[C-reactive protein as a marker of mortality in intensive care unit]

A combination of C-reactive protein and quick sequential organ failure assessment (qSOFA) score has better prognostic accuracy than qSOFA alone in patients with complicated intra-abdominal infections

INTRODUCTION

Complicated intra-abdominal infections (cIAIs) remain a serious challenge because of their unacceptably high mortality rates. Among different prognostic scoring systems quick-sequential organ failure assessment (qSOFA) score is the most recent. However, as mortality predictor in surgical patients, qSOFA showed lack of sensitivity. The aim of this study was to find prognostic superiority of our new qSOFA-CRP score in patients with cIAIs.

MATERIALS AND METHODS

We retrospectively analyzed 78 patients presented to ED and admitted to Department of Surgical Diseases between January 2017 and October 2018 with diagnosis cIAIs. CRP levels, qSOFA score and systemic inflammatory response syndrome (SIRS) were established at admission. We analyzed area under receiver operating characteristics (AUROC) curves of SIRS, qSOFA and qSOFA-CRP and performed a comparison to explore their prognostic values.

RESULTS

The identified in-hospital mortality was 25.6%. qSOFA-CRP score showed the best prognostic performance compared to qSOFA alone (AUROC = 0.818 vs. 0.746, p = .0219) and SIRS (AUROC = 0.818 vs. 0.579, p = .0009). The new qSOFA-CRP score ≥2 points showed excellent specificity (91.4%) and the highest sensitivity in comparison to qSOFA ≥2 and SIRS ≥2 (60% vs. 35% vs. 40%) for mortality prediction.

CONCLUSIONS

qSOFA-CRP score showed better prognostic value than quick-SOFA alone in patients with cIAIs.

C-Reactive Protein in the Prediction of Localization of Gastrointestinal Perforation

AIM

Information regarding the localization of the anatomic site of gastrointestinal (GI) tract perforation is essential for the following surgical procedure. The purpose of this study was to evaluate the significance of C-reactive protein (CRP) and other circulating markers for the prediction of the localization of intra-abdominal hollow organ perforation.

METHODS

Measurements of serum markers were analyzed in 423 patients with GI tract perforations, who were divided according to the intraoperative diagnosis into colorectal and upper GI tract perforation groups.

RESULTS

Levels of CRP were higher in patients with colorectal perforations than in upper GI tract perforations (p < 0.001). Moreover, high levels of CRP were associated with increased mortality of patients with hollow organ perforations (p = 0.009), which was largely driven by the subset of patients with perforations of the upper GI tract (p = 0.001).

CONCLUSION

Increased CRP levels predict worse clinical outcome in patients with intra-abdominal hollow organ perforations and are associated with perforations in the colorectal tract. Thus, CRP might be a useful marker for preoperative risk stratification and prediction of the localization of the perforation site.

Role of leucocytes cell population data in the early detection of sepsis

AIMS

The cell population data (CPD) parameters reported by XN analyser (Sysmex, Kobe, Japan) reflect the size and internal structure of leucocytes. We aimed to assess the clinical utility of these parameters as biomarkers for the early diagnosis of sepsis.

METHODS

The study group (G1) included 586 controls (no quantitative or morphological alterations in the complete blood count) and 137 patients diagnosed with sepsis. The reliability of the model was evaluated using a validation group (G2) of 212 controls and 60 patients with sepsis. The optimal cut-off for the diagnosis of sepsis and the OR for CPD were established using a univariate logistic regression. A multivariate logistic regression model was then created. The OR and area under the curve were recorded. A risk stratification scale (neutrophils and monocytes (NEMO)) for diagnosing sepsis was established on the basis of the coefficients of the multivariate model.

RESULTS

MO-X and neutrophils fluorescence intensity (NE-SFL) were found to be the most relevant of the CPD in predicting sepsis applying multivariate analysis to G1.NEMO score was composed using the above-mentioned CPD and subsequently stratified into three risk groups: mild (≤3), moderate (4≤NEMO≤5) and high (≥6). The OR for patients with a score of 4-5 was 10 and 249 for a score of ≥6. When applied to G2, the positive predictive value was 84.8 % and the negative predictive value was 96.0%.

CONCLUSIONS

CPD are potentially useful for the early diagnosis of sepsis. Their values were used to compose in NEMO score can help in rapid and reliable decision making.

Predictors of mortality of severe sepsis among adult patients in the medical Intensive Care Unit

Background:

Sepsis is an important cause of mortality in the Intensive Care Units (ICUs) worldwide. Information regarding early predictive factors for mortality and morbidity is limited.

Aims and Objectives:

The primary objective of the study was to estimate the mortality of severe sepsis among adult patients admitted into the medical ICU. The secondary objective was to identify the predictors associated with mortality.

Materials and Methods:

Adult patients admitted with severe sepsis in the medical ICU were studied. The primary outcome was the mortality among the study population. Baseline demographic, clinical, and laboratory data were recorded upon inclusion into the study. Risk factors associated with mortality were studied by univariate analysis. The variables having statistical significance were further included in multivariate analysis to identify the independent predictors of mortality.

Results:

Out of eighty patients, 54 (67.5%) died. Univariate analysis showed that age >60 years, tachycardia, hypotension, elevated C-reactive protein (CRP) and lactate, thrombocytopenia, need of mechanical ventilation, and high Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment scores were variables associated with high mortality. The independent predictors of mortality identified by multivariate regression analysis were platelet count below 1 lakhs, serum levels of CRP >100, APACHE II score >25 on the day of admission to the ICU with severe sepsis, and the need for invasive mechanical ventilation.

Conclusions:

Low platelet count, elevated serum levels of CRP, APACHE score >25, and the need for invasive mechanical ventilation were found to be independent predictors of mortality of severe sepsis among adult patients with severe sepsis in the medical ICU.

Coupled Plasma Filtration and Adsorption (CPFA): A Single Center Experience

Background

Coupled plasma filtration adsorption (CPFA) is a novel extracorporeal blood purification therapy for sepsis which adsorbs both proinflammatory and anti-inflammatory mediators from filtered plasma, thereby achieving early haemodynamic stability and a reduction in inotropic support requirement.

Objectives

The main objective was to review our centers' experience with CPFA in septic patients.

Patients and Methods

A retrospective chart review of all septic patients who received CPFA was performed. All patients were initially treated according to the ‘surviving sepsis care bundle’ with fluid resuscitation, antibiotics, and inotropes as required. CPFA was started as soon as possible after a nephrologists’ assessment.

Results

Twenty five patients with sepsis received CPFA (15 M, 10 F, mean age 49.60 ± 18.97 years). Comorbidities included hypertension (n = 10, 40%), diabetes mellitus (n = 6, 24%), ischemic heart disease (n = 6, 24%), and an immunosuppressed state (n = 10, 40%). All patients received one cycle of CPFA with median duration of 5 (1-10) hours. CPFA was well tolerated but we encountered technical problems, especially filter clotting as CPFA was performed heparin free. 14 (56%) patients died within 28 days of treatment. CRP correlated with PCT (P = 0.040) and had an inverse trend with albumin (P = 0.066). Serum albumin was a strong predictor of mortality.

Conclusions

The high prevalence of fungaemia and mortality could be attributed to many patients on chronic immunosuppressive therapy. Nonetheless, CPFA albeit expensive, does add to our armamentarium of extracorporeal treatment for severe sepsis. Regional citrate anticoagulation with CPFA may overcome problems with filter clotting.

The role of C-reactive protein and the SOFA score as parameter for clinical decision making in surgical patients during the intensive care unit course

Introduction

C-reactive Protein (CRP) is used next to clinical scoring systems to recognize critically ill patients prone to develop complications on the Intensive Care Unit (ICU). The purpose of this study is to assess the predictive value of CRP as parameter for clinical deterioration and/or clinical decision making as ordering diagnostic procedures or performing (re)interventions. Also, we wanted to determine the value of CRP in early detection of surgical complications in the critically ill general surgical patient in the ICU and its interpretation in adjunct to a clinical scoring system, the Sequential Organ Failure Assessment Score.

Materials and Methods

In our prospective observational study, 174 general surgical patients admitted into the Intensive Care Unit were included. We evaluated the Sequential Organ Failure Assessment Score (SOFA) and daily measured the C-reactive protein (CRP) concentrations. All events (diagnostic or therapeutic interventions) and surgical complications were registered. Then the relationship between SOFA score, CRP concentrations, events and complications were studied.

Results

Each 10% increase in CRP resulted in a 3.5% increase in the odds of an event (odds ratio 1.035, 95% CI: 1.004–1.068; p = 0.028). However, an increase in CRP levels did not lead to a higher odds of complication (OR 0.983, 95% CI: 0.932–1.036; p = 0.52). When adjusting for the SOFA score the effect of CRP on the probability of a first event remained significant (OR 1.033, 95% CI: 1.001–1.065; p = 0.046), and again did not significantly affect the complication probability (OR 0.980, 95% CI: 0.929–1.035; p = 0.46).

Conclusions

An increase in C-reactive protein is a poor parameter for early detection of complications in the critically ill surgical patient in the ICU by means of diagnostic procedures or therapeutic (re)-interventions.

C-reactive protein as a predictor of mortality in patients affected with severe sepsis in intensive care unit

BACKGROUND

Severe sepsis is a primary cause of morbidity and mortality in the intensive care unit (ICU). Numerous biomarkers have been assessed to predict outcome and CRP is widely used. However, the relevance for mortality risk of the CRP level and the day when it is measured have not been well studied. We aimed to assess whether initial and/or third dayCRP values are as good predictors of mortality in ICU patients with severe sepsis as other well-known complex predictors of mortality, i.e., SOFA scores.

METHODS

An observational cohort study was performed in a 20-bed respiratory ICU in a chest disease center. Patients with severe sepsis due to respiratory disease were enrolled in the study. SOFA scores, CRP values on admission and on the third day of hospital stay, and mortality rate were recorded. ROC curves for SOFA scores and CRP values were calculated.

RESULTS

The study included 314 ICU patients with sepsis admitted between January 2009 and March 2010. The mortality rate was 14.2% (n = 45). The area under the curve (AUC) for CRP values and SOFA scores on admission and on the 3rd day in ICU were calculated as 0.57 (CI: 0.48-0.66); 0.72 (CI: 0.63-0.80); 0.72 (CI: 0.64-0.81); and 0.76 (CI: 0.67-0.86), respectively. Sepsis due to nosocomial infection, a CRP value > 100 mg/L and higher SOFA scores on 3rd day, were found to be risk factors for mortality (odds ratio [OR]: 3.76, confidence interval [CI]: 1.68-8.40, p < 0.001, OR: 2.70, CI: 1.41-2.01, p < 0.013, and OR: 1.68, CI: 1.41-2.01, p < 0.0001, respectively).

CONCLUSIONS

The risk of sepsis related mortality appears to be increased when the 3rd day CRP value is greater than 100 mg/dL. Thus, CRP appears to be as valuable a predictor of mortality as the SOFA score.

[Usefulness of procalcitonin upon admission to intensive care in the diagnosis and prognosis of sepsis]

OBJECTIVE

To assess the usefulness of procalcitonin (PCT) upon admission to the Intensive Care Unit (ICU) in the diagnosis and prognosis of sepsis

DESIGN

A 12-month prospective observational cohort study was carried out

SETTING

An 11-bed polyvalent ICU Belonging to a University hospital

PATIENTS

Fifty patients with systemic inflammatory response syndrome (SIRS) were included. The mean age of the patients was 51.66 years, and 68% of them were males

VARIABLES OF INTEREST

Upon admission, the concentration of PCT and C-reactive protein (CRP) was assessed. At discharge, the final diagnosis and outcome were reviewed

RESULTS

Thirty-six patients had sepsis. Mean PCT ± SD was higher in sepsis than in non-infectious SIRS (19.3 ± 4.9 vs. 0.65 ± 0.2) ng/ml) (P=.001). PCT had greater discriminating power than CRP (AUC 0.932 vs. 0.827). The cut-off value of PCT for the diagnosis of sepsis was 0.92 ng/dl, with a sensitivity of 80.56%, specificity 85.71%, positive predictive value 93.55% and negative predictive value 63.16%, LR+ 5.64 and LR- 0.23. Mortality was higher in patients with sepsis (52.78% vs. 21.43%) (P=.039). Mean PCT ± SD upon admission among survivors and deceased patients with sepsis was 18.7 ± 6.7 and 19.5 ± 7.5 ng/ml, respectively (P=.934).

CONCLUSIONS

PCT upon admission to the ICU is useful for the diagnosis of sepsis, and is more effective than PCR in this respect. However, it is of no help in estimating the short-term prognosis.