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Tiozzo C, Mukhopadhyay S. Noninfectious influencers of early-onset sepsis biomarkers. Pediatr Res 2022; 91:425-431. [PMID: 34802035 PMCID: PMC8818022 DOI: 10.1038/s41390-021-01861-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 01/21/2023]
Abstract
Diagnostic tests for sepsis aim to either detect the infectious agent (such as microbiological cultures) or detect host markers that commonly change in response to an infection (such as C-reactive protein). The latter category of tests has advantages compared to culture-based methods, including a quick turnaround time and in some cases lower requirements for blood samples. They also provide information on the immune response of the host, a critical determinant of clinical outcome. However, they do not always differentiate nonspecific host inflammation from true infection and can inadvertently lead to antibiotic overuse. Multiple noninfectious conditions unique to neonates in the first days after birth can lead to inflammatory marker profiles that mimic those seen among infected infants. Our goal was to review noninfectious conditions and patient characteristics that alter host inflammatory markers commonly used for the diagnosis of early-onset sepsis. Recognizing these conditions can focus the use of biomarkers on patients most likely to benefit while avoiding scenarios that promote false positives. We highlight approaches that may improve biomarker performance and emphasize the need to use patient outcomes, in addition to conventional diagnostic performance analysis, to establish clinical utility.
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Affiliation(s)
- Caterina Tiozzo
- Division of Neonatology, Department of Pediatrics, New York University, Langone Health, New York City, New York, United States
| | - Sagori Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. .,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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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: 86] [Impact Index Per Article: 17.2] [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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Bobillo-Perez S, Rodríguez-Fanjul J, Jordan Garcia I. Is Procalcitonin Useful in Pediatric Critical Care Patients? Biomark Insights 2018; 13:1177271918792244. [PMID: 30093797 PMCID: PMC6081751 DOI: 10.1177/1177271918792244] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/11/2018] [Indexed: 12/11/2022] Open
Abstract
This review examines the use of procalcitonin in different clinical situations in the pediatric patient, with special emphasis on those requiring intensive care. We review the latest articles on its potency as a biomarker in both infectious processes at diagnosis and on the response to treatment.
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Affiliation(s)
- Sara Bobillo-Perez
- Pediatric Intensive Care Unit Service, Research Group of the Pediatric Critical Patient, Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Déu 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 Garcia
- Pediatric Intensive Care Unit, Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, CIBERESP, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
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Bobillo S, Rodríguez-Fanjul J, Solé A, Moreno J, Balaguer M, Esteban E, Cambra FJ, Jordan I. Kinetics of Procalcitonin in Pediatric Patients on Extracorporeal Membrane Oxygenation. Biomark Insights 2018; 13:1177271917751900. [PMID: 29343939 PMCID: PMC5764148 DOI: 10.1177/1177271917751900] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/11/2017] [Indexed: 11/27/2022] Open
Abstract
Objectives: To assess the kinetics of procalcitonin (PCT) and C-reactive protein (CRP) in pediatric patients who required extracorporeal membrane oxygenation (ECMO) and to analyze its relationship with morbidity and mortality. Patients and methods: Prospective observational study including pediatric patients who required ECMO. Both PCT and CRP were sequentially drawn before ECMO (P0) and until 72 hours after ECMO. Results: A total of 40 patients were recruited. Two cohorts were established based on the value of the P0 PCT (>10 ng/mL). Comparing the kinetics of PCT and CRP in these cohorts, the described curves were the expected for each clinical situation. The cutoff for P0 PCT to predict multiple organ dysfunction syndrome was 2.55 ng/mL (sensibility 83%, specificity 100%). Both PCT and CRP did not predict risk of neurologic sequelae or mortality in any group. Conclusions: Procalcitonin does not seem to be modified by ECMO and could be a good biomarker of evolution.
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Affiliation(s)
- Sara Bobillo
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
| | - Javier Rodríguez-Fanjul
- Neonatal Intensive Care Unit Service, Maternal, Fetal and Neonatology Center Barcelona (BCNatal), Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
| | - Anna Solé
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
| | - Julio Moreno
- Neonatal Intensive Care Unit Service, Maternal, Fetal and Neonatology Center Barcelona (BCNatal), Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
| | - Mònica Balaguer
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
| | - Elisabeth Esteban
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
| | - Francisco José Cambra
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit, Paediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu, CIBERESP, Barcelona, Spain
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Yuki K, Matsunami E, Tazawa K, Wang W, DiNardo JA, Koutsogiannaki S. Pediatric Perioperative Stress Responses and Anesthesia. TRANSLATIONAL PERIOPERATIVE AND PAIN MEDICINE 2017; 2:1-12. [PMID: 28217718 PMCID: PMC5310630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Surgical stress responses cause an array of endocrinological, metabolic and immunological changes in patients. The landmark studies in the 1980s showed that adequate anesthesia dramatically improved the outcomes of pediatric surgical patients by attenuating stress hormonal responses, pointing out the harm of 'inadequate' anesthesia. Subsequent studies questioned the role of administering very high-dose anesthetics to further attenuate stress responses. Here we review the feature of surgical stress responses in pediatric patients including their difference from those in adult patients. Overall, pediatric patients show minimal or no resting energy expenditure change postoperatively. In adult patients, increased resting energy expenditure has been described. Pediatric patients demonstrated robust cortisol and catecholamine responses than adult patients. However, the duration of these surges is often short-lived. Systemic proinflammatory and anti-inflammatory cytokine levels have been measured. Pediatric patients showed less proinflammatory cytokine elevation, but had similar anti-antiinflamatory responses. We also review in detail the immunological changes in response to surgical stress. Based on our current knowledge, we attempted to understand the underlying mechanism how adequate anesthesia dramatically improved the outcome of patients. Although more work is needed to be done, understanding how pediatric patients respond to perioperative stress, and its mechanism and consequence will allow us to direct us into a better, perioperative management in this population.
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Affiliation(s)
- Koichi Yuki
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - Erika Matsunami
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - Kazumasa Tazawa
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - Wei Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - James A. DiNardo
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - Sophia Koutsogiannaki
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
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Orth K, Knoefel WT, van Griensven M, Matuschek C, Peiper M, Schrumpf H, Gerber PA, Budach W, Bölke E, Buhren BA, Schauer M. Preventively enteral application of immunoglobulin enriched colostrums milk can modulate postoperative inflammatory response. Eur J Med Res 2013; 18:50. [PMID: 24266958 PMCID: PMC3879091 DOI: 10.1186/2047-783x-18-50] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 11/11/2013] [Indexed: 12/12/2022] Open
Abstract
Several studies demonstrated acute inflammatory response following traumatic injury. Inflammatory response during surgical interventions was verified by a significant increase of endotoxin plasma levels and a decrease of the endotoxin neutralizing capacity (ENC). However, the incidence of elevated endotoxin levels was significantly higher (89%) than detected bacterial translocation (35%). Thus parts or products of Gram-negative bacteria seem to translocate more easily into the blood circulation than whole bacteria. Along with the bacterial translocation, the inflammatory response correlated directly with the severity of the surgical intervention. In comparison after major and minor surgery Interleukin-6 (IL-6) and C-reactive protein (CRP) was also significantly different. Similar effects in mediator release were shown during endovascular stent graft placement and open surgery in infrarenal aortic aneurysm. Open surgery demonstrated a significant stronger endotoxin translocation and a decrease of ENC. Strategies to prevent translocation seem to be sensible. Colostrum is the first milk produced by the mammary glands within the first days after birth. It contains a complex system of immune factors and has a long history of use in traditional medicine. Placebo-controlled studies verified that prophylactic oral application of immunoglobulin-enriched colostrum milk preparation diminishes perioperative endotoxemia, prevents reduction of ENC and reduces postoperative CRP-levels, suggesting a stabilization of the gut barrier. This effect may be caused by immunoglobulin transportation by the neonatal receptor FcRn of the mucosal epithelium.In conclusion, there is an association of perioperative endotoxemia and the subsequent increase in mediators of the acute phase reaction in surgical patients. A prophylactic oral application of colostrum milk is likely to stabilize the gut barrier i.e. reduces the influx of lipopolysaccharides arising from Gram-negative bacterial pathogens and inhibits enterogenic endotoxemia. This appears to be a major mechanism underlying the therapeutic effect in patients at risk for Gram-negative septic shock.
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Affiliation(s)
- Klaus Orth
- Medical Faculty, Department of General, Visceral, and Thoracal Surgery, Asclepios Harz Hospitals, Goslar, Germany
| | - Wolfram Trudo Knoefel
- Medical Faculty, Department of General, Visceral-, and Pediatric Surgery, Heinrich Heine Universität Düsseldorf, Germany University of Düsseldorf, Dusseldorf, Germany
| | - Martijn van Griensven
- Department of Trauma Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Christiane Matuschek
- Medical Faculty Department of Radiation Oncology, Heinrich Heine Universität Düsseldorf, Germany University of Düsseldorf, Moorenstrasse 5, Duesseldorf D-40225, Germany
| | - Matthias Peiper
- Medical Faculty, Department of General, Visceral, and Thoracal Surgery, Asclepios Harz Hospitals, Goslar, Germany
- Klinik für Allgemein-, Viszeral-, Gefäß- und Unfallchirurgie, Krankenhaus St. Joseph. Propsteistr. 2, Essen-Werden 45239, Germany
| | - Holger Schrumpf
- Medical Faculty Department of Dermatology, Heinrich Heine Universität Düsseldorf, Germany University of Düsseldorf, Dusseldorf, Germany
| | - Peter Arne Gerber
- Medical Faculty Department of Dermatology, Heinrich Heine Universität Düsseldorf, Germany University of Düsseldorf, Dusseldorf, Germany
| | - Wilfried Budach
- Medical Faculty Department of Radiation Oncology, Heinrich Heine Universität Düsseldorf, Germany University of Düsseldorf, Moorenstrasse 5, Duesseldorf D-40225, Germany
| | - Edwin Bölke
- Medical Faculty Department of Radiation Oncology, Heinrich Heine Universität Düsseldorf, Germany University of Düsseldorf, Moorenstrasse 5, Duesseldorf D-40225, Germany
| | - Bettina Alexandra Buhren
- Medical Faculty Department of Dermatology, Heinrich Heine Universität Düsseldorf, Germany University of Düsseldorf, Dusseldorf, Germany
| | - Matthias Schauer
- Medical Faculty, Department of General, Visceral-, and Pediatric Surgery, Heinrich Heine Universität Düsseldorf, Germany University of Düsseldorf, Dusseldorf, Germany
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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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A clinic-biological score for diagnosing early-onset neonatal infection in critically ill preterm infants. Pediatr Crit Care Med 2011; 12:203-9. [PMID: 20495505 DOI: 10.1097/pcc.0b013e3181e2a53b] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify the best combination of serum cytokines and clinical parameters to diagnose rapidly early-onset neonatal infection (EONI) in critically ill preterm infants. At birth, most critically ill neonates are receiving broad-spectrum antibiotics pending bacterial culture results, because distinguishing infected from noninfected infants at birth is difficult. DESIGN Prospective study. SETTING Neonatal intensive care unit in a tertiary care hospital. PATIENTS Two hundred thirteen infants, born before 33 wks' gestation, admitted to the neonatal intensive care unit within 6 hrs of life with a presumptive diagnosis of EONI. INTERVENTION A presumptive diagnosis of EONI was associated with a 300-μL blood sample to measure six cytokine (interleukin [IL]-1β, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor-α) concentrations, using the cytometric bead array technique. MEASUREMENTS AND MAIN RESULTS Of the 213 infants included, 31 had a definite or possible EONI and 182 were not infected. Concentrations of IL-6, IL-8, and IL-10 were significantly increased in infected neonates, in comparison with infants without EONI. In contrast, IL-1β, IL-12, and tumor necrosis factor-α concentrations were not. Logistic regression analyses were performed to construct multivariate predictive models that could distinguish infected from noninfected infants at birth. A clinical score was based on three parameters independently associated with EONI (i.e., interval of >12 hrs between the membranes rupture and delivery, prenatal maternal colonization and mechanical ventilation at birth). This score was compared with scores including clinical parameters and serum cytokines, alone or in combination. The best predictive model combined the three clinical parameters, IL-6 (positive threshold, 300 pg/mL) and IL-8 (positive threshold, 300 pg/mL) concentrations. CONCLUSION A predictive model combining serum IL-6 and IL-8 measurements and selected clinical variables could distinguish infected from noninfected preterm infants at birth and should help the clinician in reducing or shortening the unnecessary use of antibiotics.
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Hamrick SEG, Strickland MJ, Shapira SK, Autry A, Schendel D. Use of special education services among children with and without congenital gastrointestinal anomalies. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2010; 115:421-432. [PMID: 20687825 DOI: 10.1352/1944-7558-115-5.421] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Our objective was to evaluate the relationship between congenital gastrointestinal anomalies requiring neonatal surgery and neurodevelopmental outcome. Among the children born in metropolitan Atlanta during 1982-2001 who survived to age 1 year (N = 762,824), we identified children with congenital gastrointestinal anomalies via linkage with the Metropolitan Atlanta Congenital Defects Program and children who received special education services via linkage with the Special Education Database of Metropolitan Atlanta. Several modest increases in special education service use were observed among children with isolated congenital gastrointestinal anomalies; no association was statistically significant. Among children with Hirschsprung disease, gastroschisis, esophageal atresia, intestinal malrotation, bowel atresia, or imperforate anus who had multiple anomalies, we observed statistically significant increases in special education service use.
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Affiliation(s)
- Shannon E G Hamrick
- Emory University School of Medicine, Division of Neonatology, Atlanta, GA 30322, USA.
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Sbragia L, Schmidt AF, Moraes S, Bittencourt DG, Gonçalves FLL, Pereira LAVD, Velloso LA. Inflammatory response in a rat model of gastroschisis is associated with an increase of NF-kappaB. ACTA ACUST UNITED AC 2010; 43:160-5. [PMID: 20098844 DOI: 10.1590/s0100-879x2010005000005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 12/17/2009] [Indexed: 11/22/2022]
Abstract
Babies with gastroschisis have high morbidity, which is associated with inflammatory bowel injury caused by exposure to amniotic fluid. The objective of this study was to identify components of the inflammatory response in the intestine and liver in an experimental model of gastroschisis in rats. The model was surgically created at 18.5 days of gestation. The fetuses were exposed through a hysterotomy and an incision at the right of the umbilicus was made, exposing the fetal bowel. Then, the fetus was placed back into the uterus until term. The bowel in this model had macro- and microscopic characteristics similar to those observed in gastroschisis. The study was conducted on three groups of 20 fetuses each: gastroschisis, control, and sham fetuses. Fetal body, intestine and liver weights and intestine length were measured. IL-1beta, IL-6, IL-10, TNF-alpha, IFN-gamma and NF-kappaB levels were assessed by ELISA. Data were analyzed statistically by ANOVA followed by the Tukey post-test. Gastroschisis fetuses had a decreased intestine length (means +/- SD, 125 +/- 25 vs 216 +/- 13.9; P < 0.005) and increased intestine weight (0.29 +/- 0.05 vs 0.24 +/- 0.04; P < 0.005). Intestine length correlated with liver weight only in gastroschisis fetuses (Pearson's correlation coefficient, r = 0.518, P = 0.019). There were no significant differences in the concentrations of IL-1beta, TNF-alpha or IFN-gamma in the intestine, whereas the concentration of NF-kappaB was increased in both the intestine and liver of fetuses with gastroschisis. These results show that the inflammatory response in the liver and intestine of the rat model of gastroschisis is accompanied by an increase in the amount of NF-kappaB in the intestine and liver.
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Affiliation(s)
- L Sbragia
- Disciplina de Cirurgia Pediátrica, Departamento de Cirurgia, Universidade Estadual de Campinas, SP, Brasil.
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Rao SC, Pirie S, Minutillo C, Gollow I, Dickinson JE, Jacoby P. Ward reduction of gastroschisis in a single stage without general anaesthesia may increase the risk of short-term morbidities: results of a retrospective audit. J Paediatr Child Health 2009; 45:384-8. [PMID: 19490405 DOI: 10.1111/j.1440-1754.2009.01505.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ward reduction of gastroschisis in a single stage without the need for general inhalational anaesthesia (ward reduction) has been reported by some authors to be effective and safe. We introduced this practice to our neonatal unit 2 years ago. AIM To compare the short-term outcomes of this new practice with the standard procedure of reduction under general anaesthesia (GA). METHODS Retrospective case series of all infants with gastroschisis between January 2004 and January 2008. RESULTS Twenty-seven infants were managed with the traditional approach and 11 infants underwent ward reduction without GA. Infants in the ward reduction group had an increased frequency for all the three major adverse events (ischemic necrosis of bowel: 27.3% vs. 3.7%, odds ratio (OR) 10.72, 95% confidence interval (CI): 0.72, 159.6; need for total parenteral nutrition (TPN) more than 60 days: 18% vs. 3.7%, OR 4.13, 95% CI: 0.28, 61.55; and unplanned return to theatre: 27.3% vs. 7.4%, OR 3.88, 95% CI: 0.44, 34.08), although none of these events reached statistical significance. There were no significant differences between the groups for the outcomes of time to reach full feeds, duration of hospital stay and number of days on antibiotics. CONCLUSIONS These results raise concerns over the role of ward reduction of gastroschisis in a single sitting without the use of GA. Randomised trials with appropriate design and sample size are needed before embracing this method as a standard practice.
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Affiliation(s)
- Shripada C Rao
- Department of Neonatology, King Edward Memorial Hospital for Women, Western Australia, Australia.
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Pavcnik-Arnol M, Hojker S, Derganc M. Lipopolysaccharide-binding protein, lipopolysaccharide, and soluble CD14 in sepsis of critically ill neonates and children. Intensive Care Med 2007; 33:1025-32. [PMID: 17410342 DOI: 10.1007/s00134-007-0626-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Accepted: 03/12/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the diagnostic accuracy of lipopolysaccharide-binding protein (LBP) for sepsis in critically ill neonates and children with the two markers participating in the same inflammatory pathway, lipopolysaccharide and soluble CD14. DESIGN AND SETTING Prospective, observational study in a multidisciplinary neonatal and pediatric intensive care unit. PATIENTS 47 critically ill neonates and 49 critically ill children with systemic inflammatory response syndrome (SIRS) and suspected sepsis, classified into two groups: those with and those without sepsis. INTERVENTIONS Serum LBP, lipopolysaccharide, soluble CD14, C-reactive protein, and procalcitonin were measured on 2 consecutive days. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and predictive values were evaluated. RESULTS AUC for LBP on the first day of suspected infection was 0.97 in neonates aged under 48 h, 0.93 in neonates over 48 h and 0.82 in children. AUCs for lipopolysaccharide and soluble CD14 were 0.77 and 0.74 in neonates under 48 h, 0.53 and 0.76 in neonates over 48 h, and 0.72 and 0.53 in children. AUCs for procalcitonin and C-reactive protein were 0.65 and 0.89 in neonates under 48 h, 0.65 and 0.91 in neonates over 48 h, and 0.76 and 0.69 in children. CONCLUSIONS In critically ill neonates and children LBP concentration on the first day of suspected sepsis is a better marker of sepsis than lipopolysaccharide, soluble CD14, procalcitonin, and in neonates younger than 48 h and children, also a better marker than C-reactive protein. Lipopolysaccharide and soluble CD14 are not suitable markers for the differentiation of infectious and noninfectious SIRS.
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Affiliation(s)
- Maja Pavcnik-Arnol
- University Medical Center Ljubljana, Department of Pediatric Surgery and Intensive Care, Zaloska 7, 1525 Ljubljana, Slovenia.
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Alcaraz AJ, Manzano L, Sancho L, Vigil MD, Esquivel F, Maroto E, Reyes E, Alvarez-Mon M. Different Proinflammatory Cytokine Serum Pattern in Neonate Patients Undergoing Open Heart Surgery. Relevance of IL-8. J Clin Immunol 2005; 25:238-45. [PMID: 15981089 DOI: 10.1007/s10875-005-4081-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Accepted: 12/29/2004] [Indexed: 11/30/2022]
Abstract
The purpose of this work was to investigate the clinical significance of serum levels of proinflammatory cytokines in pediatric patients undergoing cardiopulmonary bypass. We divided the patients in two groups: 8 neonates, and 19 non-newborn children. IL-1beta, IL-6, IL-8, and TNF serum levels were quantified before sternotomy, at admission to the PICU (30 min postoperatively), 24 h after the onset of surgery and 3 days after the operation. Surgical cardiac stress elicits significant increments of IL-6, IL-8 and TNF serum concentrations in both neonates and non-neonates, regardless of their preoperative clinical condition. However, in newborns the magnitude of the proinflammatory cytokine increments was, in particular with IL-8, remarkably greater than in older children. Moreover, neonate and non-neonate patients showed clearly disparate patterns of serum concentrations over time of both IL-8 and TNF. There was a marked relationship between IL-8 levels and postoperative morbidity, evaluated by pulmonary dysfunction, days on inotropic support and days of PICU stay in both neonates and non-neonates patients. In contrast, we found no relationship between serum levels of IL-6 and TNF and postoperative clinical data. Newborn and non-newborn patients undergoing cardiopulmonary bypass exhibit dissimilar patterns of proinflammatory cytokines. IL-8 might be implicated in the multiorganic dysfunction related to cardiopulmonary bypass in pediatric patients.
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Affiliation(s)
- A J Alcaraz
- Departamento de Pediatría y Cirugía Pediátrica, Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Gitto E, Romeo C, Reiter RJ, Impellizzeri P, Pesce S, Basile M, Antonuccio P, Trimarchi G, Gentile C, Barberi I, Zuccarello B. Melatonin reduces oxidative stress in surgical neonates. J Pediatr Surg 2004; 39:184-9; discussion 184-9. [PMID: 14966737 DOI: 10.1016/j.jpedsurg.2003.10.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE Cytokines are inflammatory mediators found in the circulation after surgery. Newborns have less protection against oxidation and are very susceptible to free radical oxidative damage. Melatonin has been reported recently to reduce oxidative stress in neonates with sepsis, asphyxia, and respiratory distress. The aim of this study has been to determine if melatonin would lower interleukin (IL)-6, IL-8, tumor necrosis factor alpha (TNF-alpha) and nitrite/nitrate (NOx) levels and modify serum inflammation parameters, improving the clinical course of surgical neonates. METHODS Ten newborns (group 1), 5 with surgical malformations and respiratory distress (group 1a) and 5 with isolated abdominal surgical malformations (group 1b) received a total of 10 doses of melatonin (10 mg/kg) at defined times interval for 72 hours. The treatment was started within 3 hours after the end of surgery. Ten surgical neonates (group 2), did not receive melatonin. Twenty healthy neonates (group 3) served as control. Blood samples were collected at the end of operation; before treatment with the antioxidant; and 24 hours 72 hours, and 7 days after start of treatment with melatonin or placebo, respectively. RESULTS Postoperative value of cytokines and NOx levels of groups 1 and 2 were significantly higher than group 3. Compared with group 1b, group 2 displayed significantly higher cytokines and NOx levels at 24 hours, 72 hours, and at 7 days. In group 1a the immediate postoperative values of cytokines were significantly higher than group 1b and group 2, but a significant improvement was observed after administration of melatonin with significantly lower levels of IL-6 and IL-8 with respect to group 2. An improvement of clinical outcome was observed by progressive reduction of clinical parameters of inflammation. CONCLUSIONS Melatonin reduces cytokines and NOx levels showing potent antioxidant properties with improvement in clinical outcome. Further studies are warranted to define, on larger numbers, the role of melatonin in surgical patients.
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Affiliation(s)
- E Gitto
- Department of Medical and Surgical Pediatric Sciences, Neonatal Intensive Care Unit, University of Messina, Messina, Italy
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Belik J, Davidge ST, Zhang W, Pan J, Greer JJ. Airway smooth muscle changes in the nitrofen-induced congenital diaphragmatic hernia rat model. Pediatr Res 2003; 53:737-43. [PMID: 12612200 DOI: 10.1203/01.pdr.0000057986.74037.7b] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In the fetal rat, nitrofen induces congenital diaphragmatic hernia (CDH) and pulmonary vascular remodeling similar to what is observed in the human condition. Airway hyperactivity is common in infants with CDH and attributed to the ventilator-induced airway damage. The purpose of this study was to test the hypothesis that airway smooth muscle mechanical properties are altered in the nitrofen-induced CDH rat model. Lungs from nitrofen-exposed fetuses with hernias (CDH) or intact diaphragm (nitrofen) and untreated fetuses (control) were studied on gestation d 21. The left intrapulmonary artery and bronchi were removed and mounted on a wire myograph, and lung expression, content, and immunolocalization of cyclooxygenases COX-1 and COX-2 were evaluated. Pulmonary artery muscle in the CDH group had significantly (p < 0.01) lower force generation compared with control and nitrofen groups. In contrast, the same generation bronchial smooth muscle of the CDH and nitrofen groups developed higher force compared with control. Whereas no differences were found in endothelium-dependent pulmonary vascular muscle tone, the epithelium-dependent airway muscle relaxation was significantly decreased (p < 0.01) in the CDH and nitrofen groups. The lung mRNA levels of COX-1 and COX-2 were increased in the CDH and nitrofen groups. COX-1 vascular and airway immunostaining, as well as COX-1 and COX-2 lung protein content, were increased in the CDH group. This is the first report of airway smooth muscle abnormalities in the nitrofen-induced fetal rat model of CDH. We speculate that congenital airway muscle changes may be present in the human form of this disease.
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MESH Headings
- 15-Hydroxy-11 alpha,9 alpha-(epoxymethano)prosta-5,13-dienoic Acid/pharmacology
- Acetylcholine/pharmacology
- Airway Obstruction/congenital
- Airway Obstruction/physiopathology
- Animals
- Cyclooxygenase 1
- Cyclooxygenase 2
- Disease Models, Animal
- Female
- Hernia, Diaphragmatic/chemically induced
- Hernia, Diaphragmatic/physiopathology
- Hernias, Diaphragmatic, Congenital
- Isoenzymes/genetics
- Isoenzymes/metabolism
- Membrane Proteins
- Muscle, Smooth/drug effects
- Muscle, Smooth/physiology
- Muscle, Smooth/physiopathology
- Pesticides
- Phenyl Ethers
- Potassium Chloride/pharmacology
- Pregnancy
- Prostaglandin-Endoperoxide Synthases/genetics
- Prostaglandin-Endoperoxide Synthases/metabolism
- Pulmonary Artery/physiology
- RNA, Messenger/analysis
- Rats
- Rats, Sprague-Dawley
- Vasoconstrictor Agents/pharmacology
- Vasodilator Agents/pharmacology
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Affiliation(s)
- Jaques Belik
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Ontario, Canada.
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Update on Anti-Endotoxin Therapies. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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