative day after cardiac surgery. Significant elevation of PCT was only observed when complications were present.
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Affiliation(s)
- Cristina Prat
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
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Procalcitonin versus C-reactive protein and immature-to-total neutrophil ratio as markers of infection after cardiopulmonary bypass in children. Pediatr Crit Care Med 2009; 10:217-21. [PMID: 19057447 DOI: 10.1097/pcc.0b013e31819369f3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To document concentrations of procalcitonin (PCT), C-reactive protein (CRP), and immature-to-total neutrophil ratio (ITR), postcardiopulmonary bypass (CPB), and to test the hypothesis that PCT is a more reliable marker of infection than CRP or ITR in the post-CPB child. DESIGN Prospective cohort study. SETTING Pediatric intensive care units at Royal Children's Hospital, Melbourne, Australia and Birmingham Children's Hospital, UK. PATIENTS First stage: 283 post-CPB children; second stage: 65 post-CPB children with suspected infection. INTERVENTIONS In the first stage, PCT, ITR, and CRP were measured serially on the first, second, third, and fifth postoperative day (POD). In the second stage, PCT, ITR, and CRP were measured in the specimens taken in the period before and after the clinical diagnosis of infection. MEASUREMENTS AND MAIN RESULTS In children without infection, the median peak PCT concentration more than 5 PODs was 1.0 ng/mL, in children with local infection 1.0 ng/mL, and in children with definite sepsis 14.8 ng/mL. CRP increased in all subgroups of children studied, reaching a peak on POD 3 (median 51 mg/L). In definite sepsis, CRP was increased more than the other subgroups. ITR remained high with a median of 0.08 from POD 1 and gradually decreased, except in definite sepsis, where it remained high. In a receiver operating characteristic curve analysis, PCT was the most reliable variable for the diagnosis of probable/definite sepsis with area under the curve 0.84 (95% confidence interval, 0.75-0.92) compared with 0.73 (0.62-0.84) for ITR and 0.62 (0.52-0.73) for CRP. CONCLUSIONS CRP was a poor marker of sepsis in this study. Children with a PCT <2.2 ng/mL or ITR <0.08 were unlikely to have definite or probable sepsis. However, only a third of children with high values of PCT and ITR had definite or probable sepsis.
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Corral L, Carrió ML, Ventura JL, Torrado H, Javierre C, Rodriguez-Castro D, Farrero E, Valero J, Ortiz D. Is C-reactive protein a biomarker for immediate clinical outcome after cardiac surgery? J Cardiothorac Vasc Anesth 2009; 23:166-9. [PMID: 19201207 DOI: 10.1053/j.jvca.2008.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the possible correlation between inflammatory activation after cardiac surgery with cardiopulmonary bypass, measured by postoperative C-reactive protein concentrations, and immediate intensive care unit outcome. DESIGN A prospective, clinical cohort study. SETTING A 10-bed surgical intensive care unit at a tertiary university hospital. PATIENTS Two hundred sixteen consecutive patients undergoing nonemergency cardiac surgery with cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS Parsonnet and Acute Physiology and Chronic Health Evaluation scores, characteristics of the surgical intervention, intensive care unit length of stay, and mortality were recorded along with the following variables: cardiac (hours requiring inotropic support and new atrial fibrillation), respiratory (oxygenation index and hours requiring intubation), renal (difference between serum creatinine at admission and maximum creatinine), and analytic (C-reactive protein at admission and 6, 24, and 48 hours later; troponin I; CK-MB; and lactate). RESULTS Postoperative C-reactive protein concentrations did not correlate with variables such as time requiring inotropic support or intubation, oxygenation index, delta serum creatinine, and intensive care unit length of stay (with the exception of cardiopulmonary bypass time and the more frequent norepinephrine requirement in patients with higher C-reactive protein concentration at 48 hours); nor did C-reactive protein correlate with the analytic variables (with the exception of the lactate peak and C-reactive protein concentrations at 24 and 48 hours). There was no correlation between C-reactive protein and postoperative variables for coronary artery bypass graft surgery and valvular groups analyzed separately. CONCLUSION Postoperative C-reactive protein does not seem to be a useful marker in predicting outcome after 48 hours in the intensive care unit.
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Affiliation(s)
- Luisa Corral
- Department of Intensive Care, Hospital Universitari de Bellvitge, Barcelona, Spain
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Madershahian N, Wittwer T, Strauch J, Wippermann J, Rahmanian P, Franke UF, Wahlers T. Kinetic of Procalcitonin in the Early Postoperative Course Following Heart Transplantation. J Card Surg 2008; 23:468-73. [DOI: 10.1111/j.1540-8191.2008.00625.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Forsberg JA, Elster EA, Andersen RC, Nylen E, Brown TS, Rose MW, Stojadinovic A, Becker KL, McGuigan FX. Correlation of procalcitonin and cytokine expression with dehiscence of wartime extremity wounds. J Bone Joint Surg Am 2008; 90:580-8. [PMID: 18310708 DOI: 10.2106/jbjs.g.00265] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite technological advances in the treatment of severe extremity trauma, the timing of wound closure remains the subjective clinical decision of the treating surgeon. Traditional serum markers are poor predictors of wound-healing. The objective of this study was to evaluate the cytokine and chemokine profiles of severe extremity wounds prior to closure to determine if wound effluent markers can be used to predict healing. METHODS Serum and effluent (exudate) samples were collected prospectively from adult volunteers with multiple high-energy penetrating extremity wounds sustained during military combat. Samples were collected prior to definitive wound closure or flap coverage. Wounds were followed clinically for six weeks. The primary clinical outcome measures were wound-healing and dehiscence. Control serum samples were collected from normal age and sex-matched adult volunteers. All samples were analyzed for the following cytokines and chemokines: procalcitonin; eotaxin; granulocyte macrophage colony stimulating factor; interferon (IFN)-gamma; interleukin (IL)-1 through 8, 10, 12, 13, and 15; IFN-gamma inducible protein-10; monocyte chemotactic protein-1; macrophage inflammatory protein-1alpha; the protein regulated on activation, normal T expressed and secreted (RANTES); and tumor necrosis factor (TNF)-alpha. RESULTS Fifty wounds were analyzed in twenty patients. Four of the fifty wounds dehisced. An increased rate of wound dehiscence was observed in patients with a concomitant closed head injury as well as in those with an associated arterial injury of the affected limb (p < 0.05). Among the serum chemokines and cytokines, only serum procalcitonin levels correlated with wound dehiscence (p < 0.05). Effluent analysis showed that, compared with wounds that healed, wounds that dehisced were associated with elevated procalcitonin, decreased RANTES protein, and decreased IL-13 concentrations (p < 0.05). No wound with an effluent procalcitonin concentration of <220 pg/mL, an IL-13 concentration of >12 pg/mL, or a RANTES protein concentration of >1000 pg/mL failed to heal. CONCLUSIONS Effluent procalcitonin, IL-13, and RANTES protein levels as well as serum procalcitonin levels correlate with wound dehiscence following closure of severe open extremity wounds. These preliminary results indicate that effluent biomarker analysis may be an objective means of determining the timing of traumatic wound closure.
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Affiliation(s)
- Jonathan Agner Forsberg
- Department of Orthopaedic Surgery, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
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Chastre J, Luyt CE, Trouillet JL, Combes A. New diagnostic and prognostic markers of ventilator-associated pneumonia. Curr Opin Crit Care 2006; 12:446-51. [PMID: 16943724 DOI: 10.1097/01.ccx.0000244125.46871.44] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to analyze the potential advantages and drawbacks of using biomarkers of bacterial infection for the diagnosis and prognosis of ventilator-associated pneumonia. RECENT FINDINGS Whereas procalcitonin and soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) have both greater diagnostic accuracies than most commonly used clinical parameters and other biomarkers of infection, such as C-reactive protein, they can be increased in noninfectious conditions or remain low in patients with true infection. Furthermore, these assays cannot determine the causative organisms and associated patterns of antibiotic susceptibility. SUMMARY Procalcitonin and sTREM-1 should be used only as a complementary tool, to reinforce the usual diagnostic work-up. However, serial serum procalcitonin and sTREM-1 measurements may provide an opportunity to change the treatment early in the course of patients with ventilator-associated pneumonia, either to intensify treatment when their levels stay high, or to avoid unnecessary prolonged courses of antibiotics when their levels rapidly decrease. Whether procalcitonin and/or sTREM-1 guidance can reduce antibiotic use in such a setting will require additional studies, but such a strategy appears promising.
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Affiliation(s)
- Jean Chastre
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Pierre and Marie Curie University, Paris, France.
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Celebi S, Koner O, Menda F, Balci H, Hatemi A, Korkut K, Esen F. Procalcitonin kinetics in pediatric patients with systemic inflammatory response after open heart surgery. Intensive Care Med 2006; 32:881-7. [PMID: 16715328 DOI: 10.1007/s00134-006-0180-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 03/31/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate procalcitonin and C-reactive protein as markers of inflammation severity and their value in predicting development of organ failure after pediatric open heart surgery. DESIGN Prospective, observational, clinical study. SETTING Single university hospital. PATIENTS Thirty-three pediatric patients with systemic inflammatory response syndrome (SIRS; n=19) and SIRS+organ failure (SIRS+OF; n=14) following open heart surgery were included. MEASUREMENTS AND RESULTS Plasma procalcitonin and C-reactive protein levels were measured before and after the operation, and 1, 2, 3, and 4 days after surgery. Patients were evaluated daily to assess organ failure. Postoperative procalcitonin levels in the SIRS+OF group were significantly higher than in the SIRS group. C-reactive protein levels were similar between the groups throughout the study period. Peak procalcitonin levels were found to be positively correlated with aortic cross-clamp and cardiopulmonary bypass times, duration of mechanical ventilation, intensive care unit and hospital stay, mortality and organ failure development. Peak procalcitonin was found to be a good predictor of postoperative organ failure development and mortality. However, the predictive value of peak C-reactive protein for organ failure and mortality was found to be weak. Double-peak procalcitonin curves were observed in SIRS+OF patients with infection during the intensive care unit stay. CONCLUSION In the SIRS+OF group peak procalcitonin levels were found to be highly predictive for mortality and organ failure development, whereas C-reactive protein levels were not. Daily procalcitonin measurements in SIRS+OF patients may help identify the postoperative infection during the follow-up period.
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Affiliation(s)
- Serdar Celebi
- Istanbul University, Cardiology Institute, Anesthesiology and Intensive Care Department, Istanbul, Turkey.
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Arkader R, Troster EJ, Lopes MR, Júnior RR, Carcillo JA, Leone C, Okay TS. Procalcitonin does discriminate between sepsis and systemic inflammatory response syndrome. Arch Dis Child 2006; 91:117-20. [PMID: 16326799 PMCID: PMC2082702 DOI: 10.1136/adc.2005.077446] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS To evaluate whether procalcitonin (PCT) and C reactive protein (CRP) are able to discriminate between sepsis and systemic inflammatory response syndrome (SIRS) in critically ill children. METHODS Prospective, observational study in a paediatric intensive care unit. Kinetics of PCT and CRP were studied in patients undergoing open heart surgery with cardiopulmonary bypass (CPB) (SIRS model; group I1) and patients with confirmed bacterial sepsis (group II). RESULTS In group I, PCT median concentration was 0.24 ng/ml (reference value <2.0 ng/ml). There was an increment of PCT concentrations which peaked immediately after CPB (median 0.58 ng/ml), then decreased to 0.47 ng/ml at 24 h; 0.33 ng/ml at 48 h, and 0.22 ng/ml at 72 h. CRP median concentrations remained high on POD1 (36.6 mg/l) and POD2 (13.0 mg/l). In group II, PCT concentrations were high at admission (median 9.15 ng/ml) and subsequently decreased in 11/14 patients who progressed favourably (median 0.31 ng/ml). CRP levels were high in only 11/14 patients at admission. CRP remained high in 13/14 patients at 24 h; in 12/14 at 48 h; and in 10/14 patients at 72 h. Median values were 95.0, 50.9, 86.0, and 20.3 mg/l, respectively. The area under the ROC curve was 0.99 for PCT and 0.54 for CRP. Cut off concentrations to differentiate SIRS from sepsis were >2 ng/ml for PCT and >79 mg/l for CRP. CONCLUSION PCT is able to differentiate between SIRS and sepsis while CRP is not. Moreover, unlike CRP, PCT concentrations varied with the evolution of sepsis.
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Affiliation(s)
- R Arkader
- Laboratory of Medical Investigation-LIM/36-Department of Pediatrics, School of Medicine, University of São Paulo, Brazil
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Sponholz C, Sakr Y, Reinhart K, Brunkhorst F. Diagnostic value and prognostic implications of serum procalcitonin after cardiac surgery: a systematic review of the literature. Crit Care 2006; 10:R145. [PMID: 17038199 PMCID: PMC1751067 DOI: 10.1186/cc5067] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Revised: 09/24/2006] [Accepted: 10/13/2006] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Systemic inflammatory response syndrome is common after surgery, and it can be difficult to discriminate between infection and inflammation. We performed a review of the literature with the aims of describing the evolution of serum procalcitonin (PCT) levels after uncomplicated cardiac surgery, characterising the role of PCT as a tool in discriminating infection, identifying the relation between PCT, organ failure, and severity of sepsis syndromes, and assessing the possible role of PCT in detection of postoperative complications and mortality. METHODS We performed a search on MEDLINE using the keyword 'procalcitonin' crossed with 'cardiac surgery,' 'heart,' 'postoperative,' and 'transplantation.' Our search was limited to human studies published between January 1990 and June 2006. RESULTS Uncomplicated cardiac surgery induces a postoperative increase in serum PCT levels. Peak PCT levels are reached within 24 hours postoperatively and return to normal levels within the first week. This increase seems to be dependent on the surgical procedure and on intraoperative events. Although PCT values reported in infected patients are generally higher than in non-infected patients after cardiac surgery, the cutoff point for discriminating infection ranges from 1 to 5 ng/ml, and the dynamics of PCT levels over time may be more important than absolute values. PCT is superior to C-reactive protein in discriminating infections in this setting. PCT levels are higher with increased severity of sepsis and the presence of organ dysfunction/failure and in patients with a poor outcome or in those who develop postoperative complications. PCT levels typically remain unchanged after acute rejection but increase markedly after bacterial and fungal infections. Systemic infections are associated with greater PCT elevation than is local infection. Viral infections are difficult to identify based on PCT measurements. CONCLUSION The dynamics of PCT levels, rather than absolute values, could be important in identifying patients with infectious complications after cardiac surgery. PCT is useful in differentiating acute graft rejection after heart and/or lung transplantation from bacterial and fungal infections. Further studies are needed to define cutoff points and to incorporate PCT levels in useful prediction models.
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Affiliation(s)
- Christoph Sponholz
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University, Erlanger Allee 103, 07743 Jena, Germany
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University, Erlanger Allee 103, 07743 Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University, Erlanger Allee 103, 07743 Jena, Germany
| | - Frank Brunkhorst
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University, Erlanger Allee 103, 07743 Jena, Germany
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