Effect of cardiopulmonary bypass on serum procalcitonin and C-reactive protein concentrations

Procalcitonin for the diagnosis of postoperative bacterial infection after adult cardiac surgery: a systematic review and meta-analysis

BACKGROUND AND AIMS

Patients undergoing cardiac surgery are subject to infectious complications that adversely affect outcomes. Rapid identification is essential for adequate treatment. Procalcitonin (PCT) is a noninvasive blood test that could serve this purpose, however its validity in the cardiac surgery population is still debated. We therefore performed a systematic review and meta-analysis to estimate the accuracy of PCT for the diagnosis of postoperative bacterial infection after cardiac surgery.

METHODS

We included studies on adult cardiac surgery patients, providing estimates of test accuracy. Search was performed on PubMed, EmBase and WebOfScience on April 12th, 2023 and rerun on September 15th, 2023, limited to the last 10 years. Study quality was assessed with the QUADAS-2 tool. The pooled measures of performance and diagnostic accuracy, and corresponding 95% Confidence Intervals (CI), were calculated using a bivariate regression model. Due to the variation in reported thresholds, we used a multiple-thresholds within a study random effects model for meta-analysis (diagmeta R-package).

RESULTS

Eleven studies were included in the systematic review, and 10 (2984 patients) in the meta-analysis. All studies were single-center with observational design, five of which with retrospective data collection. Quality assessment highlighted various issues, mainly concerning lack of prespecified thresholds for the index test in all studies. Results of bivariate model analysis using multiple thresholds within a study identified the optimal threshold at 3 ng/mL, with a mean sensitivity of 0.67 (0.47-0.82), mean specificity of 0.73 (95% CI 0.65-0.79), and AUC of 0.75 (IC95% 0.29-0.95). Given its importance for practice, we also evaluated PCT's predictive capability. We found that positive predictive value is at most close to 50%, also with a high prevalence (30%), and the negative predictive value was always > 90% when prevalence was < 20%.

CONCLUSIONS

These results suggest that PCT may be used to help rule out infection after cardiac surgery. The optimal threshold of 3 ng/mL identified in this work should be confirmed with large, well-designed randomized trials that evaluate the test's impact on health outcomes and on the use of antibiotic therapy. PROSPERO Registration number CRD42023415773. Registered 22 April 2023.

ECMO in Myocardial Infarction-Associated Cardiogenic Shock: Blood Biomarkers as Predictors of Mortality

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (va-ECMO) can provide circulatory and respiratory support in patients with cardiogenic shock. The main aim of this work was to investigate the association of blood biomarkers with mortality in patients with myocardial infarction needing va-ECMO support.

METHODS

We retrospectively analyzed electronic medical charts from patients receiving va-ECMO support in the period from 2008 to 2021 at the Medical University Innsbruck, Department of Anesthesiology and Intensive Care Medicine.

RESULTS

Of 188 patients, 57% (108/188) survived to discharge, with hemorrhage (46%) and thrombosis (27%) as the most frequent adverse events. Procalcitonin levels were markedly higher in non-survivors compared with survivors during the observation period. The multivariable model identified higher blood levels of procalcitonin (HR 1.01, p = 0.002) as a laboratory parameter associated with a higher risk of mortality.

CONCLUSIONS

In our study population of patients with myocardial infarction-associated cardiogenic shock, deceased patients had increased levels of inflammatory blood biomarkers throughout the whole study period. Increased procalcitonin levels have been associated with a higher risk of mortality. Future studies are needed to show the role of procalcitonin in patients receiving ECMO support.

Utility of heparin-binding protein following cardiothoracic surgery using cardiopulmonary bypass

Cardiothoracic surgery using cardiopulmonary bypass (CPB) triggers an inflammatory state that may be difficult to differentiate from infection. Heparin-binding protein (HBP) is a candidate biomarker for sepsis. As data indicates that HBP normalizes rapidly after cardiothoracic surgery, it may be a suitable early marker of postoperative infection. We therefore aimed to investigate which variables influence postoperative HBP levels and whether elevated HBP concentration is associated with poor surgical outcome. This exploratory, prospective, observational study enrolled 1475 patients undergoing cardiothoracic surgery using CPB, where HBP was measured at ICU arrival. Patients with HBP in the highest tercile were compared to remaining patients. Multivariable logistic regressions were performed to identify factors predictive of elevated HBP and 30-day mortality. Overall median HBP was 30.0 ng/mL. Patients undergoing isolated CABG or surgery with CPB-duration ≤ 60 min had a median HBP of 24.9 ng/mL and 23.2 ng/mL, respectively. Independent predictors of elevated postoperative HBP included increased EuroSCORE, prolonged CPB-duration and high intraoperative temperature. Increased HBP was an independent predictor of 30-day mortality. This study confirms the promising characteristics of HBP as a biomarker for identification of postoperative sepsis, especially after routine procedures. Further studies are required to investigate whether HBP may detect postoperative infections.

Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults

BACKGROUND

Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness.

OBJECTIVES

The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies.

SELECTION CRITERIA

RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported.

DATA COLLECTION AND ANALYSIS

Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2.

MAIN RESULTS

A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low.

AUTHORS' CONCLUSIONS

A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.

Influence of Renal Dysfunction on the Differential Behaviour of Procalcitonin for the Diagnosis of Postoperative Infection in Cardiac Surgery

Background: procalcitonin is a valuable marker in the diagnosis of bacterial infections; however, the impairment of renal function can influence its diagnostic precision. The objective of this study is to evaluate the differential behaviour of procalcitonin, as well as its usefulness in the diagnosis of postoperative pulmonary infection after cardiac surgery, depending on the presence or absence of impaired renal function. Materials and methods: A total of 805 adult patients undergoing cardiac surgery with extracorporeal circulation (CBP) were prospectively recruited, comparing the behaviour of biomarkers between the groups with and without postoperative pneumonia and according to the presence or absence of renal dysfunction. Results: Pulmonary infection was diagnosed in 42 patients (5.21%). In total, 228 patients (28.32%) presented postoperative renal dysfunction. Procalcitonin was significantly higher in infected patients, even in the presence of renal dysfunction. The optimal procalcitonin threshold differed markedly in patients with renal dysfunction compared to patients without renal dysfunction (1 vs. 0.78 ng/mL p < 0.05). The diagnostic accuracy of procalcitonin increased significantly when the procalcitonin threshold was adapted to renal function. Conclusions: Procalcitonin is an accurate marker of postoperative infection in cardiac surgery, even in the presence of renal dysfunction. Renal function is an important determinant of procalcitonin levels and, therefore, its diagnostic thresholds must be adapted in the presence of renal dysfunction.

ECMO in Cardiogenic Shock: Time Course of Blood Biomarkers and Associated Mortality

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a temporary life support for severe cardiogenic shock, gaining time for organ recovery, permanent assistance, or transplantation. In this work, we aimed to investigate the trends of blood biomarkers over the period of ECMO support and their role in patient outcome.

METHODS

This retrospective study comprised patients receiving va-ECMO support over the period of 14 years at a tertiary university center.

RESULTS

Of 435 patients, 62% (268/435) survived to discharge, and the most frequent adverse event was hemorrhage (46%), followed by thrombosis (25%). Deceased patients had increased blood levels of C-reactive protein, procalcitonin, and white blood cells during the whole observation period, with higher peaks compared with survivors. The multivariable model identified hemorrhage (HR 1.73, p = 0.005) and higher levels of procalcitonin (HR 1.01, p = 0.001) as independent risk factors for death.

CONCLUSIONS

In our population of critically ill patients receiving va-ECMO support, deceased patients had increased inflammatory biomarkers during the whole observation period. Patients having higher values of procalcitonin and experiencing bleeding events showed an increased risk for mortality. Further studies focusing on inflammation in ECMO patients, clarifying its role in patient outcome and potential therapeutic interventions, are warranted.

A novel case of impaired C-reactive protein response following open-heart surgery: A case report and review of the literature

BACKGROUND

C-reactive protein (CRP) is expected to increase in response to a range of inflammatory stimuli such as infections or extensive tissue trauma.

CASE REPORT

We present a novel case of severely impaired CRP response following NSTEMI, influenza A infection and open-heart surgery in which serum CRP concentrations remained < 1 mg/L during an observational period of 28 days.

CONCLUSION

To our knowledge, no previous publications exists describing patients with a lack of CRP response following cardiothoracic surgery. We believe this to be a novel finding warranting further investigations regarding the etiology and prevalence of this phenomenon.

Heparin-binding protein and procalcitonin in the diagnosis of pathogens causing community-acquired pneumonia in adult patients: a retrospective study

The performance of inflammatory markers in community-acquired pneumonia (CAP) caused by different pathogens has not been fully studied. We sought to find the differences in the concentrations of procalcitonin (PCT) and heparin-binding protein (HBP) between patients with CAP caused by different pathogens. We enrolled 162 patients with CAP, divided into three groups on the basis of bacterial (n = 108), fungal (n = 21) and viral (n = 33) infection. Complete leukocyte counts and the concentration of HBP and PCT were measured, and the differences were compared with nonparametric tests. The receiver operating characteristic (ROC) curve was used to evaluate the significant differences in the sensitivity and specificity of the indicators. The leukocyte and neutrophils counts and the concentrations of HBP and PCT in the viral group were significantly lower than those in the other two groups (p < 0.001). The area under the ROC curve (AUC) of the concentration of HBP and PCT as well as leukocyte and neutrophils counts were 0.927, 0.892, 0.832 and 0.806 for distinguishing bacterial from viral infection, respectively. The best cut-off value was 20.05 ng/mL for HBP, with a sensitivity of 0.861 and specificity of 0.939. The best cut-off value was 0.195 ng/mL for PCT, with a sensitivity of 0.991 and specificity of 0.636. The best cut-off value was 5.195 × 10⁹/L and 4.000 × 10⁹/L for leukocyte and neutrophils counts, with sensitivity of 0.694 and 0.880 and specificity of 0.667 and 0.636, respectively. The AUC of HBP, PCT and leukocyte and neutrophil counts for distinguishing fungal from viral infection were 0.851, 0.883, 0.835 and 0.830, respectively. The best cut-off values were 29.950 ng/mL, 0.560 ng/mL, 5.265 × 10⁹/L and 3.850 × 10⁹/L, with sensitivity of 0.667, 0.714, 0.905 and 0.952 and specificity of 0.970, 0.879 0.667 and 0.606, respectively. There were no significant differences in the three indicators between the bacterial and fungal infection groups. The concentration of CRP showed no significant differences among the three groups. Consequently, the stronger immune response characterized by higher inflammation markers including HBP and PCT can help distinguish bacterial and fungal CAP from viral CAP.

Procalcitonin in special patient populations: Guidance for antimicrobial therapy

PURPOSE

Procalcitonin (PCT) is an endogenous hormone that increases reliably in response to bacterial infection, and measurement of serum PCT levels is recommended to help guide antimicrobial therapy. The utility of PCT assessment in special patient populations (eg, patients with renal dysfunction, cardiac compromise, or immunocompromised states and those undergoing acute care surgery) is less clear. The evidence for PCT-guided antimicrobial therapy in special populations is reviewed.

SUMMARY

In the presence of bacterial infection, nonneuroendocrine PCT is produced in response to bacterial toxins and inflammatory cytokines, resulting in markedly elevated levels of serum PCT. Cytokine induction in nonbacterial inflammatory processes activated by acute care surgery may alter the interpretation of PCT levels. The reliability of PCT assessment has also been questioned in patients with renal dysfunction, cardiac compromise, or immunosuppression. In many special populations, serum PCT may be elevated at baseline and increase further in the presence of infection; thus, higher thresholds for diagnosing infection or de-escalating therapy should be considered, although the optimal threshold to use in a specific population is unclear. Procalcitonin-guided antimicrobial therapy may be recommended in certain clinical situations.

CONCLUSION

Procalcitonin may be a reliable marker of infection even in special populations with baseline elevations in serum PCT. However, due to unclear threshold values and the limited inclusion of special populations in relevant clinical trials, PCT levels should be considered along with clinical criteria, and antibiotics should never be initiated or withheld based on PCT values alone. Procalcitonin measurement may have a role in guiding de-escalation of antibiotic therapy in special populations; however, the clinician should be aware of disease states and concomitant therapies that may affect interpretation of results.

Perioperative Procalcitonin in Predicting Infection in Children Undergoing Surgical Procedures

BACKGROUND

Procalcitonin (PCT) is a biomarker of bacterial infections with more sensitivity and specificity than commonly used inflammatory markers. PCT can be particularly helpful in the postsurgical population where the surgery itself often leads to noninfectious inflammation. We aimed to examine the utility of perioperative profiles of PCT in predicting infection in two pediatric surgical populations.

METHODS

We conducted a prospective observational study of perioperative PCT in children undergoing cardiac or neurosurgery. Consenting patients with no preoperative infection or immune deficiency were enrolled. We measured plasma PCT levels within 24 h preprocedure and 24-48 h postprocedure. Demographic, clinical, and laboratory data were collected from the medical records including clinical suspicion and confirmed infections. Perioperative PCT changes and their associations with these data are reported.

RESULTS

We enrolled 26 neuro and 15 cardiac surgery patients. There was postoperative clinical suspicion of infection in 3 neuro and 5 cardiac patients, and 1 neuro and 2 cardiac patients had subsequently confirmed infections. Cardiac patients had higher overall perioperative PCT increase than neuro cohort (P = 0.006). Neuro patient with infection had higher perioperative change in PCT (0.5 to 1.4 ng/mL) than noninfected neurosurgery patients. Cardiac patients with confirmed infections had higher postoperative levels which exceeded the previously described infection threshold of 2 ng/mL.

CONCLUSIONS

PCT is a useful early biomarker of postoperative infection in pediatric patients undergoing cardiac and neurosurgery. Patients who underwent cardiac surgery have significantly higher perioperative PCT rise than patients who underwent neurosurgery, and all patients with subsequently confirmed infections had at least 2-fold perioperative PCT increase.

Can serum procalcitonin levels be useful in predicting spontaneous ureteral stone passage?

Background

Medical expulsive therapy (MET) is recommended for ureteral stones when there is no indication for interventional treatment. Spontaneous passage (SP) may not always be perceived in patients undergoing MET. We aimed to demonstrate the effects of inflammatory factors on spontaneous ureteral stone passage in patients undergoing MET.

Methods

Our study was conducted between August and November, 2016, in healthy volunteers and patients with a single distal ureteral stone between 5 and 10 mm in diameter and no indications for interventional therapy. Blood and urine samples from all patients and healthy volunteers were tested. The patients were followed up every 2 weeks for 1 month unless emergency situations appeared. Patients with stone-free status at follow-up were concluded to have achieved complete stone passage [SP(+)], and failure [SP(−)] was concluded if the patient had not passed the stone by the end of the study. Blood samples of the patients and the control group were analyzed, recording WBC (white blood cell), CRP (c-reactive protein), SED (sedimentation), MPV (mean platelet volume), NLR (neutrophil-to-lymphocyte ratio), and serum procalcitonin levels. Abnormalities in urine samples were recorded. All patients received diclofenac sodium 75 mg/day, tamsulosin 0.4 mg/day, and at least 3 l/day fluid intake. Patients were followed for a month with kidney, ureter, bladder (KUB) plain films, ultrasonography (USG), and unenhanced abdominal CT scans while undergoing MET. Comparative statistical analyses were performed between the SP(+) and SP(−) groups.

Results

The procalcitonin levels of the SP(−) group were significantly higher (207 ± 145.1 pg/ml) than in the SP(+) group (132.7 ± 28.1 pg/ml) (p = 0.000). The leucocyturia rate of the SP(−) group was significantly higher than in the SP(+) group (p = 0.004). Based on the ROC curve analysis, 160 pg/ml (86.7% sensitivity, 70.8% specificity, p < 0.001; AUC: 0.788 95% CI (0.658–0.917) was identified as the optimal cut-off value for procalcitonin. In logistic regression analysis, a significant efficacy of procalcitonin and leucocyturia was observed in the univariate analysis on spontaneous passage. In the multivariate analysis, significant independent activity was observed with procalcitonin. (p < 0.05).

Conclusion

Our findings suggest that high procalcitonin levels and the presence of leucocyturia have a strong negative effect on SP of ureteral stones between 5 and 10 mm in diameter. This relationship can be explained by stone impaction, possibly caused by increased mucosal inflammation.

Procalcitonin Kinetics After Heart Transplantation and as a Marker of Infection in Early Postoperative Course

INTRODUCTION

Procalcitonin (PCT) is a biomarker of systemic infection. Specificity of PCT is decreased because PCT is also elevated after heart transplantation (HTx). There is no established normal range of serum PCT concentrations after HTx yet. Our aim was to determine the course of PCT concentrations in patients after HTx in the early postoperative period, if we can discriminate postoperative increase in values from infectious complications.

RESULTS

Of 39 patients we diagnosed infection in 11. These patients develop acute kidney injury significantly more often than in control group (group C) (5 in infection group [group I] and 2 in group C, P < .05), and 1 patient died within 30 days in group C. Seven patients developed primary graft dysfunction (3/4 + ECMO [extracorporeal membrane oxygenation], respectively, group I/group C) and 2 neurologic disorders in group I. Reoperation due to bleeding was 3 in each group. During the 14 days after HTx, serum PCT concentrations increased with maximum on the second postoperative day (group C: 30.6 ± 15.3 ng/mL; group I: 24.9 ± 44.3 ng/mL). Normal values for PCT were reached on day 8 in group C and 11 in group I. Mean PCT levels were similar: 8.7 ± 5.7 ng/mL vs 11.9 ± 13.1 ng/mL in group I vs group C, respectively. Patients in group I stayed longer in the intensive care unit.

CONCLUSIONS

Despite increase in serum concentration of PCT in early postoperative course after HTx there is no marker of infection. Trends in PCT serum concentration may be a valuable tool in diagnosis of infection in patients after HTx, but further investigation is needed.

Changes in the levels of inflammatory markers after transthoracic device closure of ventricular septal defects in pediatric patients

Background

Transthoracic device closure of ventricular septal defect (VSD) is widely used in the clinic, especially in China. Changes in inflammatory marker levels after transthoracic device closure of VSD in pediatric patients have not been reported.

Methods

We retrospectively collected clinical data for 85 pediatric patients in our hospital from September 2017 to January 2018. The patients were divided into two groups according to treatment (device group vs. surgical group). The clinical and experimental data from the two groups were statistically analyzed.

Results

Clinical outcomes were good in all patients without any fatal complications. Similar increasing trends in inflammatory markers (white blood cell (WBC) count, procalcitonin (PCT), C-reactive protein (CRP), and interleukin-6 (IL-6)) were found in the two groups, both of which showed noticeable systemic inflammatory responses. In addition, no significant difference in the postoperative levels of inflammatory markers was observed between these two groups.

Conclusions

Although transthoracic device closure of VSD seems to be less traumatic and involves a quicker recovery, it also induces a systemic inflammatory response as measured by WBC count and PCT, CRP and IL-6 levels, and the altered trends in inflammatory markers were similar to those of conventional surgery under CPB.

Prognostic Significance of Serum NGAL and Troponin I against Acute Kidney Injury in Egyptian ICU Patients after Open Heart Surgery: A Pilot Study

Background

Acute kidney injury (AKI) is a common complication following cardiac surgery and percutaneous coronary interventions, with an estimated incidence rate around 30%, depicted by long-term intensive care unit stay and culminating renal dysfunction over time, triggering either perpetual renal damage evolving to chronic kidney disease/end-stage renal disease transitions or high vulnerability for sudden death after surgery. The classical diagnosis of AKI is based on a sharp rise in serum creatinine that takes at least 48 h to be visible and is associated with multiple nonrenal factors.

Objective

We aimed to evaluate the predictive performance of both neutrophil gelatinase-associated lipocalin (NGAL) and Klotho for AKI in patients who underwent cardiothoracic surgery using cardiopulmonary bypass (CPB).

Results

Out of the 182 patients included in the study, 65 had AKI and 117 had non-AKI according to the Kidney Disease: Improving Global Outcomes criteria relying on serum creatinine levels. Baseline serum NGAL was 103.5 ± 41.69 μg/L in the AKI group compared to 79.12 ± 48.02 μg/L in the non-AKI group (p < 0.01) and then manifested a peak-fall-rise pattern until 48 h of CPB, with a more remarkable change in the AKI than in the non-AKI group. ROC curve analysis for all measured biomarkers after 2 h of CPB showed that serum NGAL (0.819, > 75% cutoff, 83.5% accuracy) came after serum creatinine (0.864, > 140% cutoff, 85% accuracy), and troponin I was poorer than both (0.606, > 5.5% cutoff, 60% accuracy). Furthermore, multivariate analysis showed that preoperative serum NGAL, preoperative eGFR ≤60 mL/min/1.73 m², and arterial hypertension were possible risk factors for AKI with adverse outcomes.

Conclusions

Our study suggests the role of preoperative serum NGAL as a prognostic tool for renal consequences after cardiac surgery. Besides, postoperative serum NGAL is a sensitive marker for AKI, but is less specific than serum creatinine. Troponin I is considered to be a risk confirmatory tool and may help in the prediction of AKI. However, its diagnostic utility is restricted due to age-dependent cutoff values and poor standardization and harmonization because of interassay variations.

Postoperative serum levels of Endocan are associated with the duration of norepinephrine support after coronary artery bypass surgery

BACKGROUND

Cardiopulmonary bypass (CPB) is associated with a systemic inflammatory response and an endothelial dysfunction, whose qualitative assessment appears to be a major issue. Endocan (ESM-1, endothelial cell specific molecule-1) is a protein preferentially expressed by the endothelium and previously associated with prognosis of septic shock or acute respiratory distress syndrome. In this pilot study, we investigated the kinetic of Endocan in planned coronary artery bypass grafting (CABG) surgery with CPB.

PATIENTS AND METHODS

We conducted an observational, prospective, mono centre study. All adult patients with left systolic ejection fraction>50%, undergoing planned on-pump CABG, were screened for inclusion. A written informed consent was obtained. Measurements and main results Serum Endocan concentrations were respectively 2.4 [2.1-3.0] ng. mL^-1, 10.4 [7.4-13.9] ng.mL^-1, 5.7 [4.4-8.2] ng.mL^-1, and 5.4 [4.1-7.5] ng.mL^-1 at day 0, day 1, day 3 and day 5. Endocan concentrations increased at day 1, day 3, and day 5 in comparison with preoperative concentration (P<0.001). In the multivariate analysis, age (P=0.002), history of acute coronary syndrome (P=0.024) and the catecholamine-free days at day 28 (P=0.007) were associated to the increase of perioperative Endocan concentrations.

CONCLUSION

Serum Endocan concentration increases after CABG surgery with CPB until day 1. The norepinephrine support increases the risk of Endocan release, suggesting a relationship between the kinetic of Endocan and the vasoplegic syndrome. At day 3, Endocan concentration decreases slowly but is not normalised at day 5. Further studies should investigate the prognostic value of the magnitude of postoperative Endocan concentration after cardiac surgery.

Acute systemic inflammatory response after cardiac surgery in patients infected with human immunodeficiency virus using clinical and inflammatory markers

BACKGROUND

Immediate post-cardiopulmonary bypass (CPB) immune responses and organ injuries in immune-compromised patients remain poorly documented.

METHOD

Sixty-one consecutive patients (30 HIV seropositive and 31 seronegative), undergoing elective cardiac valve(s) replacement were enrolled, from a single center hospital, after informed consent was obtained. C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) were used as biomarkers of acute inflammatory response.

RESULTS

The mean age was similar between the HIV seropositive and negative group. Pre-operatively, CRP (p=0.388) and ESR (p=0.817) were comparable. The CPB events and durations were significantly different between the two groups: duration (p=0.021), clamp aortic duration (p=0.026), bloodtransfusion (p=0.013), total urine output (p=0.035) and peak lactate (p=0.040). Post-operatively, there was significant increased biomarkers level in both groups, albeit not between the groups with a significant negative correlation between the mean change in CRP levels and mechanical ventilation (r=0.548, p=0.002) in the seropositive group (r=0.025, p=0.893). The correlation between pre-operative and post-operative difference in CRP and ICU stay was not significant in both groups. A significant drop (p=<0.001) in CD4 cells was documented post-operatively in the HIV seropositive group.

CONCLUSION

HIV positive patients' post-operative reactions to cardiac surgery supported by CPB are similar to those of HIV seronegative patients.

Influence of the postoperative inflammatory response on cognitive decline in elderly patients undergoing on-pump cardiac surgery: a controlled, prospective observational study

Background

The role of non-infective inflammatory response (IR) in the aetiology of postoperative cognitive dysfunction (POCD) is still controversial. The aim of this controlled, prospective observational study was to assess the possible relationship between the grade of IR, defined by procalcitonin (PCT) changes, and development of POCD related to cardiac surgery.

Methods

Forty-two patients, who were ≥ 60 years of age and scheduled for elective cardiac surgery, were separated into the low inflammatory (LIR) and high inflammatory (HIR) response groups based on their PCT levels measured on the first postoperative day. A matched normative control group of 32 subjects was recruited from primary care practice. The PCT and C-reactive protein (CRP) levels were monitored daily during the first five postoperative days. The cognitive function and mood state were preoperatively tested with a set of five neurocognitive tests and two mood inventories and at the seventh postoperative day. The Reliable Change Index modified for practice (RCIp) using data from normative controls was applied to determine the significant decline in test performance.

Results

The LIR (n = 20) and HIR (n = 22) groups differed significantly in the PCT (p < 0.001) but not in the CRP time courses. The incidence of POCD at the first postoperative week was 35.7% in the cohort. The LIR and HIR groups did not vary in the RCIp Z scores of neurocognitive tests and frequencies of POCD (7 vs 8 cases, respectively, p > 0.05). Additionally, there was no difference in the mood states, anxiety levels and perioperative parameters known to influence the development of POCD.

Conclusions

In this study, the magnitude of the non-infective inflammatory response generated by on-pump cardiac surgery did not influence the development of POCD in the early postoperative period in elderly patients.

Early Kinetics of Procalcitonin in Predicting Surgical Outcomes in Type A Aortic Dissection Patients

BACKGROUND

In cardiac surgery, elevation of procalcitonin (PCT) could be observed postoperatively in the absence of any evidence of infection and also seems to be a prognostic marker. PCT levels measured in patients undergoing Type A aortic dissection (TAAD) were used to determine prognostic values for complications and surgical outcomes.

METHODS

Measurements of PCT, C-reactive protein (CRP), and leukocyte count were observed in TAAD surgery patients (n = 251; average age: 49.02 ± 12.83 years; 78.5% male) at presurgery (T0) and 24 h (T1), 48 h (T2), and 7 days (T3) postsurgery. PCT clearance (PCTc) on days 2 and 7 was calculated: (PCTday1- PCTday2/day7)/PCTday1 × 100%. Endotracheal intubation duration, length of stay (LOS) in the Intensive Care Unit (ICU)/hospital, and complications were recorded.

RESULTS

PCT peaked 24 h postsurgery (median 2.73 ng/ml) before decreasing. Correlation existed between PCT levels at T1 and duration of cardiopulmonary bypass (P = 0.001, r = 0.278). Serum PCT concentrations were significantly higher in nonsurvivor and multiple organ dysfunction syndrome groups on all postoperative days. PCT levels at T1 correlated with length of time of ventilation support and ICU/hospital LOS. Comparing PCT values of survivors versus nonsurvivors, a PCT cutoff level of 5.86 ng/ml at T2 had high sensitivity (70.6%) and specificity (74.3%) in predicting in-hospital death. PCTc-day 2 and 7 were significantly higher in survivor compared with nonsurvivor patients (38% vs. 8%, P= 0.012, 83% vs. -39%, P< 0.001). A PCTc-day 7 cutoff point of 48.7% predicted survival with high sensitivity (77.8%) and specificity (81.8%).

CONCLUSIONS

PCT level and PCTc after TAAD surgery might serve as early prognostic markers to predict postoperative outcome. PCT measurement may help identify high-risk patients.

Diagnostic Value of Procalcitonin on Early Postoperative Infection After Pediatric Cardiac Surgery

OBJECTIVES

Assess the diagnostic value of serial monitoring of procalcitonin levels on early postoperative infection after pediatric cardiac surgery with cardiopulmonary bypass.

DESIGN

Prospective, observational study.

SETTING

A pediatric cardiac surgical ICU (PICU) and pediatric cardiac surgery department at Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College.

PATIENTS

Patients were 3 years old and below, underwent cardiac surgery involving cardiopulmonary bypass, the Aristotle Comprehensive Complexity score was 8 or higher and free from active preoperative infection or inflammatory disease.

INTERVENTIONS

Blood samples for measurement of procalcitonin, C-reactive protein, and WBC were taken before surgery and daily for 7 days in postoperative period. Clinical, laboratory, and imaging data were collected on enrollment. Procalcitonin, C-reactive protein, WBC levels, and procalcitonin variation were calculated and compared between those with and without infection.

MEASUREMENTS AND MAIN RESULTS

Two hundred and thirty-eight children were enrolled. Presence of infection within 7 days of surgery, length of intubation, and ICU stay were documented. Two independent experts in regard to the complete medical chart determined the final diagnosis of postoperative infection. Infection was diagnosed in 45 patients. Procalcitonin peaked on the first postoperative day. No differences were found on procalcitonin within 3 days after operation between the infected and the noninfected patients, and significant correlation was found between procalcitonin on postoperative days 1-3 and cardiopulmonary bypass duration. Serum procalcitonin concentration was always higher than 1.0 ng/mL within 7 days after surgery and/or procalcitonin variation between postoperative days 4 and 7 was positive in the infected patients. Best receiver operating characteristics curves area under the curve were obtained for procalcitonin and procalcitonin variation from postoperative days 5 to 7. WBC- and C-reactive protein-related receiver operating characteristics curves area under the curve revealed a very poor ability to predict infection. Logistic regression found that only procalcitonin on postoperative day 7 and PICU stay was independently correlated to the infection status. There was no significant correlation between the absolute value of procalcitonin and timing of infection.

CONCLUSIONS

Procalcitonin was more accurate than C-reactive protein and WBC to predict early postoperative infection, but the diagnostic properties of procalcitonin could not be observed during the first 3 postoperative days due to the inflammatory process related to cardiopulmonary bypass. The dynamic change of procalcitonin is more important than the absolute value to predict postoperative infection. The maintenance of a high level (procalcitonin > 1.0 ng/mL) within 7 days after surgery and/or a second increase in procalcitonin between the fourth and the seventh postoperative day could be used as an indicator of postoperative infection. Continuous procalcitonin monitoring might help to discover infection earlier.

Severe neutrophilic leukocytosis as a progression marker in granulocyte colony-stimulating factor-producing squamous cell carcinoma of the esophagus

There are very few reports of esophageal carcinoma producing granulocyte colony-stimulating factor (G-CSF). G-CSF-producing esophageal squamous cell carcinoma is an extremely aggressive carcinoma. Leukocyte counts, neutrophil counts, and serum C-reactive protein levels may be markers of its progression.

Prognostic value of procalcitonin in patients after elective cardiac surgery: a prospective cohort study

Background

Procalcitonin (PCT) is a well-known prognostic marker after elective cardiac surgery. However, the impact of elevated PCT in patients with an initially uneventful postoperative course is still unclear. The aim of this study was to evaluate PCT levels as a prognostic tool for delayed complications after elective cardiac surgery.

Methods

A prospective study was performed in 751 patients with an apparently uneventful postoperative course within the first 24 h after elective cardiac surgery. Serum PCT concentration was taken the morning after surgery. All patients were screened for the occurrence of delayed complications. Delayed complications were defined by in-hospital death, intensive care unit readmission, or prolonged length of hospital stay (>12 days). Odds ratios (OR) [with 95% confidence interval (CI)] were calculated by logistic regression analyses and adjusted for confounders. Predictive capacity of PCT for delayed complications was calculated by ROC analyses. The cutoff value of PCT was derived from the Youden Index calculation.

Results

Among 751 patients with an initially uneventful postoperative course, 117 patients developed delayed complications. Serum PCT levels the first postoperative day were significantly higher in these 117 patients (8.9 ng/ml) compared to the remaining 634 (0.9 ng/ml; p < 0.001). ROC analyses showed that PCT had a high accuracy to predict delayed complications (optimal cutoff value of 2.95 ng/ml, AUC of 0.90, sensitivity 73% and specificity 97%). Patients with PCT levels above 2.95 ng/ml the first postoperative day had a highly increased risk of delayed complications (adjusted OR, 110.2; 95% CI 51.5–235.5; p < 0.001).

Conclusions

A single measurement of PCT seems to be a useful tool to identify patients at risk of delayed complications despite an initially uneventful postoperative course.

Procalcitonin is useful whereas C-reactive protein is not, to predict complications following coronary artery bypass surgery

Background: The respective value of procalcitonin (PCT) and C-reactive protein (CRP) as markers of postoperative complications after coronary bypass surgery is unclear. Therefore, complications during one week after surgery were studied to evaluate the predictive role of PCT and CRP changes during the immediate postoperative period.

Methods: Thirty-two patients, in whom an uneventful immediate postoperative course was anticipated, were prospectively enrolled and followed-up to the 7th postoperative day. At the end of the follow-up, patients were divided into two groups. Group A were patients with an uncomplicated postoperative course and Group B were patients with a complicated postoperative course.

Results: Serum samples were drawn for PCT and CRP determination after induction of anesthesia (baseline), at the end of surgery and daily until postoperative day 2. Baseline serum PCT concentrations were 0.119 ± 0.09 and 0.209 ± 0.21 ng/mL in Groups A and B, respectively (NS). Serum PCT concentration increased compared with baseline in both groups during the first two days after surgery. The increase in serum PCT concentration was significantly greater in Group B than A patients ( p<0.0002). Considering a perioperative abnormal cut-off value of > 0.5 ng/mL, there were none in Group A versus 57% in Group B ( p<0.0001). Baseline serum CRP concentrations were 1.449 ± 1.30 and 1.589 ± 1.35 ng/mL in Groups A and B, respectively (NS). After surgery, CRP increased significantly compared with baseline in both groups. When changes in time-varying variables were included in a logistic model, complications were predicted by changes (between baseline and end of surgery values) of PCT (coefficient=9.410; t=2.18) and heart rate (coefficient=0.075; t=1.57), whereas changes of CRP, white blood cells, mean blood and central venous pressures did not contribute statistically. The model constant was -4.827 (t= -2.43) and the ROC curve area was 0.8971. Thus, absolute PCT changes of 0.20, 0.40 and 0.60 ng/mL carry an approximate risk of 5, 26 and 69%, respectively, of postoperative complications in the time frame of this study.

Conclusions: A postoperative serum PCT concentration of >0.5 ng/mL is highly suggestive of a postoperative complication. CRP changes do not contribute to predictive information.

Procalcitonin level for prediction of postoperative infection in cardiac surgery

BACKGROUND

Diagnosing infection after cardiac surgery remains difficult due to the systemic inflammatory response induced by cardiopulmonary bypass. We compared procalcitonin levels with white blood cell counts as predictors of infection after cardiac surgery.

METHODS

We prospectively enrolled 100 consecutive adult cardiac patients. Postoperative white blood cell counts, serum procalcitonin levels, and blood cultures were examined.

RESULT

The sensitivity and specificity of white blood cell count and procalcitonin > 2 ng mL(-1) were 60% and 100%, 58.8% and 42.5%, respectively. Procalcitonin > 7 ng mL(-1) had 95% sensitivity and 80% specificity. Receiver-operating characteristic analysis showed a greater area under the curve for procalcitonin level (p < 0.0001) compared to white blood cell count (p = 0.31). Patients with positive blood cultures had significantly higher procalcitonin levels (51.97 ± 39.62 vs. 6.67 ± 10.73 ng mL(-1)), Acute Physiology and Chronic Health Evaluation-II scores (16.95 ± 3.24 vs. 13.60 ± 2.98), and intensive care unit stay (6.35 ± 3.42 vs. 4.6 ± 2.2 days). Non-survivors had significantly higher Acute Physiology and Chronic Health Evaluation-II scores (19.09 ± 1.30 vs. 13.67 ± 2.97) and procalcitonin levels (43.83 ± 52.15 vs. 12.26 ± 19.89 ng mL(-1)) but on logistic regression analysis, only Acute Physiology and Chronic Health Evaluation-II score was an independent risk factor for mortality.

CONCLUSION

The diagnostic accuracy of procalcitonin for bacterial infection is fairly high. Acute Physiology and Chronic Health Evaluation-II score is a better predictor of mortality and morbidity than absolute procalcitonin level. Procalcitonin > 7 ng mL(-1) can prognosticate and identify the high-risk group.

The use and value of procalcitonin in solid organ transplantation

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.

Emotional processes in patients undergoing coronary artery bypass graft surgeries with extracorporeal circulation in view of selected indicators of the inflammatory condition

Background

The aim of this study was to describe positive and negative emotions in patients undergoing coronary artery bypass graft (CABG) surgeries with extracorporeal circulation and the correlations between emotions and basic indicators of the inflammatory condition: C-reactive protein (CRP) concentration, body temperature, and leukocyte count.

Material/Methods

Standardized tools were used to select 52 patients (aged 47–63 years, 6 women – 11.5% and 46 men – 88.5%) without dementia or depression. The Positive and Negative Affect Schedule (PANAS) was used to examine positive affect (PA) and negative affect (NA) and the State-Trait Anxiety Inventory (STAI X1 and X2) was used to examine the anxiety level. The patients underwent CABG surgery according to a common anesthesia protocol and for 5 consecutive days they were observed in the ward, where selected indicators of the inflammatory condition were monitored.

Results

A detailed description of the results of examinations of emotions was presented. The patients with low PA-trait level, high NA-trait level, and high anxiety-trait level (STAI X2) exhibited statistically significantly higher body temperatures than the other patients in the postoperative period. The patients with high NA-trait and anxiety-state levels (STAI X1) had statistically significantly lower CRP levels in the postoperative period than the patients with low NA-trait and anxiety-state levels (STAI X1).

Conclusions

Patients undergoing CABG operations express both positive and negative affects. The changes in the inflammatory markers are expressed mostly by CRP concentration. There exist relationships between the result of tests assessing emotions and the markers of the inflammatory condition.

C-reactive protein induces expression of tissue factor and plasminogen activator inhibitor-1 and promotes fibrin accumulation in vein grafts

BACKGROUND

C-reactive protein (CRP) promotes tissue factor (TF) and plasminogen activator inhibitor-1 (PAI-1) expression in vitro, and an elevated plasma CRP concentration is associated with an increased risk of vein graft (VG) thrombosis after coronary artery bypass surgery. However, little is known about the effects of CRP on VG TF and PAI-1 expression in vivo, or on VG thrombosis.

OBJECTIVES

We studied transgenic (Tg) mice expressing human CRP in a VG model to explore in vivo cause-and-effect relationships between CRP and TF, PAI-1, and VG thrombosis.

METHODS

Vein segments from wild-type (WT) and CRP-Tg donors were transplanted into carotid arteries of WT and CRP-Tg recipients. VGs were analyzed 1-4 weeks later.

RESULTS

Human CRP accumulated in VGs during the first 4 weeks after surgery, but appeared to originate exclusively from systemic sources, rather than local production. Human CRP significantly increased TF gene expression, protein concentration and activity in VGs. Human CRP also increased PAI-1 concentrations in VGs, although only in vascular endothelial cells. Human CRP stimulated macrophage migration, invasion into VGs, and TF expression. Fibrin deposition was significantly greater in VGs of CRP-Tg mice than in WT controls.

CONCLUSIONS

CRP accumulates in VGs early after surgery, originating from systemic sources rather than local synthesis. Human CRP promotes TF and PAI-1 expression in VGs, although with different expression patterns. Human CRP stimulates macrophage invasion and fibrin deposition within VGs. These results suggest that CRP induces pathologic changes in VGs that contribute to early VG occlusion.

A cardiopulmonary bypass with deep hypothermic circulatory arrest rat model for the investigation of the systemic inflammation response and induced organ damage

Background

Cardiopulmonary bypass (CPB) is a commonly used technique in cardiac surgery. CPB is however associated with a strong induction of systemic inflammatory response syndrome (SIRS) which in conjunction with ischemia and reperfusion may lead to multiple organ failure.

The aim of the study was to establish and characterize a CPB rat model incorporating deep hypothermic circulatory arrest with a specific focus on the extent of the inflammatory reactions and organ damage as a groundwork for novel therapeutics against SIRS and I/R induced organ injury.

Materials and methods

Male Wistar rats (n = 6) were cannulated for CPB, connected to a heart-lung-machine (HLM) and cooled to a temperature of 16°C before they underwent 45 minutes of deep hypothermic circulatory arrest with global ischaemia. Arrest was followed by rewarming and 60 minutes of reperfusion. Haemodynamic and vital parameters were recorded throughout the CPB procedure. Only animals displaying sinus rhythm throughout reperfusion were utilized for analysis. Rats were euthanized and tissue samples were harvested. Blood gas analysis was performed and blood samples were taken. Induction of organ damage was examined by analysis of protein levels and phosphorylation status of kinases and stress proteins. Results were compared to animals (n = 6) which did not undergo CPB.

Results

CPB induced leucocytosis and an increase of interleukin-6 and TNF-α plasma values indicating an inflammatory response. Markers of tissue damage and dysfunction, such as troponin T, creatinine and AST were elevated. Phosphorylation of STAT3 was induced in all examined organs. Activation of MAPK and induction of heat shock proteins occurred in an organ-specific manner with most pronounced effects in heart, lungs and kidneys.

Conclusions

The presented CPB rat model shows the induction of SIRS and activation of specific signalling cascades. SIRS seems not to be provoked during DHCA and is elicited mainly during reperfusion. This model might be suitable to test the efficacy of therapeutics applied in major heart surgery with and without DHCA.

Prevention of infectious complications after heart surgery in children: procalcitonin-guided strategy

Introduction

Infectious complications remain a significant problem of modern cardiac surgery. New prevention strategies, based on the pathogenesis of such complications occurring after cardiopulmonary bypass (CPB) procedures, should be evaluated.

Aim of the study

To evaluate the effectiveness of a procalcitonin (PCT)-guided strategy involving the use of IgM-enriched intravenous immunoglobulins (IVIGs) in children with congenital heart disease with systemic inflammation during the early postoperative period.

Material and methods

Sixty consecutive patients aged 25 (21-30) months who underwent cardiac surgery with CPB and had blood PCT levels > 2 ng/mL on the 1^st postoperative day were enrolled in this single-center prospective randomized clinical trial. The patients were randomized into two groups, comparable in terms of the severity of their initial condition, age, and CPB time. IgM-enriched IVIGs (Pentaglobin, Biotest Pharma GmbH, Germany) were administered during the first 3 postoperative days (5 mL/kg each day) in the study group (n = 30) in addition to the standard treatment, which was also provided to the control group (n = 30). The data are presented as medians with 25-75^th percentiles; they were compared by the Mann-Whitney U-test, and p values of < 0.05 were considered as statistically significant.

Results

Postoperatively, 1/30 (3.3%) patients in the study group and 8/30 (26.7%) in the control group suffered from infectious complications (study group: urinary tract infection [UTI] – 1; control group: pneumonia – 4, pneumonia and sepsis – 2, peritonitis with multiorgan failure – 1, UTI – 1), p = 0.03. The length of hospital stay in the study group was shorter than in the control group: 19 (16-23) days vs. 24 (19-29) days, p = 0.002, as was the length of intensive care unit (ICU) stay: 3 (2-4) days vs. 4 (2-8) days, p = 0.03.

Conclusions

High PCT levels on the 1st postoperative day are associated with an increased risk of infectious complications after cardiac surgery. Early administration of IgM-enriched IVIGs can prevent the development of infectious complications.

Unchanged plasma levels of the soluble urokinase plasminogen activator receptor in elective coronary artery bypass graft surgery patients and cardiopulmonary bypass use

OBJECTIVE AND DESIGN

The soluble urokinase plasminogen activator receptor (suPAR) has been recently recognized as a potential biological marker of various disease states, but the impact of a major surgical intervention on the suPAR level has not yet been established. The aim of our study was to investigate if the induction of a systemic inflammatory reaction in response to cardiopulmonary bypass would be accompanied by an increase in the plasma suPAR level.

METHODS AND SUBJECTS

Patients undergoing coronary artery bypass grafting under cardiopulmonary bypass (CPB) were added. Based on the baseline suPAR level, patients were divided into group 1 (suPAR within normal range) or group 2 (suPAR above range). Blood was collected before the induction of anesthesia and 6 and 24 hours after surgery. Plasma suPAR, IL-6, IL-8, TNF-α, troponin I, NT-proBNP, and NGAL were quantified to assess the impact of surgical trauma on these markers.

RESULTS

The baseline suPAR level was within the normal range in 31 patients (3.3 ng/mL), and elevated in 29 (5.1 ng/mL) (p<0.001). Baseline mediators of systemic inflammatory reaction concentrations (IL-6, TNF-α, and IL-8) and organ injury indices (troponin I, NT-proBNP, and NGAL) were low and increased after surgery in all patients (p<0.05). The surgery did not cause significant changes in the suPAR level either at 6 or 24 hours after, however the difference between groups observed at baseline remained substantial during the postoperative period.

CONCLUSIONS

There was no change in the suPAR level observed in patients subjected to elective cardiac coronary artery bypass surgery and CPB, despite activation of a systemic inflammatory reaction.

The role of procalcitonin and N-terminal pro-B-type natriuretic peptide in predicting outcome after cardiac surgery

OBJECTIVE(S)

Determine the thresholds of procalcitonin (PCT) and N-terminal pro-B-type natriuretic peptide (Nt-pro-BNP) associated with poor prognosis after heart surgery with CPB.

DESIGN

Prospective observational study.

SETTING

Academic Medical Center Habib Bourguiba.

PARTICIPANTS

Adult patients consecutively operated for coronary or valve surgery with CPB, elective or semi-urgent.

INTERVENTIONS

Serum concentrations of PCT and Nt-pro-BNP were determined before and after CPB, in the fourth postoperative hour (H4) and every day during the first 4 days. Receiver-operating characteristic curves and cut-off values were used to assess the ability of these markers to predict length of intensive care unit (ICU) stay >3 days.

MEASUREMENTS AND MAIN RESULTS

Forty patients were included in the study. Systemic inflammatory response syndrome (SIRS) occurred in 35 (87.5%) patients. Seventeen of them (42.5%) showed severe SIRS. Significantly higher serum concentrations of Nt-pro-BNP and PCT were found in patients with severe SIRS. Receiver operating characteristic (ROC) analysis showed that the threshold of PCT was 0.737 ng/mL and that of Nt-pro-BNP was 1235 pg/mL on day 1 could predict an ICU stay of more than 3 days. The association of Nt-pro-BNP to procalcitonin (p=0.009) better predicted the ICU stay than PCT alone (p=0.02) or Nt-pro-BNP alone (p=0.03). The best combination is Nt-pro-BNP + PCT + C-reactive protein (CRP) (p=0.007).

CONCLUSIONS

PCT and Nt-pro-BNP on day 1 may be associated with severe SIRS and predict the length of stay. A biomarker approach combining PCT, CRP and BNP is superior to a traditional single marker for predicting ICU stay.

Procalcitonin in acute cardiac patients

Procalcitonin (PCT) levels are below the detection level in healthy subjects, while pre-procalcitonin mRNA is over expressed in human medullar thyroid carcinoma, in small cell lung tumor, and occasionally in other rare neuroendocrine tumors such as phaeochromocytoma. PCT is known as a sensitive and specific biomarker for bacterial sepsis, being produced by extra-thyroidal parenchymal tissues, mainly hepatocytes. The increase in plasma level correlates with the severity of infection and the magnitude and the time course of its increase can be strictly related to the patient's outcome, and to the bacterial load. So far, data on serum PCT levels in patients with cardiogenic shock and in those with acute coronary syndromes (ACS) are scarce and controversial. While some studies report that PCT levels are increased in ACS patients on admission, other investigations document that plasma PCT concentrations are in the normal range. We recently reported that the degree of myocardial ischemia (clinically indicated by the whole spectrum of ACS, from unstable angina to cardiogenic shock following ST-elevation myocardial infarction) and the related inflammatory-induced response are better reflected by C-reactive protein (which was positive in most acute cardiac care patients of all our subgroups) than by PCT, which seems more sensitive to a higher degree of inflammatory activation, being positive only in patients with cardiogenic shock. Few studies investigated the dynamics of PCT in cardiac acute patients, and, despite the paucity of data and differences in patients' selection criteria, an increase in PCT values seems to be associated with the development of complications. In acute cardiac patients, the clinical values of procalcitonin rely not on its absolute value, but only on its kinetics over time.

[Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery]

INTRODUCTION AND OBJECTIVES

The systemic inflammatory response syndrome developed after cardiac surgery impedes the detection of complications. The aim of our study was to examine the behaviour of C-reactive protein (CRP) and procalcitonin (PCT), as well as to evaluate its relationship with severity and to analyse its usefulness in the identification of complications.

METHODS

A total of 59 children who underwent cardiac surgery with cardiopulmonary bypass were prospectively studied. CRP and PCT were determined after surgery and at 24, 48 and 72 hours. The relationships between both parameters and the clinical severity were analysed (evaluated with PRISM and TISS scoring systems), as well as with the incidence of complications (infectious and haemodynamics).

RESULTS

Serum concentrations of CRP and PCT increased in the first 24 hours after surgery, with a gradual decrease over the following days. There was no association between CRP and severity or development of complications. A moderate correlation was observed between PCT after surgery, at 24 and 48 hours, and PRISM (r=0.548; 0.434 and 0.446) and a low correlation between PCT and TISS. When studying the identification of complications, we obtained cut-off values of PCT>0.17ng/ml (Ss 73.3%; Sp 72.2%) and PCT>1.98ng/ml (Ss 57.1%; Sp 87%) immediately and 48 hours after surgery. No differences were found in CPR and PCT levels among patients with infectious and haemodynamics complications.

CONCLUSIONS

CPR does not correlate with the severity or the incidence of complications after paediatric cardiac surgery. PCT correlates with clinical severity and may be able to detect post-surgical complications.

Kinetics of procalcitonin in cardiogenic shock and in septic shock. Preliminary data

BACKGROUND

In cardiac acute patients, data on procalcitonin (PCT) are controversial and the clinical interpretation of absolute PCT values represents a major challenge since they may be influenced by several factors. No data are so far available on the dynamics of PCT levels in patients with cardiogenic shock.

AIMS

to evaluate the serum evolution of PCT during intensive cardiac care unit (ICCU) staying in a group of 24 patients with cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI) with no laboratory or clinical sign of infection. Furthermore we assessed the kinetics of PCT in a series of 24 patients with septic shock.

RESULTS

In septic shock, no significant difference was detectable in PCT kinetics between survivors (R2 = 0.90; P = 0.051) and non-survivors (R2 = 0.63; P = 0.204). In cardiogenic shock, survivors exhibited a significant reduction in PCT values (R2 = 0.94; P = 0.032) while non survivors did not (R2 = 0.68; P = 0.178).

CONCLUSIONS

differently from septic shock, cardiogenic shock following STEMI was associated with heterogeneous patterns of temporal PCT variations since only patients who survived exhibited a significant PCT reduction during ICCU stay. Our findings support the contention that the 'dynamic' approach may be more reliable that the static one especially in cardiogenic shock.

No effect of a homoeopathic combination of Arnica montana and Bryonia alba on bleeding, inflammation, and ischaemia after aortic valve surgery

AIMS

" Arnica montana is a popular homoeopathic treatment with potential haemostatic and anti-inflammatory properties. A homoeopathic combination of A. montana and Bryonia alba was used in aortic valve surgery to evaluate its effectiveness in reducing bleeding, inflammation, pain and myocardial ischaemia.

METHODS

One day before surgery, 92 adult patients were randomly assigned to a double-blind parallel trial with either homoeopathic granules or a matching placebo until 4 days after surgery. The primary outcome was the volume of blood/liquid in the drains at their removal. The secondary outcomes included postoperative blood/liquid losses at 12 and 24 h as well as C-reactive protein (CRP), pain, temperature and plasma troponin Ic.

RESULTS

At 12 h and 24 h after surgery, then at drain removal, blood losses in homoeopathy and placebo groups were not statistically significant (362 +/- 218, 520 +/- 269 and 640 +/- 297 ml vs. 456 +/- 440, 620 +/- 477 and 796 +/- 717 ml; P= 0.19, 0.23 and 0.35, respectively). The statistical modelling did not show significantly different patterns of CRP, troponin and body temperature changes or of pain perception. The number of transfused packed red cells was not significantly different either (P= 0.58). Two patients from each group died during the study period and the number of serious adverse events was not statistically different (six in homoeopathy vs. 10 in placebo groups; Fisher's exact test P= 0.41).

CONCLUSIONS

In the study setting, there was no evidence of effects of A. montana and B. alba combination on bleeding, inflammation, pain or myocardial ischaemia.

C-reactive protein levels and post-ICU mortality in nonsurgical intensive care patients

BACKGROUND

There are no data on the association between acute inflammation during critical illness and long-term mortality in ICU patients.

METHODS

Nonsurgical patients with an ICU length of stay > 24 h surviving until ICU discharge were included into this prospective, observational, follow-up study. Demographics, chronic diseases, admission diagnosis, the Simplified Acute Physiology Score (SAPS) II, length of ICU stay, maximum C-reactive protein (CRP) levels during the ICU stay (CRPmax), and CRP levels at ICU discharge (CRPdis) were documented. After a follow-up time of 1.88 ± 1.16 years (range, 0.5-4 years), the survival status was determined.

RESULTS

Seven hundred sixty-five patients were enrolled into the study protocol. One hundred fifty-eight patients (20.7%) died within 0.62 ± 0.88 years after ICU discharge. Cumulative survival rates differed between patients grouped into the CRPmax and CRPdis quartiles. Patients in the first and second CRPmax quartiles had better cumulative survival rates than those in higher CRPmax quartiles (all P < .001). Patients in the first CRPdis quartile had better cumulative survival rates than those in higher CRPdis quartiles (all P < .001). Using adjusted Cox proportional hazards models, both CRPmax and CRPdis were independently associated with post-ICU mortality (both P < .001). Furthermore, the number of chronic diseases (P < .001), age (P < .001), and the SAPS II (P = .03) were associated with post-ICU mortality in both Cox models.

CONCLUSIONS

CRP levels during critical illness seem independently associated with post-ICU survival in nonsurgical ICU patients. Future research focusing on the association between acute systemic inflammation and post-ICU outcome is warranted in order to improve long-term survival of critically ill patients.

Effect of cardiopulmonary bypass on activated partial thromboplastin time waveform analysis, serum procalcitonin and C-reactive protein concentrations

Introduction

Systemic inflammatory response syndrome (SIRS) is a frequent condition after cardiopulmonary bypass (CPB) and makes conventional biological tests fail to detect postoperative sepsis. Biphasic waveform (BPW) analysis is a new biological test derived from activated partial thromboplastin time that has recently been proposed for sepsis diagnosis. The aim of this study was to investigate the accuracy of BPW to detect sepsis after cardiac surgery under CPB.

Methods

We conducted a prospective study in American Society of Anesthesiologists' (ASA) physical status III and IV patients referred for cardiac surgery under CPB. Procalcitonin (PCT) and BPW were recorded before surgery and every day during the first week following surgery. Patients were then divided into three groups: patients presenting no SIRS, patients presenting with non-septic SIRS and patients presenting with sepsis.

Results

Thirty two patients were included. SIRS occurred in 16 patients (50%) including 5 sepsis (16%) and 11 (34%) non-septic SIRS. PCT and BPW were significantly increased in SIRS patients compared to no SIRS patients (0.9 [0.5-2.2] vs. 8.1 [2.0-21.3] ng/l for PCT and 0.10 [0.09-0.14] vs. 0.29 [0.16-0.56] %T/s for BPW; P < 0.05 for both). We observed no difference in peak PCT value between the sepsis group and the non-septic SIRS group (8.4 [7.5-32.2] vs. 7.8 [1.9-17.5] ng/l; P = 0.67). On the other hand, we found that BPW was significantly higher in the sepsis group compared to the non-septic SIRS group (0.57 [0.54-0.78] vs. 0.19 [0.14-0.29] %T/s; P < 0.01). We found that a BPW threshold value of 0.465%T/s was able to discriminate between sepsis and non-septic SIRS groups with a sensitivity of 100% and a specificity of 93% (area under the curve: 0.948 +/- 0.039; P < 0.01). Applying the previously published threshold of 0.25%T/s, we found a sensitivity of 100% and a specificity of 72% to discriminate between these two groups. Neither C-reactive protein (CRP) nor PCT had significant predictive value (area under the curve for CRP was 0.659 +/- 0.142; P = 0.26 and area under the curve for PCT was 0.704 +/- 0.133; P = 0.15).

Conclusions

BPW has potential clinical applications for sepsis diagnosis in the postoperative period following cardiac surgery under CPB.

The Role of Procalcitonin in Gynaecological Surgery

We evaluated postoperative concentrations of inflammatory indicators, including procalcitonin, after gynaecological operations for benign and malignant tumours in patients with a normal postoperative course and assessed the utility of procalcitonin in differentiating between non-bacterial inflammation and bacteraemic complications in the postoperative period. This prospective study included 99 patients: 47 after a standard gynaecological operation (Piver I) and no postoperative infectious complications (group 1), 35 after a major procedure (Piver II or III) and no postoperative infectious complications (group 2), and five with postoperative sepsis after Piver II or III procedures (group 3). We also studied serum procalcitonin concentrations in a group of 12 patients (group 4) with terminal forms of gynaecological cancer who were hospitalized for palliative treatment but did not undergo surgery. Postoperative C-reactive protein (CRP) concentration corresponded with extent of tissue trauma in groups 1 and 2 and was significantly lower in group 1 than group 2. Inflammatory indicators were highest in groups 1 and 2 on postoperative day 2. In group 3, in which sepsis developed, values were highest on postoperative day 4. In particular, procalcitonin was > 2 ng/ml in all patients with postoperative sepsis by postoperative day 2 but was always ≤ 2 ng/ml in patients without sepsis. In contrast, high procalcitonin levels were noted in the patients in group 4 compared with group 3, with two-thirds of group 4 patients having levels > 2 ng/ml, with no signs of infection or raised CRP. It is concluded that, for early detection of postoperative infectious complications after gynaecological surgery, procalcitonin levels > 2 ng/ml are more specific than CRP.

Serum concentrations of procalcitonin after cardiac surgery

BACKGROUND AND AIM

Monitoring of complications in patients undergoing cardiac surgery may be difficult because cardiopulmonary bypass (CPB) can lead to a systemic inflammatory response syndrome because of exposure of blood to nonphysiological surfaces. The purpose of the study was to establish the baseline levels of procalcitonin (PCT) after cardiac surgery in our population in order to analyze a possible induction of the inflammatory response that might interfere with the diagnosis of infection by PCT.

METHODS

Serum samples from patients undergoing coronary artery bypass grafting or valve replacement were collected at the time of admission to intensive care unit, after surgery as well as in the first and second postoperative days. Patients were followed for the development of postoperative complications. PCT levels were measured by immunoluminometric assay.

RESULTS

The mean PCT values were significantly higher in the first postoperative day in all the groups except the control group. No increased PCT levels were found related neither to duration of CPB, nor to time of aortic clamping. Only patients who presented complications had significantly increased PCT values immediately after surgery (p = 0.004), in the first postoperative day (p < 0.0001), and in the second postoperative day (p < 0.0001) with respect to those who recovered uneventfully.

CONCLUSIONS

A slight and transient increase in PCT levels was observed in the first postoperative day after cardiac surgery. Significant elevation of PCT was only observed when complications were present.

Is C-reactive protein a biomarker for immediate clinical outcome after cardiac surgery?

OBJECTIVE

The purpose of this study was to determine the possible correlation between inflammatory activation after cardiac surgery with cardiopulmonary bypass, measured by postoperative C-reactive protein concentrations, and immediate intensive care unit outcome.

DESIGN

A prospective, clinical cohort study.

SETTING

A 10-bed surgical intensive care unit at a tertiary university hospital.

PATIENTS

Two hundred sixteen consecutive patients undergoing nonemergency cardiac surgery with cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

Parsonnet and Acute Physiology and Chronic Health Evaluation scores, characteristics of the surgical intervention, intensive care unit length of stay, and mortality were recorded along with the following variables: cardiac (hours requiring inotropic support and new atrial fibrillation), respiratory (oxygenation index and hours requiring intubation), renal (difference between serum creatinine at admission and maximum creatinine), and analytic (C-reactive protein at admission and 6, 24, and 48 hours later; troponin I; CK-MB; and lactate).

RESULTS

Postoperative C-reactive protein concentrations did not correlate with variables such as time requiring inotropic support or intubation, oxygenation index, delta serum creatinine, and intensive care unit length of stay (with the exception of cardiopulmonary bypass time and the more frequent norepinephrine requirement in patients with higher C-reactive protein concentration at 48 hours); nor did C-reactive protein correlate with the analytic variables (with the exception of the lactate peak and C-reactive protein concentrations at 24 and 48 hours). There was no correlation between C-reactive protein and postoperative variables for coronary artery bypass graft surgery and valvular groups analyzed separately.

CONCLUSION

Postoperative C-reactive protein does not seem to be a useful marker in predicting outcome after 48 hours in the intensive care unit.

Atrial fibrillation following cardiac surgery: clinical features and preventative strategies

Atrial fibrillation (AF) is a common complication of cardiac surgery, with an increasing incidence. Post-operative AF results in many complications and increased healthcare resources. Despite substantial interest in the prediction and prevention of post-operative AF, as well as guidelines for the management of this common arrhythmia, there is still some uncertainty about appropriate risk stratification and management. The aim of this review article is to provide an overview of clinical predictive features for the development of AF following cardiac surgery and suitable preventive measures, using both antiarrhythmic and non-antiarrhythmic strategies.

'Lone' increase in C-reactive protein after cardiac surgery: prevalence, clinical characteristics, in-hospital course, and prognostic value

BACKGROUND

Serum C-reactive protein (CRP) is involved in the acute phase reaction after surgery, even though its clinical significance remains a matter of debate. We evaluated CRP levels in cardiac surgery patients without clinical or laboratory signs of infection.

METHODS

We screened 737 consecutive patients referred to our center 8+/-5 days after cardiac surgery. Patients with fever (>37.2 degrees C), elevated white blood cell count (>11,000/ml), neutrophilia (>70%), or any inflammatory, infective or malignant disease were excluded. CRP levels were measured on admission and at discharge and the values were related to the following variables: age, sex, diabetes mellitus, renal failure, type of surgery, postoperative atrial fibrillation, pericardial or pleural effusion, and length of hospital stay. Follow-up (mean: 23+/-8.5 months) was available for 175 patients (94%).

RESULTS

In the 187 patients enrolled in the study, the CRP values were significantly elevated (median: 4.23 mg/dl, interquartiles range: 2.68-6.64) independent of any variable analyzed. At discharge, CRP levels were significantly reduced compared with values on admission (median: 1.55 mg/dl, interquartiles range: 0.84-2.37, P<0.001). At follow-up, 19 events (10.8%) occurred (two noncardiac deaths, 17 hospital readmissions for cardiac reasons); nonetheless, no correlation was found with CRP values either on admission or at discharge.

CONCLUSION

Early after cardiac surgery, in patients without clinical or laboratory signs of acute infection, CRP levels are significantly elevated, do not correlate with clinical variables, and decrease at discharge. These findings suggest a systemic inflammatory response to surgery-related stress, which carries a favorable prognosis at follow-up.

Sepsis is characterized by the increases in percentages of circulating CD4+CD25+ regulatory T cells and plasma levels of soluble CD25

The function of immune system is to protect hosts from invading microorganisms by destroying infected cells while minimizing damage to tissues. Among immune cells, CD4(+)CD25(+) regulatory T cells (Treg cells) control immune responses by limiting infectious processes. However, it remains unclear whether Treg cells are induced in systemic inflammatory response syndrome (SIRS) or infectious SIRS (i.e. sepsis). SIRS and sepsis are associated with stressful inflammatory conditions. We therefore measured CD25(+) T cells and circulating CD4(+) T cells, along with plasma levels of CD25, interleukin (IL)-6, and IL-10, in 20 septic patients (64 +/- 11 years), 16 SIRS patients (59 +/- 16 years), and control subjects: 13 elderly (60 +/- 16 years) and 14 young volunteers (28 +/- 3 years). Septic patients (23.3 +/- 11.8%, p < 0.01) showed significantly higher percentages of CD25(+) cells among CD4(+) T cells (i.e. Treg cells) than did either young (10.6 +/- 3.7%) or elderly volunteers (11.1 +/- 3.8%). The percentages of Treg cells in septic patients were higher than those in SIRS patients (12.4 +/- 6.9%, p < 0.01). Moreover, plasma levels of soluble CD25 were significantly higher in septic patients, compared to the levels in SIRS patients or volunteers (p < 0.01). No significant difference in plasma levels of IL-6 or IL-10 was found between septic patients and SIRS patients. Thus, sepsis is associated with the increased percentages of Treg cells and elevated plasma level of soluble CD25. The elevation of these parameters might be a useful marker of infections in SIRS.

Lipopolysaccharide-binding protein: a new biomarker for infectious endocarditis?

BACKGROUND

Infectious endocarditis (IE) is a bacterial infection of the endocardium. Diagnosis is based on results obtained from echocardiography, blood cultures, and molecular genetic screening for bacteria and on data for inflammatory markers such as the leukocyte (WBC) count and the C-reactive protein (CRP) concentration. The aim of the present study was to evaluate lipopolysaccharide-binding protein (LBP) as a supportive biomarker for the diagnosis and therapeutic monitoring of IE.

METHODS

We measured LBP and CRP concentrations and WBC counts in 57 IE patients at hospital admission, 40 patients with noninfectious heart valve diseases (HVDs), and 55 healthy blood donors. The progression of these 3 markers and the influence of cardiac surgery on them were evaluated in 29 IE patients and 21 control patients.

RESULTS

Serum LBP concentrations were significantly higher in IE patients [mean (SD), 33.41 (32.10) mg/L] compared with HVD patients [6.67 (1.82) mg/L, P < 0.0001] and healthy control individuals [5.61 (1.20) mg/L]. The progression in the LBP concentration during therapy of IE patients correlated with the changes in the CRP concentration. The 2 markers were equally influenced by antibiotic treatment and surgical intervention.

CONCLUSIONS

Serial LBP measurement may provide an effective and useful tool for evaluating the response to therapy in IE patients. We found a strong correlation between LBP and CRP concentrations; LBP has a tendency to increase earlier in cases of reinfection.

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

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).

Combination of biphasic transmittance waveform with blood procalcitonin levels for diagnosis of sepsis in acutely ill patients

OBJECTIVES

To assess the diagnostic utility of combining measurement of blood procalcitonin (PCT) concentrations with the presence of a biphasic transmittance waveform (BPW) from the activated partial thromboplastin time (aPTT) to identify sepsis in critically ill patients.

DESIGN

Prospective observational study.

SETTING

Thirty-one-bed university hospital department of medico-surgical intensive care.

PATIENTS

Two hundred consecutive adult patients admitted to the department during a 3-month period.

MEASUREMENTS AND MAIN RESULTS

aPTT waveform analysis was performed on admission and daily throughout the intensive care unit (ICU) stay. Receiver operating characteristic curves were created to determine the best threshold values of BPW and PCT for prediction of sepsis. Of the 200 patients, 63 (32%) had sepsis during the ICU stay; 29 (15%) patients were diagnosed with sepsis at admission. Using a threshold value of BPW slope_1 = -0.075%T/sec, 37 patients (19%) had a BPW at ICU admission and 84 (42%) at some time during the ICU stay. At this threshold, 23 of the patients (62%) with a BPW at admission and 51 (61%) with a BPW during the ICU stay were diagnosed with sepsis. Using a cut-off value of 1 ng/ml, 60 patients (30%) had abnormal PCT at admission, and 86 during the ICU stay. At this threshold, 24 of the patients (40%) with abnormal PCT at admission and 52 (60%) with abnormal PCT during the ICU stay were diagnosed with sepsis. Thirty patients had a BPW and an abnormal PCT, and 23 (77%) of these had sepsis. Of the other 170 patients, only six patients (4%) had sepsis. Hence, the sensitivity of the combination of BPW and PCT at admission was 79% and specificity 96%; the negative predictive value was 96%.

CONCLUSION

aPTT waveform analysis is an easy and rapid method for identification of sepsis; its combination with PCT increases its specificity.