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Mesolella M, Allosso S, Petruzzi G, Evangelista A, Motta G, Motta G. Procalcitonin for Early Detection of Pharyngocutaneous Fistula after Total Laryngectomy: A Pilot Study. Cancers (Basel) 2024; 16:768. [PMID: 38398159 PMCID: PMC10886710 DOI: 10.3390/cancers16040768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES The aim of this prospective study was to investigate the role of procalcitonin as an early diagnostic marker of pharyngocutaneous fistula (PCF) in a cohort of head and neck patients treated with total laryngectomy for squamous cell carcinoma. METHODS This prospective study was conducted on a sample of patients enrolled from January 2019 to March 2022. All patients were subjected to a "protocol" of blood chemistry investigations, scheduled as follows: complete blood count with formula, ESR dosage, CPR, and PCT. PCT was also dosed by salivary sampling and a pharyngo-cutaneous swab in patients who presented with PCF. The dosage scheme was systematically repeated: the day before the intervention (t0); the 5th day postoperative (t1); the 20th day postoperative (t2); and at time X, the day of the eventual appearance of the pharyngocutaneous fistula. RESULTS A total of 36 patients met the inclusion criteria. The patients enrolled in the study were subsequently divided into two groups: 27 patients underwent total laryngectomy (TL) for laryngeal cancer without postoperative complications, and 9 patients were undergoing TL with postoperative PCF. Using the Cochran's Q test, statistical significance was found for PCT among T0, T1, Tx, and T2 (p-value < 0.001) between the PCF and non-PCF groups. The Z test demonstrated that there is a difference in PCT levels at T1 and T2 and that this difference is statistically significant (p < 0.001). CONCLUSIONS PCT could be considered an early marker of complications in open laryngeal surgery. According to our results, it could be useful in the precocious detection of pharyngocutaneous fistulas and in the management of antibiotic therapy.
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Affiliation(s)
- Massimo Mesolella
- Unit of Otorhinolaryngology, Department of Neuroscience, Reproductive Sciences and Dentistry, University Federico II of Naples, 80131 Naples, Italy
| | - Salvatore Allosso
- Unit of Otorhinolaryngology, Department of Neuroscience, Reproductive Sciences and Dentistry, University Federico II of Naples, 80131 Naples, Italy
| | - Gerardo Petruzzi
- Department of Otolaryngology—Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy;
| | | | - Giovanni Motta
- Unit of Otorhinolaryngology, Department of Mental and Physical Health and Preventive Medicine, University Luigi Vanvitelli, 80131 Naples, Italy; (G.M.); (G.M.)
| | - Gaetano Motta
- Unit of Otorhinolaryngology, Department of Mental and Physical Health and Preventive Medicine, University Luigi Vanvitelli, 80131 Naples, Italy; (G.M.); (G.M.)
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Al Hussan M, Qiao S, Abuheit EMI, Abdun MA, Al Mahamid M, Guo H, Zheng F, Nobah AMAM. The Role of C-reactive Protein and Procalcitonin in Predicting the Occurrence of Pancreatic Fistula in Patients who Underwent Laparoscopic Pancreaticoduodenectomy: a Retrospective Study. Zentralbl Chir 2023; 148:508-515. [PMID: 37798903 DOI: 10.1055/a-2157-7550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
The occurrence of postoperative pancreatic fistula following laparoscopic pancreaticoduodenectomy (LPD) is a significant concern, yet there is currently a lack of consensus on reliable predictive methods for this complication. Therefore, the aim of this study was to assess the clinical significance of C-reactive protein (CRP) and procalcitonin (PCT) values and their reliability in early predicting the development of clinically relevant pancreatic fistula (CRPF) following LPD.A retrospective analysis was conducted using data from 120 patients who had LPD between September 2019 and December 2021. Preoperative assessment data, standard patients' demographic and clinicopathological characteristics, intra- and postoperative evaluation, as well as postoperative laboratory values on postoperative days (PODs) 1, 3, and 7, including white blood cells (WBCs), CRP, and PCT, were prospectively recorded on a dedicated database. Two clinicians separately collected and cross-checked all of the data.Among 120 patients [77 men (64%), 43 women (36%], CRPF occurred in 15 patients (11 grade B and 4 grade C fistulas). The incidence rate of CRPF was 12.3%. A comparison of the median values of WBCs, PCT, and CRP across the two groups revealed that the CRPF group had higher values on most PODs than the non-CRPF group. Receiver operating characteristic (ROC) analysis was used to calculate the area under the curve (AUC) and cutoff values. It was discovered that POD 3 has the most accurate and significant values for WBCs, CRP, and PCT. According to the ROC plots, the AUC for WBCs was 0.842, whereas the AUC for PCT was 0.909. As for CRP, the AUC was 0.941 (95% CI 0.899-0.983, p < 0.01) with a cutoff value of 203.45, indicating a sensitivity of 93.3% and specificity of 91.4%.Both CRP and PCT can be used to predict the early onset of CRPF following LPD, with CRP being slightly superior on POD 3.
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Affiliation(s)
- Maher Al Hussan
- Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou City, China
| | - Shishi Qiao
- Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou City, China
| | - Ezaldin M I Abuheit
- Cardiovascular Department, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mohammed Awadh Abdun
- Hepatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou City, China
| | - Mohamad Al Mahamid
- Hepatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou City, China
| | - Huahu Guo
- Hepatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou City, China
| | - Fengyu Zheng
- Hepatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou City, China
| | - Ali Mansour Ali Mi Nobah
- Cardiovascular Department, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Tian BWCA, Agnoletti V, Ansaloni L, Coccolini F, Bravi F, Sartelli M, Vallicelli C, Catena F. Management of Intra-Abdominal Infections: The Role of Procalcitonin. Antibiotics (Basel) 2023; 12:1406. [PMID: 37760703 PMCID: PMC10525176 DOI: 10.3390/antibiotics12091406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.
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Affiliation(s)
- Brian W. C. A. Tian
- Department of General Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore;
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, M. Bufalini Hospital, 47521 Cesena, Italy
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, 27100 Pavia, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, 56126 Pisa, Italy
| | | | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Carlo Vallicelli
- Department of Emergency and Trauma Surgery, M. Bufalini Hospital, 47521 Cesena, Italy
| | - Fausto Catena
- Department of Surgery, “Maurizio Bufalini” Hospital, 47521 Cesena, Italy
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Frick K, Beller EA, Kalisvaart M, Dutkowski P, Schüpbach RA, Klinzing S. Procalcitonin in early allograft dysfunction after orthotopic liver transplantation: a retrospective single centre study. BMC Gastroenterol 2022; 22:404. [PMID: 36045337 PMCID: PMC9429388 DOI: 10.1186/s12876-022-02486-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/16/2022] [Indexed: 11/11/2022] Open
Abstract
Background Ischemia–reperfusion injury (IRI) is the pathophysiological hallmark of hepatic dysfunction after orthotopic liver transplantation (OLT). Related to IRI, early allograft dysfunction (EAD) after OLT affects short- and long-term outcome. During inflammatory states, the liver seems to be the main source of procalcitonin (PCT), which has been shown to increase independently of bacterial infection. This study investigates the association of PCT, IRI and EAD as well as the predictive value of PCT during the first postoperative week in terms of short- and long-term outcome after OLT. Methods Patients ≥ 18 years undergoing OLT between January 2016 and April 2020 at the University Hospital of Zurich were eligible for this retrospective study. Patients with incomplete PCT data on postoperative days (POD) 1 + 2 or combined liver-kidney transplantation were excluded. The PCT course during the first postoperative week, its association with EAD, defined by the criteria of Olthoff, and IRI, defined as aminotransferase level > 2000 IU/L within 2 PODs, were analysed. Finally, 90-day as well as 12-month graft and patient survival were assessed. Results Of 234 patients undergoing OLT, 110 patients were included. Overall, EAD and IRI patients had significantly higher median PCT values on POD 2 [31.3 (9.7–53.8) mcg/l vs. 11.1 (5.3–25.0) mcg/l; p < 0.001 and 27.7 (9.7–51.9) mcg/l vs. 11.5 (5.5–25.2) mcg/l; p < 0.001] and impaired 90-day graft survival (79.2% vs. 95.2%; p = 0.01 and 80.4% vs. 93.8%; p = 0.033). IRI patients with PCT < 15 mcg/l on POD 2 had reduced 90-day graft and patient survival (57.9% vs. 93.8%; p = 0.001 and 68.4% vs. 93.8%; p = 0.008) as well as impaired 12-month graft and patient survival (57.9% vs. 96.3%; p = 0.001 and 68.4% vs. 96.3%; p = 0.008), while the outcome of IRI patients with PCT > 15 mcg/l on POD 2 was comparable to that of patients without IRI/EAD. Conclusion Generally, PCT is increased in the early postoperative phase after OLT. Patients with EAD and IRI have a significantly increased PCT maximum on POD 2, and impaired 90-day graft survival. PCT measurement may have potential as an additional outcome predictor in the early phase after OLT, as in our subanalysis of IRI patients, PCT values < 15 mcg/l were associated with impaired outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02486-5.
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Mikkelsen G, Lillebo B, Faxvaag A. Disease-associated reference intervals for twenty laboratory tests in patients with rheumatoid arthritis, Crohn's disease or ulcerative colitis. Pract Lab Med 2021; 25:e00225. [PMID: 34095413 PMCID: PMC8145736 DOI: 10.1016/j.plabm.2021.e00225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 04/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Population based reference intervals are fundamental for interpreting results for quantitative laboratory tests. In patients with a specific chronic disorder, however, results of various tests may regularly be different than in healthy individuals. Health-associated reference intervals may therefore have limited value in such patients. Instead, disease-associated reference intervals may be useful, as they describe the results distribution in populations resembling the specific patients. Few disease-associated reference intervals are available in the literature. The aim of this study was to estimate reference intervals for common laboratory tests for patient populations with rheumatoid arthritis, Crohn's disease or ulcerative colitis without significant comorbidity, using a novel algorithm. MATERIAL AND METHODS Laboratory test results and hospital discharge diagnoses were collected for relevant patients. An algorithm was developed to identify discharge diagnoses significantly associated with high or low results for specific tests. After excluding patients with such diagnoses, reference intervals were estimated, representing results distributions in patients with each of the specific chronic disorders, but without significant comorbidity. RESULTS Disease-associated reference intervals were estimated for 20 common laboratory tests. Most of the estimated reference limits were significantly different from corresponding health-associated reference limits. Thirty percent of the estimated reference intervals were different from estimates based on crude patient populations, indicating that the algorithm applied managed to exclude patients with relevant comorbidity. CONCLUSION Disease-associated reference intervals could be estimated for a number of tests in patients with rheumatoid arthritis, ulcerative colitis or Crohn's disease using a highly automated algorithm based on routinely recorded patient data.
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Affiliation(s)
- Gustav Mikkelsen
- Department of Clinical Chemistry, St Olav’s Hospital, Trondheim University Hospital, Postboks 3250 Torgarden, 7006, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Børge Lillebo
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Kirkegata 2, 7601, Levanger, Norway
- Clinic of Medicine and Rehabilitation, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Arild Faxvaag
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Rheumatology, St Olav’s Hospital, Trondheim University Hospital, Postboks 3250 Torgarden, 7006, Trondheim, Norway
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Ruszkai Z, Kiss E, László I, Bokrétás GP, Vizserálek D, Vámossy I, Surány E, Buzogány I, Bajory Z, Molnár Z. Effects of intraoperative positive end-expiratory pressure optimization on respiratory mechanics and the inflammatory response: a randomized controlled trial. J Clin Monit Comput 2020; 35:469-482. [PMID: 32388650 PMCID: PMC7222900 DOI: 10.1007/s10877-020-00519-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/04/2020] [Indexed: 12/18/2022]
Abstract
Applying lung protective mechanical ventilation (LPV) during general anaesthesia even in patients with non-injured lungs is recommended. However, the effects of an individual PEEP-optimisation on respiratory mechanics, oxygenation and their potential correlation with the inflammatory response and postoperative complications have not been evaluated have not been compared to standard LPV in patients undergoing major abdominal surgery. Thirty-nine patients undergoing open radical cystectomy were enrolled in this study. In the study group (SG) optimal PEEP was determined by a decremental titration procedure and defined as the PEEP value resulting the highest static pulmonary compliance. In the control group (CG) PEEP was set to 6 cmH2O. Primary endpoints were intraoperative respiratory mechanics and gas exchange parameters. Secondary outcomes were perioperative procalcitonin kinetics and postoperative pulmonary complications. Optimal PEEP levels (median = 10, range: 8–14 cmH2O), PaO2/FiO2 (451.24 ± 121.78 mmHg vs. 404.15 ± 115.87 mmHg, P = 0.005) and static pulmonary compliance (52.54 ± 13.59 ml cmH2O-1 vs. 45.22 ± 9.13 ml cmH2O-1, P < 0.0001) were significantly higher, while driving pressure (8.26 ± 1.74 cmH2O vs. 9.73 ± 4.02 cmH2O, P < 0.0001) was significantly lower in the SG as compared to the CG. No significant intergroup differences were found in procalcitonin kinetics (P = 0.076). Composite outcome results indicated a non-significant reduction of postoperative complications in the SG. Intraoperative PEEP-optimization resulted in significant improvement in gas exchange and pulmonary mechanics as compared to standard LPV. Whether these have any effect on short and long term outcomes require further investigations. Trial registration: Clinicaltrials.gov, identifier: NCT02931409.
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Affiliation(s)
- Zoltán Ruszkai
- Department of Anaesthesiology and Intensive Therapy, Pest Megyei Flór Ferenc Hospital, Semmelweis Square 1, Kistarcsa, 2143, Hungary.
| | - Erika Kiss
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Semmelweis Street 6, Szeged, 6725, Hungary
| | - Ildikó László
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Semmelweis Street 6, Szeged, 6725, Hungary
| | - Gergely Péter Bokrétás
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Dóra Vizserálek
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Ildikó Vámossy
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Erika Surány
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - István Buzogány
- Department of Urology, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Zoltán Bajory
- Department of Urology, University of Szeged, Kálvária Avenue 57, Szeged, 6725, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, University of Pécs, Szigeti Street 12, Pécs, 7624, Hungary
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The Importance of Serological Procalcitonin Levels After Autologous Microsurgical Transplantation. J Craniofac Surg 2019; 30:e278-e281. [PMID: 30817542 DOI: 10.1097/scs.0000000000005431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Published data on procalcitonin (PCT) levels after microsurgical interventions are very scarce, although infection within these patients is not only associated with severe morbidity but also significantly higher mortality rates. MATERIAL AND METHODS Retrospective study on 20 patients, who were operated on by a single experienced plastic and reconstructive surgeon within one year (June 2017-June 2018). The authors included all patients, who received microvascular transplants for reconstruction of soft tissue defects. Furthermore, age above 18 years and appropriate documentation allowing sufficient data collection were defined as inclusion criteria. The authors excluded all patients with perioperative systemic inflammation and transplant loss, as our aim was to solely determine and evaluate potential alterations of serological PCT levels after microsurgical interventions. RESULTS The PCT cutoff level to differentiate physiological and pathological levels was defined as 0.1 μg/L. There was no detectable increase in procalcitonin in all of our 20 patients, for whom the authors performed microvascular transplantation to reconstruct soft tissue defects. CONCLUSION Serological PCT levels remain stable after the considered surgical interventions and therefore PCT levels might be utilized to identify systemic inflammation, thus helping to reduce severe complications by early individualized antiinfective treatment strategies.
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8
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Procalcitonin levels predicting the infliximab response of immunoglobulin resistant Kawasaki disease. Cytokine 2019; 114:26-31. [DOI: 10.1016/j.cyto.2018.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/30/2018] [Accepted: 11/25/2018] [Indexed: 12/24/2022]
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The Role of C-Reactive Protein in the Early Prediction of Serious Pancreatic Fistula Development after Pancreaticoduodenectomy. Gastroenterol Res Pract 2018; 2018:9157806. [PMID: 29619047 PMCID: PMC5830281 DOI: 10.1155/2018/9157806] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 12/06/2017] [Accepted: 12/13/2017] [Indexed: 12/14/2022] Open
Abstract
Introduction Despite recent advances in surgical techniques, pancreatic fistulas are common. We aimed to determine the role of C-reactive protein in the prediction of clinically relevant fistula development. Materials and Methods Data from patients who underwent pancreaticoduodenectomy between 2012 and 2015 is collected. Postoperative 1st, 3rd, and 5th day (POD1, POD3, and POD5) C-reactive protein (CRP) levels, postoperative pancreatic fistula (POPF) development, other complications, length of hospital stay, and mortality were recorded. Results Of 117 patients, 43 patients (36.8%) developed complications (including fistulas). Of the patients developing fistulas, 21 (17.9%) had POPF A, 2 (1.7%) had POPF B, and 7 (6.0%) had POPF C. POD5 CRP and POD3 CRP were shown to be significantly correlated with mortality and development of clinically relevant POPF (p = 0.001 and p = 0.0001, resp.) and with mortality (p = 0.017), respectively. The development of clinically relevant POPFs (B and C) could be predicted with 90% sensitivity and 82.2% specificity by POD5 CRP cut-off level of 19 mg/dL and with 100% sensitivity and 63.6% specificity by the difference between POD5 and POD1 CRP cut-off level of >2.5 mg/dL. Conclusion CRP levels can effectively predict the development of clinically relevant pancreatic fistulas.
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Spoto S, Valeriani E, Caputo D, Cella E, Fogolari M, Pesce E, Mulè MT, Cartillone M, Costantino S, Dicuonzo G, Coppola R, Ciccozzi M, Angeletti S. The role of procalcitonin in the diagnosis of bacterial infection after major abdominal surgery: Advantage from daily measurement. Medicine (Baltimore) 2018; 97:e9496. [PMID: 29504973 PMCID: PMC5779742 DOI: 10.1097/md.0000000000009496] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Postsurgical infections represent an important cause of morbidity after abdominal surgery. The microbiological diagnosis is not achieved in at least 30% of culture with consequent worsening of patient outcome. In this study, procalcitonin measurement, during the first 3 days after abdominal surgery, has been evaluated for the early diagnosis of postsurgical infection.Ninety consecutive patients subjected to major abdominal surgery at the University Campus Bio-Medico of Rome, have been included. PCT concentrations were measured by time-resolved amplified cryptate emission (TRACE) assay at admission and at the first, second, and third day after surgery. PCT levels were compared using the Mann-Whitney test and by ANOVA test for variance analysis. Receiver operating characteristic (ROC) analysis was performed to define the diagnostic ability of PCT in case of postsurgical infections.PCT values resulted significantly different between patients developing or not developing postsurgical infections. PCT >1.0 ng/mL at first or second day after surgery and >0.5 ng/mL at third day resulted diagnostic for infectious complication, whereas a value <0.5 ng/mL at the fifth day after surgery was useful for early and safety discharge of patients.In conclusion, PCT daily measurement could represent a useful diagnostic tool improving health care in the postsurgical period following major abdominal surgery and should be recommended.
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Affiliation(s)
- Silvia Spoto
- Internal Medicine Department, University Campus Bio-Medico of Rome, Rome Internal Medicine Department, University G. D'Annunzio, Chieti Department of Surgery, University Campus Bio-Medico of Rome Department of Public Health and Infectious Diseases, Sapienza University of Rome Unit of Clinical Laboratory Science, University Campus Bio-Medico of Rome, Rome, Italy
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Ruszkai Z, Kiss E, László I, Gyura F, Surány E, Bartha PT, Bokrétás GP, Rácz E, Buzogány I, Bajory Z, Hajdú E, Molnár Z. Effects of intraoperative PEEP optimization on postoperative pulmonary complications and the inflammatory response: study protocol for a randomized controlled trial. Trials 2017; 18:375. [PMID: 28800778 PMCID: PMC5553792 DOI: 10.1186/s13063-017-2116-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/21/2017] [Indexed: 12/03/2022] Open
Abstract
Background Patients undergoing general anesthesia and mechanical ventilation during major abdominal surgery commonly develop pulmonary atelectasis and/or hyperdistention of the lungs. Recent studies show benefits of lung-protective mechanical ventilation with the use of low tidal volumes, a moderate level of positive end-expiratory pressure (PEEP) and regular alveolar recruitment maneuvers during general anesthesia, even in patients with healthy lungs. The purpose of this clinical trial is to evaluate the effects of intraoperative lung-protective mechanical ventilation, using individualized PEEP values, on postoperative pulmonary complications and the inflammatory response. Methods/design A total number of 40 patients with bladder cancer undergoing open radical cystectomy and urinary diversion (ileal conduit or orthotopic bladder substitute) will be enrolled and randomized into a study (SG) and a control group (CG). Standard lung-protective ventilation with a PEEP of 6 cmH2O will be applied in the CG and an optimal PEEP value determined during a static pulmonary compliance (Cstat)-directed PEEP titration procedure will be used in the SG. Low tidal volumes (6 mL/Kg ideal bodyweight) and a fraction of inspired oxygen of 0.5 will be applied in both groups. After surgery both groups will receive standard postoperative management. Primary endpoints are postoperative pulmonary complications and serum procalcitonin kinetics during and after surgery until the third postoperative day. Secondary and tertiary endpoints will be: organ dysfunction as monitored by the Sequential Organ Failure Assessment Score, in-hospital stay, 28-day and in-hospital mortality. Discussion This trial will assess the possible benefits or disadvantages of an individualized lung-protective mechanical ventilation strategy during open radical cystectomy and urinary diversion regarding postoperative pulmonary complications and the inflammatory response. Trial registration ClinicalTrials.gov, ID: NCT02931409. Registered on 5 October 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2116-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zoltán Ruszkai
- Department of Anaesthesiology and Intensive Care, Péterfy Sándor Hospital, Péterfy Sándor u. 8-20, Budapest, 1076, Hungary
| | - Erika Kiss
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Semmelweis u. 6, Szeged, 6725, Hungary
| | - Ildikó László
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Semmelweis u. 6, Szeged, 6725, Hungary
| | - Fanni Gyura
- Department of Anaesthesiology and Intensive Care, Péterfy Sándor Hospital, Péterfy Sándor u. 8-20, Budapest, 1076, Hungary
| | - Erika Surány
- Department of Anaesthesiology and Intensive Care, Péterfy Sándor Hospital, Péterfy Sándor u. 8-20, Budapest, 1076, Hungary
| | - Péter Töhötöm Bartha
- Department of Anaesthesiology and Intensive Care, Péterfy Sándor Hospital, Péterfy Sándor u. 8-20, Budapest, 1076, Hungary
| | - Gergely Péter Bokrétás
- Department of Anaesthesiology and Intensive Care, Péterfy Sándor Hospital, Péterfy Sándor u. 8-20, Budapest, 1076, Hungary
| | - Edit Rácz
- Department of Anaesthesiology and Intensive Care, Péterfy Sándor Hospital, Péterfy Sándor u. 8-20, Budapest, 1076, Hungary
| | - István Buzogány
- Department of Urology, Péterfy Sándor Hospital, Péterfy Sándor u. 8-20, Budapest, 1076, Hungary
| | - Zoltán Bajory
- Department of Urology, University of Szeged, Kálvária sgt.57, Szeged, 6725, Hungary
| | - Erzsébet Hajdú
- Department of Urology, University of Szeged, Kálvária sgt.57, Szeged, 6725, Hungary
| | - Zsolt Molnár
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Semmelweis u. 6, Szeged, 6725, Hungary.
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Rabensteiner J, Prüller F, Prattes J, Valentin T, Zollner-Schwetz I, Krause R, Hoenigl M. suPAR remains uninfluenced by surgery in septic patients with bloodstream infection. GMS INFECTIOUS DISEASES 2016; 4:Doc04. [PMID: 30671318 PMCID: PMC6301737 DOI: 10.3205/id000022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Surgical trauma induces activation of the immune system and may cause an increase of inflammatory biomarkers tested postoperatively in septic patients treated for bloodstream infection. The aim of this study was to determine the impact of surgical interventions on the novel sepsis biomarker soluble urokinase plasminogen activator receptor (suPAR) and to compare results with those of routine laboratory parameters CRP, PCT, and IL-6 in patients with culture-proven bloodstream infection. Forty-six adult patients with positive blood culture undergoing minor or major surgical intervention were investigated, 12 blood culture positive patients served as control group. Blood was collected 24 hours before and after surgical intervention for determination of the sepsis biomarkers suPAR, CRP, PCT, and IL-6. Within the surgical study cohort, a non-significant increase of suPAR, CRP, and PCT was observed postoperatively (p 0.642; p 0.773; p 0.087). In contrast, a slight decrease of IL-6 (p 0.599) was observed. A significant correlation was calculated for the pre- and postoperative difference of CRP (p 0.028) and PCT (p 0.008) and type of surgical intervention received: after minor surgical intervention only PCT decreased significantly (p<0.001), while after major surgical interventions no significant differences were observed for all biomarkers evaluated. In the control group, a significant decrease of CRP (p 0.005) and PCT (p 0.005) was observed. In patients treated adequately for bloodstream infections, postoperative suPAR levels remained uninfluenced of the surgical trauma and might therefore be a reliable parameter for postoperative infectious monitoring. After minor surgical intervention, PCT seems to be the most reliable parameter.
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Affiliation(s)
- Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria
| | - Jürgen Prattes
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Austria
| | - Thomas Valentin
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Austria
| | - Ines Zollner-Schwetz
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Austria
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Austria
| | - Martin Hoenigl
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Austria.,Division of Infectious Diseases, Department of Medicine, University of California, San Diego, CA, USA
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Jun KR, Lee JN, Song SA, Oh SH, Lee JY, Shin JH, Kim HR. Serial changes in serum procalcitonin, interleukin 6, and C-reactive protein levels according to non-specific surgical stimulation. Clin Chem Lab Med 2015; 53:549-58. [PMID: 25153416 DOI: 10.1515/cclm-2014-0090] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 06/27/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this study is to investigate useful perioperative monitoring markers by comparing serial levels of serum procalcitonin (PCT), interleukin 6 (IL-6), and C-reactive protein (CRP) in routine surgical circumstances. METHODS In 285 surgeries of 277 patients, blood samples were obtained serially, at least three times per patient: within 48 h before surgery, 0-6 h after surgery (post-OP1), >6-28 h after surgery (post-OP2), and/or later (post-OP3). PCT, IL-6, and CRP were measured. Their demographic, operative, laboratory, and clinical data were collected retrospectively. RESULTS The systemic inflammatory response syndrome (SIRS) (n=39) and sepsis (n=11) groups showed higher post-operative values than the non-SIRS group (n=233). Their maximum significant median levels were 8.96 vs. 0.21 μg/L for post-OP2 PCT, 743.1 vs. 85.8 ng/L for post-OP1 IL-6, and 103.4 vs. 49.0 mg/L for post-OP2 CRP. Among non-SIRS patients, 12 patients developed undesirable post-operative events, including secondary surgery and death. The highest area under receiver operator characteristic curves was 0.92 at post-OP1 PCT (cut-off, 0.1 μg/L; sensitivity, 91.7%; specificity, 78.7%), and the next highest was 0.84 at post-OP1 IL-6 (cut-off, 359 ng/L; sensitivity, 66.7%; specificity, 91.9%). All biomarkers were increased by non-specific surgical stimuli; however, post-OP1/post-OP2 PCT were <1.0 μg/L (90th percentile) except major abdominal surgeries. CONCLUSIONS Post-OP1 PCT measurement may be useful as a post-operative monitoring marker for the following reasons: pre-operative values less than the cut-off regardless of pre-operative state (age, malignancy, and American Society of Anesthesiologists class); minimal influence from surgical stimulus; and prediction of post-operative undesirable events.
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14
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Xiao Z, Wilson C, Robertson HL, Roberts DJ, Ball CG, Jenne CN, Kirkpatrick AW. Inflammatory mediators in intra-abdominal sepsis or injury - a scoping review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:373. [PMID: 26502877 PMCID: PMC4623902 DOI: 10.1186/s13054-015-1093-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 10/07/2015] [Indexed: 12/16/2022]
Abstract
Introduction Inflammatory and protein mediators (cytokine, chemokine, acute phase proteins) play an important, but still not completely understood, role in the morbidity and mortality of intra-abdominal sepsis/injury. We therefore systematically reviewed preclinical and clinical studies of mediators in intra-abdominal sepsis/injury in order to evaluate their ability to: (1) function as diagnostic/prognostic biomarkers; (2) serve as therapeutic targets; and (3) illuminate the pathogenesis mechanisms of sepsis or injury-related organ dysfunction. Methods We searched MEDLINE, PubMed, EMBASE and the Cochrane Library. Two investigators independently reviewed all identified abstracts and selected articles for full-text review. We included original studies assessing mediators in intra-abdominal sepsis/injury. Results Among 2437 citations, we selected 182 studies in the scoping review, including 79 preclinical and 103 clinical studies. Serum procalcitonin and C-reactive protein appear to be useful to rule out infection or monitor therapy; however, the diagnostic and prognostic value of mediators for complications/outcomes of sepsis or injury remains to be established. Peritoneal mediator levels are substantially higher than systemic levels after intra-abdominal infection/trauma. Common limitations of current studies included small sample sizes and lack of uniformity in study design and outcome measures. To date, targeted therapies against mediators remain experimental. Conclusions Whereas preclinical data suggests mediators play a critical role in intra-abdominal sepsis or injury, there is no consensus on the clinical use of mediators in diagnosing or managing intra-abdominal sepsis or injury. Measurement of peritoneal mediators should be further investigated as a more sensitive determinant of intra-abdominal inflammatory response. High-quality clinical trials are needed to better understand the role of inflammatory mediators. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1093-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhengwen Xiao
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada.
| | - Crystal Wilson
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada.
| | - Helen Lee Robertson
- Health Sciences Library, Health Sciences Centre, University of Calgary, 3330 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada.
| | - Derek J Roberts
- Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Community Health Sciences (Division of Epidemiology), University of Calgary, 3280 Hospital Drive Northwest, T2N 4Z6, Calgary, AB, Canada.
| | - Chad G Ball
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada.
| | - Craig N Jenne
- Department of Critical Care Medicine, Foothills Medical Centre, University of Calgary, 3134 Hospital Drive NW, T2N 5A1, Calgary, AB, Canada. .,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3280 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada.
| | - Andrew W Kirkpatrick
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Critical Care Medicine, Foothills Medical Centre, University of Calgary, 3134 Hospital Drive NW, T2N 5A1, Calgary, AB, Canada.
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15
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Liu HH, Guo JB, Geng Y, Su L. Procalcitonin: present and future. Ir J Med Sci 2015; 184:597-605. [DOI: 10.1007/s11845-015-1327-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 06/20/2015] [Indexed: 12/15/2022]
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16
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Sandkovsky U, Kalil AC, Florescu DF. The use and value of procalcitonin in solid organ transplantation. Clin Transplant 2015; 29:689-96. [PMID: 25996831 DOI: 10.1111/ctr.12568] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2015] [Indexed: 01/01/2023]
Abstract
Procalcitonin (PCT) has been increasingly used as a biomarker of bacterial infection and as a tool to guide antimicrobial therapy, especially in lower respiratory tract and bloodstream infections. Despite its increased use, data in patients with solid organ transplants are limited. Even without the presence of infection, PCT increases as a result of surgical procedures during transplantation, implantation of devices, and use of induction immunosuppressive therapy. The risk of infection is also higher in solid organ transplant recipients when compared to the general population. Monitoring PCT in the early post-transplant period seems to be a promising method for early detection of infectious complications. It has been shown that elevated PCT levels after one wk of transplantation are correlated with infectious complications. PCT may be a useful adjunctive biomarker that may improve early identification and guide appropriate treatment of infection or rejection, with the potential to further improve clinical outcomes. The use of serial PCT measurements may be more reliable than single values. It is important to recognize which factors may lead to PCT increases in the post-transplantation period, which in turn will help understand the kinetics and utility of this biomarker in this important patient population.
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Affiliation(s)
- Uriel Sandkovsky
- Division of Infectious Diseases, Transplant Infectious Diseases Program, University of Nebraska Medical Center, Omaha, NE, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Transplant Infectious Diseases Program, University of Nebraska Medical Center, Omaha, NE, USA
| | - Diana F Florescu
- Division of Infectious Diseases, Transplant Infectious Diseases Program, University of Nebraska Medical Center, Omaha, NE, USA.,Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE, USA
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17
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Abstract
Sepsis is the primary cause of death in the intensive care unit. The prevention of sepsis complications requires an early and accurate diagnosis as well as the appropriate mon itoring. A deep knowledge of the immunologic basis of sepsis is essential to better understand the scope of incorporating a new marker into clinical practice. Besides revising this theoretical aspect, the current available tools for bacterial iden tification have been briefly reviewed as well as a variety of new markers showing either well-recognized or potential usefulness for diagnosis and prognosis of infections in crit ically ill patients. Particular conditions such as community acquired pneumonia, pedi atric sepsis, or liver transplantation, among others, have been separately treated, since the optimal approaches and markers might be different in these special cases.
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18
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Silvestre J, Rebanda J, Lourenço C, Póvoa P. Diagnostic accuracy of C-reactive protein and procalcitonin in the early detection of infection after elective colorectal surgery - a pilot study. BMC Infect Dis 2014; 14:444. [PMID: 25132018 PMCID: PMC4143543 DOI: 10.1186/1471-2334-14-444] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/12/2014] [Indexed: 02/06/2023] Open
Abstract
Background Colorectal surgery is associated with postoperative infectious complications in up to 40% of cases, but the diagnosis of these complications is frequently misleading, delaying its resolution. Several biomarkers have been shown to be useful in infection diagnosis. Methods We conducted a single-centre, prospective, observational study segregating patients submitted to elective colorectal surgery with primary anastomosis, CRP and PCT were measured daily. We compared infected and non-infected patients. Results From October 2009 to June 2011, a total of 50 patients were included. Twenty-one patients developed infection. PCT and CRP before surgery were equally low in patients with or without postoperative infectious complications. After surgery, both PCT and CRP increased markedly. CRP time-course from the day of surgery onwards was significantly different in infected and non-infected patients (P = 0.001) whereas, PCT time-course was almost parallel in both groups (P = 0.866). Multiple comparisons between infected and non-infected patients from 5th to 9th postoperative days (POD) were performed and CRP concentration was significantly different (P < 0.01, Bonferroni correction), on the 6th, 7th and 8th POD. A CRP concentration > 5.0 mg/dl at the D6 was predictive of infection with a sensitivity of 85% and a specificity of 62% (positive likelihood ratio 2.2, negative likelihood ratio 0.2). Conclusions After a major elective surgical insult both CRP and PCT serum levels increased independently of the presence of infection. Besides serum CRP time-course showed to be useful in the early detection of an infectious complication whereas PCT was unhelpful. Electronic supplementary material The online version of this article (doi:10.1186/1471-2334-14-444) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joana Silvestre
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, CHLO, Lisbon, Portugal.
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19
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Mishra SP, Tiwary SK, Mishra M, Gupta SK. An introduction of Tertiary Peritonitis. J Emerg Trauma Shock 2014; 7:121-3. [PMID: 24812458 PMCID: PMC4013728 DOI: 10.4103/0974-2700.130883] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 07/13/2013] [Indexed: 12/17/2022] Open
Abstract
Intraperitoneal infection known as peritonitis is a major killer in the practice of clinical surgery. Tertiary peritonitis (TP) may be defined as intra-abdominal infection that persists or recurs ³48 h following successful and adequate surgical source control. A planned or on-demand relaparotomy after an initial operation is probably most frequent way to diagnose TP, but is a late event to occur. Hence it is desirable to have timely and nonoperative diagnosis of TP after the initial operation and subsequent initiation of an appropriate therapy to reduce the complications and to improve the outcome.
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Affiliation(s)
- Shashi Prakash Mishra
- Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Satyendra Kumar Tiwary
- Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Manjaree Mishra
- Department of Anesthesiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Sanjeev Kumar Gupta
- Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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20
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Huang TS, Huang SS, Shyu YC, Lee CH, Jwo SC, Chen PJ, Chen HY. A procalcitonin-based algorithm to guide antibiotic therapy in secondary peritonitis following emergency surgery: a prospective study with propensity score matching analysis. PLoS One 2014; 9:e90539. [PMID: 24594916 PMCID: PMC3942439 DOI: 10.1371/journal.pone.0090539] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 01/30/2014] [Indexed: 11/28/2022] Open
Abstract
Background Procalcitonin (PCT)-based algorithms have been used to guide antibiotic therapy in several clinical settings. However, evidence supporting PCT-based algorithms for secondary peritonitis after emergency surgery is scanty. In this study, we aimed to investigate whether a PCT-based algorithm could safely reduce antibiotic exposure in this population. Methods/Principal Findings From April 2012 to March 2013, patients that had secondary peritonitis diagnosed at the emergency department and underwent emergency surgery were screened for eligibility. PCT levels were obtained pre-operatively, on post-operative days 1, 3, 5, and 7, and on subsequent days if needed. Antibiotics were discontinued if PCT was <1.0 ng/mL or decreased by 80% versus day 1, with resolution of clinical signs. Primary endpoints were time to discontinuation of intravenous antibiotics for the first episode and adverse events. Historical controls were retrieved for propensity score matching. After matching, 30 patients in the PCT group and 60 in the control were included for analysis. The median duration of antibiotic exposure in PCT group was 3.4 days (interquartile range [IQR] 2.2 days), while 6.1 days (IQR 3.2 days) in control (p < 0.001). The PCT algorithm significantly improves time to antibiotic discontinuation (p < 0.001, log-rank test). The rates of adverse events were comparable between 2 groups. Multivariate-adjusted extended Cox model demonstrated that the PCT-based algorithm was significantly associated with a 87% reduction in hazard of antibiotic exposure within 7 days (hazard ratio [HR] 0.13, 95% CI 0.07–0.21, p < 0.001), and a 68% reduction in hazard after 7 days (adjusted HR 0.32, 95% CI 0.11–0.99, p = 0.047). Advanced age, coexisting pulmonary diseases, and higher severity of illness were significantly associated with longer durations of antibiotic use. Conclusions/Significance The PCT-based algorithm safely reduces antibiotic exposure in this study. Further randomized trials are needed to confirm our findings and incorporate cost-effectiveness analysis. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12612000601831
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Affiliation(s)
- Ting-Shuo Huang
- The Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
| | - Shie-Shian Huang
- Division of Infectious Diseases, Department of Medicine, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
| | - Yu-Chiau Shyu
- Institute of Biopharmaceutical Sciences, National Yang-Ming University, Taipei, Taiwan
- Department of Education and Research, Taipei City Hospital, Taipei, Taiwan
| | - Chun-Hui Lee
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
| | - Shyh-Chuan Jwo
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
| | - Pei-Jer Chen
- The Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Huang-Yang Chen
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
- * E-mail:
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Domínguez-Comesaña E, López-Gómez V, Estevez-Fernández SM, Mariño Padín E, Ballinas-Miranda J, Carrera-Dacosta E, Piñon-Cimadevila MÁ, Barreiro-Morandeira F. [Procalcitonin and C-reactive protein as early indicators of postoperative intra-abdominal infection after surgery for gastrointestinal cancer]. Cir Esp 2014; 92:240-6. [PMID: 24445075 DOI: 10.1016/j.ciresp.2013.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 09/25/2013] [Accepted: 09/26/2013] [Indexed: 12/12/2022]
Abstract
AIM to evaluate the association between serum levels of procalcitonin and C-reactive protein, on the first 3 postoperative days, and the appearance of postoperative intra-abdominal infection. METHOD Prospective observational study including 67 patients operated on for colo-rectal, gastric and pancreatic cancer. Serum levels of procalcitonin and C-reactive protein were analyzed before surgery and daily until the third postoperative day. Values of procalcitonin (PCT) and C-reactive protein (CRP) were recorded as well as their accuracy for detection of postoperative intra-abdominal infection (PIAI). RESULTS The incidence of postoperative intra-abdominal infection was 13.4%. CRP serum levels at 72h, PCT serum levels at 24, 48 and 72h and the ratio between serum levels of CRP at 72hours and serum levels of CRP at 48hours (CRP D3/CRP D2) were significantly associated with the appearance of postoperative intra-abdominal infection. The highest sensitivity corresponded to PCT at 72hours (88.9%); the highest specificity and positive predictive value corresponded to the ratio CRP D3/CRP D2 (96.49% and 71.4%, respectively); the highest negative predictive value to procalcitonin at 72h and 24h. CONCLUSIONS Serum levels of PCT are significantly associated with the appearance of postoperative intra-abdominal infection. Sensitivity and predictive positive values are low, but negative predictive value is high, even at 24h after surgery.
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Affiliation(s)
| | - Victoria López-Gómez
- Servicio de Análisis Clínicos, Complejo Hospitalario de Pontevedra, Pontevedra, España
| | | | - Esther Mariño Padín
- Servicio de Cirugía, Complejo Hospitalario de Pontevedra, Pontevedra, España
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22
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Watkins RR, Lemonovich TL. Serum procalcitonin in the diagnosis and management of intra-abdominal infections. Expert Rev Anti Infect Ther 2014; 10:197-205. [DOI: 10.1586/eri.11.164] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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23
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Schwabe P, Wichlas F, Druschel C, Jacobs C, Haas N, Schaser KD, Märdian S. Komplikationen nach osteosynthetischer Versorgung von Azetabulumfrakturen. DER ORTHOPADE 2013; 43:24-34. [DOI: 10.1007/s00132-013-2121-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Oberhofer D, Juras J, Pavicić AM, Rancić Zurić I, Rumenjak V. Comparison of C-reactive protein and procalcitonin as predictors of postoperative infectious complications after elective colorectal surgery. Croat Med J 2013; 53:612-9. [PMID: 23275327 PMCID: PMC3541587 DOI: 10.3325/cmj.2012.53.612] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Aim To assess diagnostic value of perioperative procalcitonin (PCT) levels compared to C-reactive protein (CRP) levels in early detection of infectious complications following colorectal surgery. Methods This prospective observational study included 79 patients undergoing elective colorectal surgery. White blood cell count, CRP, and PCT were measured preoperatively and on postoperative days (POD) 1, 2, 3, 5, and patients were followed for postoperative complications. Diagnostic accuracy of CRP and PCT values on each day was analyzed by the receiver operating characteristics (ROC) curve, with infectious complications as an outcome measure. ROC curves with the largest area under the curve for each inflammatory marker were compared in order to define the marker with higher diagnostic accuracy. Results Twenty nine patients (36.7%) developed infectious complications. CRP and PCT concentrations increased in the early postoperative period, with a significant difference between patients with and without complications at all measured postoperative times. ROC curve analysis showed that CRP concentrations on POD 3 and PCT concentrations on POD 2 had similar predictive values for the development of infectious complications (area under the curve, 0.746 and 0.750, respectively) with the best cut-off values of 99.0 mg/L for CRP and 1.34 µg/L for PCT. Diagnostic accuracy of CRP and PCT was highest on POD 5, however the cut-off values were not considered clinically useful. Conclusion Serial postoperative PCT measurements do not offer an advantage over CRP measurements for prediction of infectious complications following colorectal surgery.
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Affiliation(s)
- Dagmar Oberhofer
- Department of Anaesthesiology and Intensive Care, University Hospital Sveti Duh, Sveti Duh 64, 10000 Zagreb, Croatia.
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25
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Guirao X, Juvany M, Franch G, Navinés J, Amador S, Badía JM. Value of C-Reactive Protein in the Assessment of Organ-Space Surgical Site Infections after Elective Open and Laparoscopic Colorectal Surgery. Surg Infect (Larchmt) 2013; 14:209-15. [DOI: 10.1089/sur.2012.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Xavier Guirao
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Montserrat Juvany
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Guzmán Franch
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Jordi Navinés
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Sara Amador
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Jose M. Badía
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
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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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Khan ANGA, Sawan A, Likourezos A, Schnellinger M, Garcia E. The usefulness of procalcitonin in the diagnosis of appendicitis in children: a pilot study. Emerg Med Int 2012; 2012:317504. [PMID: 23304513 PMCID: PMC3529464 DOI: 10.1155/2012/317504] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 11/11/2012] [Accepted: 11/11/2012] [Indexed: 11/24/2022] Open
Abstract
Objective. To assess the predictive value of procalcitonin in detecting acute appendicitis (AP) in children, and to determine a cutoff value of procalcitonin which can safely include/exclude the diagnosis of acute appendicitis in children with acute abdominal pain. Methods. Prospective cohort study of children aged 5-17 years presenting to the emergency room with right lower quadrant (RLQ) tenderness and strong suspicion for acute AP. In addition to standard diagnostic workup for acute AP, a quantitative procalcitonin level was measured using immunoluminometric assay. Recursive partitioning model was used to assess the usefulness of procalcitonin in the diagnosis of appendicitis. Results. Of the 50 children studied, 48% were diagnosed to have AP. The mean procalcitonin level was higher among the children with appendicitis (P = 0.3). Using the recursive partitioning model, we identified a cutoff value of procalcitonin level of 0.39 with a likelihood ratio presence of appendicitis 3.25 and absence of appendicitis 0.8. None of the study subjects with procalcitonin level <0.39 and WBC count of <6.76 K had appendicitis. Conclusions. In conjunction with the clinical symptoms, a procalcitonin level and WBC count could be a strong predictor of acute appendicitis in children.
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Affiliation(s)
- Abu N. G. A. Khan
- Department of Emergency Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA
- Division of Pediatric Emergency Medicine, Morgan Stanley Children Hospital of New York-Presbyterian, 622 West 168th Street, PH 137-1, New York, NY 10032, USA
| | - Abdel Sawan
- Department of Emergency Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA
| | - Antonios Likourezos
- Department of Emergency Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA
| | - Mark Schnellinger
- Department of Emergency Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA
| | - Estavan Garcia
- Department of Emergency Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA
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Abstract
THE AIM OF THE STUDY was to answer the question whether or not determination of C-reactive protein in patients after serious abdominal surgeries can be prognostic of septic complications. MATERIAL AND METHODS 36 patients who underwent elective surgeries were included in the study. The patients were included either in the group where no postoperative SIRS developed or in the group where postoperative SIRS did occur. In the seven-day period after the surgery, in 26 patients SIRS was found, and in 10 - sepsis was suspected (according to the ACCP/SCCM definitions). In patients who underwent abdominal surgeries blood concentration of C-reactive protein was determined prior to the surgery (measurement '0'), and then on postoperative days 1, 2, 3, 5 and 7. RESULTS The test for two variables (C-reactive protein on postoperative days five and seven) showed statistically significant difference, and for one variable (C-reactive protein on day three) - difference at the limit of significance. Thus, it was found that in the postoperative SIRS group the level of C-reactive protein is higher than in the non-SIRS group. CONCLUSIONS Serial measurements of C-reactive protein are useful in the first week after surgery, as they can be prognostic of postoperative septic complications. Such complications can be anticipated if CRP on postoperative day 5 is higher than 1/2 of the maximum CRP concentration on day 2 or day 3, or CRP > 150 mg/L as of postoperative day 3. Unfortunately, the severity of the disease cannot be projected based on C-reactive protein level.
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Kibe S, Adams K, Barlow G. Diagnostic and prognostic biomarkers of sepsis in critical care. J Antimicrob Chemother 2011; 66 Suppl 2:ii33-40. [PMID: 21398306 DOI: 10.1093/jac/dkq523] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Sepsis is a leading cause of mortality in critically ill patients. Delay in diagnosis and initiation of antibiotics have been shown to increase mortality in this cohort. However, differentiating sepsis from non-infectious triggers of the systemic inflammatory response syndrome (SIRS) is difficult, especially in critically ill patients who may have SIRS for other reasons. It is this conundrum that predominantly drives broad-spectrum antimicrobial use and the associated evolution of antibiotic resistance in critical care environments. It is perhaps unsurprising, therefore, that the search for a highly accurate biomarker of sepsis has become one of the holy grails of medicine. Procalcitonin (PCT) has emerged as the most studied and promising sepsis biomarker. For diagnostic and prognostic purposes in critical care, PCT is an advance on C-reactive protein and other traditional markers of sepsis, but is not accurate enough for clinicians to dispense with clinical judgement. There is stronger evidence, however, that measurement of PCT has a role in reducing the antibiotic exposure of critical care patients. For units intending to incorporate PCT assays into routine clinical practice, the cost-effectiveness of this is likely to depend on the pre-implementation length of an average antibiotic course and the subsequent impact of implementation on emerging antibiotic resistance. In most of the trials to date, the average baseline duration of the antibiotic course was longer than is currently standard practice in many UK critical care units. Many other biomarkers are currently being investigated. To be highly useful in clinical practice, it may be necessary to combine these with other novel biomarkers and/or traditional markers of sepsis.
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Affiliation(s)
- Savitri Kibe
- Department of Infection & Tropical Medicine, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, East Yorkshire, UK
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Wong K, Shahab Y, Gill PG. Diagnostic value of an initial C-reactive protein level in acute surgical patients. ANZ J Surg 2011; 82:52-5. [PMID: 22507496 DOI: 10.1111/j.1445-2197.2011.05668.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In surgical patients, C-reactive protein (CRP) levels are often measured as a marker of inflammation and infection. However, the diagnostic and prognostic value of a single initial CRP measurement in the acute presentation has not been well established. This study was performed to investigate the usefulness of measuring CRP in such a setting. METHODS CRP levels were measured retrospectively in 473 surgical patients who presented to the Royal Adelaide Hospital emergency department. This was correlated with patient outcomes, defined by the need for imaging tests and/or surgical interventions, the length of hospital stay and 30-day mortality. Spearman's rank correlation and one-way analysis of variance were used for statistical analysis. RESULTS Of 473 patients, 42% had a CRP test in the emergency department within 24 h of admission. Approximately 80% of patients required imaging for diagnosis and 40% required surgery, regardless of the initial CRP level. No correlation was evident between initial CRP level and length of hospital stay (r= 0.06). One-way analysis of variance revealed no variation in levels between patients who required imaging or had surgery compared to those who did not, with P-values of 0.76 and 0.85, respectively. Two patients died within 30 days of presentation. CONCLUSIONS CRP has poor diagnostic and prognostic capabilities as a single initial measurement in acute surgical patients. The statistical analyses imply that CRP levels are unable to accurately predict outcomes of such patients. Therefore, we suggest that CRP should not be used as a routine screening tool.
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Affiliation(s)
- Keith Wong
- University of Adelaide, South Australia, Australia.
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31
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Al-Jabi Y, El-Shawarby A. Value of C-reactive protein after neurosurgery: a prospective study. Br J Neurosurg 2010; 24:653-9. [DOI: 10.3109/02688697.2010.500408] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Identification of patients at risk for development of tertiary peritonitis on a surgical intensive care unit. J Gastrointest Surg 2009; 13:1358-67. [PMID: 19352781 DOI: 10.1007/s11605-009-0882-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Accepted: 03/24/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tertiary peritonitis (TP) is defined as a severe recurrent or persistent intra-abdominal infection after adequate surgical source control of secondary peritonitis (SP). The aim of this study was to analyze the characteristics of patients with SP who will further develop TP in order to define early diagnostic markers for TP. STUDY DESIGN Over a 1-year period, all patients on the surgical intensive care unit (ICU) with SP were prospectively assessed for the development of TP applying the definition of the ICU consensus conference. The Mannheim Peritonitis Index (MPI), C-reactive protein (CRP) and Simplified Acute Physiology Score II (SAPS II) were assessed at the initial operation (IO) that was diagnostic for SP and in the postoperative period. RESULTS Among 69 patients with SP, 15 patients further developed TP, whereas 54 patients did not develop TP. Compared to SP, patients with transition to TP had significantly higher MPI at IO (28.6 vs. 19.8; p < 0.001), relaparotomy rate (2.00 vs. 0.11; p < 0.001), mortality (60% vs. 9%; p < 0.001), duration of ICU stay (14 vs. 4 days; p < 0.005), as well as SAPS II (45.1 vs. 28.4; p < 0.005) and CRP (265 mg/dL vs. 217 mg/dL; p < 0.05) on the second postoperative day after IO. CONCLUSIONS The MPI at IO as well as CRP and SAPS II at the second postoperative day helps to identify patients at risk for tertiary peritonitis.
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Cole DS, Watts A, Scott-Coombes D, Avades T. Clinical utility of peri-operative C-reactive protein testing in general surgery. Ann R Coll Surg Engl 2008; 90:317-21. [PMID: 18492397 DOI: 10.1308/003588408x285865] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION C-reactive protein (CRP) is an acute-phase protein used clinically to diagnose infectious and inflammatory disease and monitor response to treatment. CRP measurement in the peri-operative period was audited and patterns of change analysed for elective general surgical patients. PATIENTS AND METHODS General surgical patients (201) admitted for elective general surgery over a 3-month period were considered for the study. CRP results pre- and postoperatively were recorded, and data on co-morbid conditions and surgical procedure were noted. RESULTS CRP was requested pre-operatively on 84% of patients. A high CRP was more likely to be found in patients with co-morbidity. Postoperatively, CRP was requested during the first 3 days on 69% of patients. CRP peaked at postoperative days two or three, and then fell. In patients who had a high pre-operative CRP, the peak CRP was higher and occurred later, than those who had a normal pre-operative CRP. CONCLUSIONS CRP requesting pre-operatively is common, but is not recommended in NICE guidelines. Postoperatively, CRP levels rise; as a result, its use as a tool to screen for infection is limited. CRP has a role in diagnosis of infection after the first three postoperative days and in monitoring response to treatment. Therefore, routine use of CRP measurements pre-operatively and in the first 2 or 3 days post-operatively is not recommended. A peri-operative CRP should only be requested if there is a clear clinical indication.
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Affiliation(s)
- Duncan S Cole
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK.
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Jensen JU, Lundgren B, Hein L, Mohr T, Petersen PL, Andersen LH, Lauritsen AO, Hougaard S, Mantoni T, Bømler B, Thornberg KJ, Thormar K, Løken J, Steensen M, Carl P, Petersen JA, Tousi H, Søe-Jensen P, Bestle M, Hestad S, Andersen MH, Fjeldborg P, Larsen KM, Rossau C, Thomsen CB, Ostergaard C, Kjaer J, Grarup J, Lundgren JD. The Procalcitonin And Survival Study (PASS) - a randomised multi-center investigator-initiated trial to investigate whether daily measurements biomarker Procalcitonin and pro-active diagnostic and therapeutic responses to abnormal Procalcitonin levels, can improve survival in intensive care unit patients. Calculated sample size (target population): 1000 patients. BMC Infect Dis 2008; 8:91. [PMID: 18620598 PMCID: PMC2491622 DOI: 10.1186/1471-2334-8-91] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Accepted: 07/13/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sepsis and complications to sepsis are major causes of mortality in critically ill patients. Rapid treatment of sepsis is of crucial importance for survival of patients. The infectious status of the critically ill patient is often difficult to assess because symptoms cannot be expressed and signs may present atypically. The established biological markers of inflammation (leucocytes, C-reactive protein) may often be influenced by other parameters than infection, and may be unacceptably slowly released after progression of an infection. At the same time, lack of a relevant antimicrobial therapy in an early course of infection may be fatal for the patient. Specific and rapid markers of bacterial infection have been sought for use in these patients. METHODS Multi-centre randomized controlled interventional trial. Powered for superiority and non-inferiority on all measured end points. Complies with, "Good Clinical Practice" (ICH-GCP Guideline (CPMP/ICH/135/95, Directive 2001/20/EC)). Inclusion: 1) Age > or = 18 years of age, 2) Admitted to the participating intensive care units, 3) Signed written informed consent.Exclusion: 1) Known hyper-bilirubinaemia. or hypertriglyceridaemia, 2) Likely that safety is compromised by blood sampling, 3) Pregnant or breast feeding. Computerized Randomisation: Two arms (1:1), n = 500 per arm: Arm 1: standard of care. Arm 2: standard of care and Procalcitonin guided diagnostics and treatment of infection. Primary Trial Objective: To address whether daily Procalcitonin measurements and immediate diagnostic and therapeutic response on day-to-day changes in procalcitonin can reduce the mortality of critically ill patients. DISCUSSION For the first time ever, a mortality-endpoint, large scale randomized controlled trial with a biomarker-guided strategy compared to the best standard of care, is conducted in an Intensive care setting. Results will, with a high statistical power answer the question: Can the survival of critically ill patients be improved by actively using biomarker procalcitonin in the treatment of infections? 700 critically ill patients are currently included of 1000 planned (June 2008). Two interim analyses have been passed without any safety or futility issues, and the third interim analysis is soon to take place. Trial registration number at clinicaltrials.gov: Id. nr.: NCT00271752).
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Affiliation(s)
- Jens-Ulrik Jensen
- Dept. Of Clinical Microbiology 445, Hvidovre Hospital, Kettegård Allé 30, DK-2650, Hvidovre, Denmark.
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Neumaier M, Scherer MA. C-reactive protein levels for early detection of postoperative infection after fracture surgery in 787 patients. Acta Orthop 2008; 79:428-32. [PMID: 18622849 DOI: 10.1080/17453670710015355] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE For early detection of postoperative infections, the level of C-reactive protein (CRP) may be useful. We analyzed baseline and time-dependent reference values for the postoperative use of CRP as an indicator of infection. METHODS We studied the kinetics of CRP levels after fracture surgery in 1,418 patients. In 787 cases the operative fracture treatment was uneventful; in 17 of the other cases a deep wound infection occurred. RESULTS In the uneventful cases, a similar evolution in CRP concentrations was found: the peak level, which occurred on the second postoperative day, depended on the region (136 mg/L in femoral fractures and 45 mg/L in ankle fractures) and reflected the extent of surgical trauma. For deep wound infection, a cutoff level of 96 mg/L (sensitivity 92%, specificity 93%) after the fourth day of surgery was recorded. INTERPRETATION CRP kinetics permit establishment of a time-dependent set of reference values of CRP after operative fracture treatment. Deviations of this course--especially CRP concentrations above 96 mg/L after the fourth day--may aid in early detection of surgical complications.
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Affiliation(s)
- Markus Neumaier
- Department of Trauma and Reconstructive Surgery, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany.
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Jensen JU, Lundgren JD. Procalcitonin in liver transplant patients--yet another stone turned. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:108. [PMID: 18254924 PMCID: PMC2374640 DOI: 10.1186/cc6221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Liver transplantation has been reported to initiate increases in procalcitonin levels, in the absence of bacterial infection. The results of a study investigating the course of procalcitonin levels over several days after liver transplantation in noninfected patients were recently reported in Critical Care. This study shows that procalcitonin levels increase only transiently, immediately after surgery, and thereafter they rapidly decrease. This new information gives us hope that procalcitonin can be used as a marker of bacterial infection in these patients. Further studies of patients undergoing liver transplantation with and without bacterial infection are needed.
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Welsch T, Frommhold K, Hinz U, Weigand MA, Kleeff J, Friess H, Büchler MW, Schmidt J. Persisting elevation of C-reactive protein after pancreatic resections can indicate developing inflammatory complications. Surgery 2008; 143:20-8. [PMID: 18154929 DOI: 10.1016/j.surg.2007.06.010] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Revised: 06/07/2007] [Accepted: 06/12/2007] [Indexed: 12/17/2022]
Abstract
BACKGROUND Serum C-reactive protein (CRP) is an established discriminating factor for necrotizing pancreatitis. In this study, the CRP response with respect to inflammatory postoperative complications was examined in a large, homogeneous series of pancreatic resections in order to define a relevant clinical parameter for early detection of inflammatory postoperative complications. METHODS 688 consecutive pancreatic resections with jejunal anastomosis were screened for inflammatory postoperative complications based on a prospective database. Ninety-one patients had at least one inflammatory postoperative complication and were compared to a subgroup of 60 consecutive patients with uneventful postoperative courses. RESULTS In the postoperative setting after pancreatic resection, CRP peaked on postoperative day (POD) 3 with a median serum CRP of 132 mg/L, and gradually decreased thereafter in patients with an uncomplicated postoperative course. In complicated cases (with the exception of cholangitis), increase in CRP was significantly greater, peaked on POD 3 (median CRP 173 mg/L), and persisted thereafter, whereas white blood cell count and body temperature did not differ significantly from uneventful courses until POD 6. The median day of diagnosis of inflammatory postoperative complications was POD 9. A cutoff CRP value of 140 mg/dL on POD 4 yielded a positive predictive value of 89.1% (adjusted to the prevalence of inflammatory postoperative complications: 48.7%) with a specificity of 87.1% and a sensitivity of 69.5% for inflammatory postoperative complications. CONCLUSION Persistence of CRP elevation above 140 mg/dL on POD 4 is predictive of inflammatory postoperative complications and should prompt an intense clinical search for major septic processes (e.g. pancreatic fistula or abscess) if pneumonia and wound infection are unlikely or excluded.
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Affiliation(s)
- Thilo Welsch
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
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Jensen JU, Løken J, Mohr T. Procalcitonin: Nice to Know, Need to know, or Needs Further Research? Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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40
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Jensen JU, Lundgren B, Lundgren JD. Meta-analysis of procalcitonin for sepsis detection. THE LANCET. INFECTIOUS DISEASES 2007; 7:499-500; author reply 502-3. [PMID: 17646020 DOI: 10.1016/s1473-3099(07)70164-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Jensen JU, Heslet L, Jensen TH, Espersen K, Steffensen P, Tvede M. Procalcitonin increase in early identification of critically ill patients at high risk of mortality. Crit Care Med 2006; 34:2596-602. [PMID: 16915118 DOI: 10.1097/01.ccm.0000239116.01855.61] [Citation(s) in RCA: 245] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate day-by-day changes in procalcitonin and maximum obtained levels as predictors of mortality in critically ill patients. DESIGN Prospective observational cohort study. SETTING : Multidisciplinary intensive care unit at Rigshospitalet, Copenhagen University Hospital, a tertiary reference hospital in Denmark. PATIENTS Four hundred seventy-two patients with diverse comorbidity and age admitted to this intensive care unit. INTERVENTIONS Equal in all patient groups: antimicrobial treatment adjusted according to the procalcitonin level. MEASUREMENTS AND MAIN RESULTS Daily procalcitonin measurements were carried out during the study period as well as measurements of white blood cell count and C-reactive protein and registration of comorbidity. The primary end point was all-cause mortality in a 90-day follow-up period. Secondary end points were mortality during the stay in the intensive care unit and in a 30-day follow-up period. A total of 3,642 procalcitonin measurements were evaluated in 472 critically ill patients. We found that a high maximum procalcitonin level and a procalcitonin increase for 1 day were independent predictors of 90-day all-cause mortality in the multivariate Cox regression analysis model. C-reactive protein and leukocyte increases did not show these qualities. The adjusted hazard ratio for procalcitonin increase for 1 day was 1.8 (95% confidence interval 1.3-2.7). The relative risk for mortality in the intensive care unit for patients with an increasing procalcitonin was as follows: after 1 day increase, 1.8 (95% confidence interval 1.4-2.4); after 2 days increase, 2.2 (95% confidence interval 1.6-3.0); and after 3 days increase: 2.8 (95% confidence interval 2.0-3.8). CONCLUSIONS A high maximum procalcitonin level and a procalcitonin increase for 1 day are early independent predictors of all-cause mortality in a 90-day follow-up period after intensive care unit admission. Mortality risk increases for every day that procalcitonin increases. Levels or increases of C-reactive protein and white blood cell count do not seem to predict mortality.
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Affiliation(s)
- Jens Ulrik Jensen
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Denmark.
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Laifer G, Wasner M, Sendi P, Graber P, Gratzl O, Huber P, Fluckiger U, Zimmerli W. Dynamics of serum procalcitonin in patients after major neurosurgery. Clin Microbiol Infect 2005; 11:679-81. [PMID: 16008624 DOI: 10.1111/j.1469-0691.2005.01205.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Classical markers of infection cannot differentiate reliably between inflammation and infection after neurosurgery. This study investigated the dynamics of serum procalcitonin (PCT) in patients following major neurosurgery. PCT concentrations remained < 0.2 ng/mL during the post-operative course. In contrast, leukocyte and neutrophil counts, as well as C-reactive protein (CRP) levels, increased significantly post-operatively (leukocytes, range 7.1-23.7 x 10(9)/L, p < 0.001; neutrophils, range 70.8-94.5%, p < 0.001; CRP, median 14 mg/L, range 3-95 mg/L, p < 0.001). Analysis of PCT levels using assays with improved sensitivity may be useful in the diagnosis of neurosurgical patients with post-operative fever of unknown origin.
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Affiliation(s)
- G Laifer
- Division of Infectious Diseases, University Hospitals Basel, Basel, Switzerland.
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Szakmany T, Toth I, Kovacs Z, Leiner T, Mikor A, Koszegi T, Molnar Z. Effects of volumetric vs. pressure-guided fluid therapy on postoperative inflammatory response: a prospective, randomized clinical trial. Intensive Care Med 2005; 31:656-63. [PMID: 15812629 DOI: 10.1007/s00134-005-2606-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2004] [Accepted: 03/01/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare intrathoracic blood volume (ITBV) guided fluid management and central venous pressure (CVP) guided therapy in ameliorating the progression of early systemic inflammatory response in patients undergoing major surgery. DESIGN Prospective, randomized clinical trial. PATIENTS Forty patients undergoing major abdominal surgery were randomized into CVP and ITBV groups. INTERVENTIONS In the CVP group the target CVP was 8-12 mmHg while in the ITBV group the goal was to keep the ITBV between 850 and 950 ml/m2 during the operation. MEASUREMENTS AND RESULTS Hemodynamic parameters were determined by single arterial thermodilution. Measurements were repeated every 30 min intraoperatively. Serum procalcitonin (PCT) and C-reactive protein (CRP) was monitored preoperatively, on ICU admission, and then daily for 3 days. Serum TNF-alpha levels were measured intraoperatively hourly and then daily for 3 days. There was no significant difference between the two groups regarding hemodynamic parameters at any assessment point. In the overall population changes in the stroke volume index showed a significant correlation with changes in CVP and ITBV. TNF-alpha levels remained in the normal range intraoperatively and during the three postoperative days in both groups. Preoperatively normal PCT and CRP levels increased significantly postoperatively, without significant differences between the groups. CONCLUSIONS ITBV guided fluid therapy did not alter the magnitude of inflammatory response as monitored by serum PCT, CRP, and TNF-alpha in the early postoperative period.
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Affiliation(s)
- Tamas Szakmany
- Department of Anesthesiology and Intensive Care, University of Pécs, Pécs, Hungary.
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Rau B, Krüger CM, Schilling MK. Procalcitonin: improved biochemical severity stratification and postoperative monitoring in severe abdominal inflammation and sepsis. Langenbecks Arch Surg 2004; 389:134-44. [PMID: 15007651 DOI: 10.1007/s00423-004-0463-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2004] [Accepted: 01/21/2004] [Indexed: 02/07/2023]
Abstract
BACKGROUND Infections and sepsis are among the most devastating complications in abdominal surgery and significantly contribute to morbidity and mortality. Early and reliable diagnosis of septic complications is notoriously difficult, and the search for novel approaches to overcome this problem is still a compelling issue for clinicians. Among a large array of inflammatory parameters, procalcitonin (PCT), the 116-amino-acid pro-peptide of calcitonin, has gained considerable importance in identifying patients at risk of developing infection and sepsis in clinical practice. METHODS Along with the latest insights into pathophysiological aspects of this pro-hormone, the literature as well as our own experience on the usefulness of PCT determinations in patients with severe inflammatory abdominal disorders was reviewed. RESULTS Although the term "sepsis" does not embrace the integral properties of PCT, a remarkable number of clinical studies have demonstrated the pivotal role of this parameter in the host response to microbial and fungal infections. In acute pancreatitis PCT allows early severity stratification and closely correlates with the development of subsequent pancreatic infections. In patients with peritonitis PCT reflects overall disease severity and is an early and reliable indicator of overall prognosis. Postoperative monitoring of PCT is a helpful tool to identify patients with evolving or persisting septic complications after elective and emergency abdominal surgery. CONCLUSIONS Compared with established biochemical routine variables, PCT significantly contributes to earlier and better stratification of patients at risk of developing septic complications and provides excellent prognostic assessment in severe abdominal inflammation. The currently available test systems render PCT an applicable and readily available parameter under clinical routine and emergency conditions.
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Affiliation(s)
- B Rau
- Department of General, Visceral, and Vascular Surgery, University of the Saarland, Kirrberger Strasse, 66421 Homburg/Saar, Germany.
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