Significance of leukocytosis after cardiac device implantation

Significance of leukocytosis prior to cardiac device implantation

INTRODUCTION

Infection remains a dreaded complication after cardiac implanted electronic device (CIED) placement. The prognostic value of the preoperative white blood cell (WBC) count, in the absence of other signs of infection, at time of CIED placement as a predictor of postoperative infection, has not been previously examined.

METHODS

The study population included 1,247 consecutive device implantations over a 4-year period that met inclusion criteria. The association between preoperative WBC count and resultant infection postoperatively was examined. Early infection was defined as definite infection of the pocket or lead system or development of systemic infection identified <60 days after implantation. Preoperative WBC counts were obtained within 48 hours of the procedure.

RESULTS

Baseline characteristics of the population studied were mean age of 65 years, 66% men, and 72% Caucasian. Pacemakers, implantable cardioverter defibrillators (ICDs), and biventricular ICDs were implanted in 41%, 44%, and 15%, respectively. Average procedure time was 174 minutes ± 80. Of 1,247 device implantations, there were 10 infections (0.8%). Mean preprocedure WBC count in those diagnosed with infection was 8.1 × 10³ /uL (range 5-11.7) and in those without infection was 7.8 × 10(3)/uL (range 2.3-29) (P = 0.73). Cases resulting in infection demonstrated minimal change in WBC count (mean +5.5 ± 26.5%). There was no statistically significant difference in preprocedure WBC count between the two groups (P = 0.7). Regardless of preprocedural WBC, no patients had other signs and symptoms of infection at time of device implantation.

CONCLUSION

As an isolated finding, an elevated preprocedure WBC should not delay the implantation of an indicated device.

Preoperative asymptomatic leukocytosis and postoperative outcome in cardiac surgery patients

BACKGROUND

Despite showing a prognostic value in general surgical patients, preoperative asymptomatic elevated white blood cell (WBC) count is not considered a risk factor for cardiac surgery. Whereas there is sporadic evidence of its value as a preoperative risk marker, it has not been looked at methodically as a specific index of outcome during cardiac surgery. Using a national database we sought to determine the relationship between preoperative WBC count and postoperative outcome in cardiac surgical patients.

METHODS

Cardiac surgeries were extracted from the 2007-2013 American College of Surgeons National Surgical Quality Improvement Program database. Leukocytosis was defined by a preoperative WBC count greater than 11,000 cells/μL. A univariate analysis compared the incidence of adverse outcomes for patients with and without leukocytosis. A multivariate logistic regression model was constructed in order to test whether leukocytosis was an independent predictor of morbidity and mortality.

RESULTS

Out of a total of 10,979 cardiac surgery patients 863 (7.8%) had preoperative leukocytosis. On univariate analysis, patients with leukocytosis experienced greater incidences of 30-day mortality, wound complications, and medical complications. Wound complications included surgical site infection as well as wound dehiscence. The medical complications included all other non-surgical causes of increased morbidity and infection leading to urinary tract infection, pneumonia, ventilator dependence, sepsis and septic shock. After stepwise model adjustment, leukocytosis was a strong predictor of medical complications (OR 1.22, 95% CI: 1.09-1.36, p = 0.002) with c-statistic of 0.667. However, after stepwise model adjustment leukocytosis was not a significant predictor of 30-day mortality and wound complications.

CONCLUSION

Preoperative leukocytosis is associated with adverse postoperative outcome after cardiac surgery and is an independent predictor of infection-related postoperative complications.

Postoperative leukocyte changes in facial fracture patients: a randomized prospective study with short-term dexamethasone

PURPOSE

We investigated leukocyte changes in facial fracture patients undergoing surgery. Of specific interest was the effect of perioperative dexamethasone on leukocyte changes.

METHODS

Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone, whereas patients in the control group received no glucocorticoid. All patients received antibiotics until postoperative days 7-10. Leukocyte count was measured on postoperative days 1 and 2. Clinical infections were observed during the follow-up.

RESULTS

A total of 110 adult patients were included in the study. Postoperative leukocytosis was found in 91.2% of patients receiving dexamethasone and in 67.9% of controls. Dexamethasone was associated strongly with leukocyte rise (p < 0.001) on both postoperative days. Transoral surgery and younger age (≤40 years) showed significant associations with leukocytosis on the first postoperative day (p = 0.002). In regression analyses, dexamethasone associated with leukocytosis most significantly (p < 0.001). No association was found with infections.

CONCLUSIONS

Dexamethasone use was the most significant predictor of leukocyte rise. As a drug response, perioperative dexamethasone caused sixfold postoperative leukocytosis. High-dose dexamethasone-induced leukocytosis may confuse the clinical decision-making especially in assessment of early infections.

Biomarker-based diagnosis of pacemaker and implantable cardioverter defibrillator pocket infections: A prospective, multicentre, case-control evaluation

Background

The use of cardiac implantable electronic devices (CIED) has risen steadily, yet the rate of cardiac device infections (CDI) has disproportionately increased. Amongst all cardiac device infections, the pocket infection is the most challenging diagnosis. Therefore, we aimed to improve diagnosis of such pocket infection by identifying relevant biomarkers.

Methods

We enrolled 25 consecutive patients with invasively and microbiologically confirmed pocket infection. None of the patients had any confounding conditions. Pre-operative levels of 14 biomarkers were compared in infected and control (n = 50) patients. Our selected biomarkers included white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), lipopolysaccharide binding protein, high-sensitivity C-reactive protein (HS-CRP), polymorphonuclear-elastase, presepsin, various interleukins, tumor necrosis factor α (TNF-α), and granulocyte macrophage colony-stimulating factor (GM-CSF).

Results

Of the 25 patients with isolated pocket infection (70±13years, 76% male, 40% ICDs), none presented with leukocytosis. In contrast, they had higher serum levels of HS-CRP (p = 0.019) and PCT (p = 0.010) than control patients. Median PCT-level was 0.06 ng/mL (IQR 0.03–0.07 ng/mL) in the study group versus 0.03 ng/mL (IQR 0.02–0.04 ng/mL) in controls. An optimized PCT cut-off value of 0.05 ng/mL suggests pocket infection with a sensitivity of 60% and specificity of 82%. In addition TNF-α- and GM-CSF-levels were lower in the study group. Other biomarkers did not differ between groups.

Conclusion

Diagnosis of isolated pocket infections requires clinical awareness, physical examination, evaluation of blood cultures and echocardiography assessment. Nevertheless, measurement of PCT- and HS-CRP-levels can aid diagnosis. However, no conclusion can be drawn from normal WBC-values.

Clinical trial registration

clinicaltrials.gov identifier: NCT01619267

Postpercutaneous Nephrolithotomy Systemic Inflammatory Response Syndrome Is Not Associated With Unplanned Readmission

OBJECTIVE

To investigate the incidence of systemic inflammatory response syndrome (SIRS) following percutaneous nephrolithotomy (PCNL) and evaluate any association with unplanned 90-day readmission.

METHODS

We retrospectively reviewed consecutive patients undergoing PCNL in 2 dedicated endourologic practices between 2009 and 2013. We collected patient demographics, perioperative culture data, and operative characteristics. SIRS was defined as having 2 or more of the following: maximum white blood cell count >12,000 or <4000, temperature >38 or <34°C, heart rate >90, and respiratory rate >20 within the first 24 hours following PCNL. Proportions between groups were compared to identify significant associations.

RESULTS

We identified 389 patients undergoing PCNL and 43% (167 of 389) met SIRS criteria, more commonly in patients with multiple PCNL accesses (OR 2.3; CI: 1.1-4.8, P = .025). Readmission was required in 8% (31 of 389), most commonly for infection (n = 21). Although possession of a struvite stone was associated with unplanned readmission (16% vs 4%, P < .01), SIRS in the absence of fever within 48 hours postoperative was not associated with readmission (29.4% vs 25.8%, P = .837).

CONCLUSION

Nearly half of the patients undergoing PCNL met the criteria for SIRS within the first postoperative day. There was no association between SIRS and unplanned readmission in the postoperative PCNL patient. Despite discharge during the first postoperative day, patients with SIRS (without fever or struvite stones) had no increased risk for unplanned return. Our findings suggest that the development of SIRS immediately following PCNL does not preclude safe discharge on the first postoperative day.