Pre-surgical peripheral blood inflammation markers predict surgical site infection following mesh repair of groin hernia

Surgical site infection (SSI) is a costly postoperative complication with a decrease in the quality of life. We aimed to probe the predictive role of peripheral blood inflammation markers for SSI following mesh repair of groin hernia (GH).This retrospective study assessed the data of 1177 patients undergoing elective mesh repair of GH (open/laparoscopy) in the absence of antibiotic prophylaxis. The relation between demographics, surgical factors, pre-surgical laboratory results and the occurrence of SSI were investigated by univariate and multivariate analyses. Receiver operating characteristic analysis was performed to determine the optimal threshold of parameters and compare their veracity.The overall SSI rate was 3.2% with 1-year follow-up (38 superficial and 1 deep SSI). Patients with SSI had significant higher pre-surgical neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) than those without (P = .029 and P = .045, respectively); their NLR and PLR correlated positively with postoperative total days of antibiotic treatment for SSI (r = .689, P = .000; r = .493, P = .001; respectively). NLR and PLR had larger areas under the receiver operating characteristics curves than neutrophil (.875 vs. .601; P = .000; .726 vs. .601; P = .017). The combination of PLR and neutrophil/NLR raised the predictive sensitivity of PLR for SSI (sensitivity: PLR: 74.36%; PLR + neutrophil: 82.05%; PLR + NLR: 83.57%). On multivariate analyses, higher preoperative NLR (cut-off 2.44) and PLR (cut-off 125.42) were independent predictors for SSI.Higher pre-surgical NLR and PLR may be valuable predictors for SSI following elective mesh repair of GH.

Diagnostic performance of suction drainage fluid culture for acute surgical site infection after aseptic instrumented spine surgery: a retrospective analysis of 363 cases

PURPOSE

Analyze the diagnostic performance of suction drainage fluid culture for acute surgical site infection, which has not been specifically reported in spine surgery patients.

METHOD

This was a retrospective single-center observational study including data from 363 patients who underwent aseptic instrumented spine surgery between 2015 and 2017. A suction drain was inserted in all cases. Data analyzed were patient age, gender, ASA score, indication for surgery (degenerative disease, tumor, trauma), spine level (cervical, thoracic, lumbar), procedure performed and spine level, operative time, body temperature, postoperative C-reactive protein time-curve, clinical aspect of surgical scar, bacteriology results of suction drainage fluid, and in case of revision surgery, lavage fluid. Major criteria for periprosthetic infection proposed by the Musculoskeletal Infection Society (MSIS) were accepted as the gold standard for the diagnosis of acute surgical site infection.

RESULTS

The overall rate of surgical site infection was 6.9% (5.76% for 1- or 2-level fusion, 5.81% for 3- or 4-level fusion, and 15.6% for 5-level fusion and above). The suction drain was withdrawn on the second postoperative day in 44.1% of cases and the third day in 39.1%. The sensitivity of suction drainage fluid culture for the diagnosis of surgical site infection was 20% [95%CI 6.8-40.7%] with a 96.2% [95%CI 93.2-97.9] specificity.

CONCLUSION

The diagnostic performance of suction drainage fluid culture after aseptic instrumented spine surgery for acute surgical site infection is insufficient to warrant its use in routine practice.

Multiple preoperative biomarkers are associated with incidence of surgical site infection following surgeries of ankle fractures

The aim of the study was to investigate the epidemiologic characteristics of surgical site infection (SSI) following surgeries of ankle fractures. This was a retrospective study. Patients who underwent surgeries for ankle fractures in our hospital between January 2016 and June 2019 were included. Inpatient medical records were inquired for data collection, including demographics, comorbidities, injury-related data, laboratory biomarkers, and confirmation of the SSI cases. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors. Among the 1532 patients, 45 had a postoperative SSI, indicating the incidence rate of 2.9%. About 18% of SSIs were identified after discharge. Twenty percent of SSIs were caused by mixed bacteria, and 39% were caused by drug-resistant bacteria. In the final multivariate model, 7 factors including 5 biomarkers were identified to be independently associated with SSI: gender (male vs female, OR, 2.69; 95% CI, 1.33-4.76), perioperative blood transfusion (OR. 3.02; 95% CI, 1.30-7.04), albumin <35 g/L (OR, 2.87; 95% CI, 1.31-6.31), lower high-density lipoprotein cholesterol (HDL-C) (OR, 2.34; 95% CI, 1.19-4.60), haemoglobin (OR, 2.16; 95% CI, 1.03-4.67), elevated alanine aminotransferase (OR, 2.09; 95% CI, 1.10-3.95) and neutrophile/lymphocyte rate (NLR, OR, 3.45; 95% CI, 1.33-6.74). These epidemiologic data on SSI may help counsel patients about the risk of SSI, individualised assessment of the risk factors, and accordingly the risk stratification.

Continuous subcutaneous insulin infusion reduces the risk of postoperative infection

BACKGROUND

Perioperative hyperglycemia was associated with postoperative infection, and proper management of perioperative glucose has become critical in improving the prognosis of patients.

METHODS

A total of 1015 diabetic patients who underwent surgery and received insulin treatment for their hyperglycemia in our hospital were retrospectively reviewed. According to propensity matching, we obtained 253 pairs of patients from the group which received continuous subcutaneous insulin infusion (CSII) therapy (CSII group) and the group which received insulin injection therapy (non-CSII group). Perioperative glucose levels and corresponding outcomes were compared between the two groups.

RESULTS

Compared with the non-CSII group, the CSII group had lower fasting and mean glucose levels, lower incidence of fever (operation day: 18.6% vs 10.2%; P = .014; first postoperative day: 55.1% vs 34.7%; P < .001), a positive rate of postoperative secretion culture (6.3% vs 1.2%; P = .004), and a shorter time of antibiotics use (total antibiotics use: P = .002; postoperative antibiotics use: P < .001) and hospital stays (P < .001). However, there was no difference in the total medical expenditure between the two groups (P = .499). Further analysis showed that CSII therapy was superior to multiple daily insulin injection (MDI) therapy in its effect on infection and other postoperative outcomes when 64 pairs of patients from the CSII group and MDI group were compared.

CONCLUSIONS

CSII therapy provides better perioperative glucose control and a lower risk of postoperative infection without increasing the total medical expenditure.

Multivariate analysis of incision infection after posterior lumbar surgery in diabetic patients: A single-center retrospective analysis

BACKGROUND

Patients requiring posterior lumbar surgery have increased annually. Incision infection after lumbar surgery has serious consequences for patients. However, data on the related factors of incision infection after lumbar surgery in diabetic patients are limited. Therefore, this study aimed to analyze diabetic patients who underwent lumbar surgery and to explore the risk factors of perioperative incision infection to provide a scientific basis for perioperative intervention of lumbar spine surgery and reduce risk of incision infection in such patients.

METHODS

We retrospectively reviewed data of diabetic patients who underwent posterior lumbar surgery from 2011 to 2016. A total of 523 diabetic patients undergoing posterior lumbar surgery were analyzed for the influence of various risk factors on postoperative incision infection. Univariate and multivariate logistic regression was performed. The test level was α=.05, and P < .05 was considered statistically significant.

RESULTS

In the past 6 years, among the 523 diabetic patients, the incidence of incision infection after posterior lumbar surgery was approximately 7.1%, of which the shallow incision infection rate was 4.2% and the deep incision infection rate was 2.9%. Incision infection of posterior lumbar surgery in diabetic patients is related to smoking, preoperative glycosylated hemoglobin A1c, postoperative albumin (Alb), surgical segment, operation time, and intraoperative blood loss, especially on postoperative fasting blood glucose, postoperative postprandial blood glucose, local subcutaneous fat thickness, and operation sequence (odds ratio >5.00). Meanwhile, sex, age, body mass index (BMI), preoperative Alb, and newly diagnosed diabetes were not highly correlated with incision infection after posterior lumbar surgery.

CONCLUSION

Local subcutaneous fat thickness is a better indicator for predicting incision infection compared with BMI. In diabetic patients undergoing lumbar surgery, actively controlling blood glucose fluctuations, restoring normal diet early after surgery, and optimizing surgical procedures to reduce trauma and operative time can effectively reduce the risk of infection after posterior lumbar surgery.

C-reactive protein kinetics and its predictive value in orthopedic (trauma) surgery: A systematic review

In Orthopedic Trauma Surgery (OTS), C-reactive- protein (CRP) is a widely used marker for the diagnosis of postoperative wound infections (POWI's) and other complications. The aim of this systematic review was to describe specific CRP kinetics and to evaluate the diagnostic value of CRP for te detection of post-operative complications in OTS. The same pattern is reported consistently, where the highest levels of CRP are found at post-operative-day two or three, returning to normal in three weeks. Amplitude varies per procedure. Persistently high CRP levels or secondary increases may indicate complications. A low CRP may be used to rule out complications.

Albumin Versus American Society of Anesthesiologists Score: Which Is More Predictive of Complications Following Total Joint Arthroplasty?

Malnutrition is not uncommon in arthroplasty patients, and hypoalbuminemia has been shown to be predictive of postoperative complications. The authors sought to compare albumin concentration with a global assessment of physical health, the American Society of Anesthesiologists (ASA) score, to further discriminate the importance of albumin in predicting postoperative complications. A cohort of 128,412 patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) were identified from 2005 to 2015 through use of the American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided based on surgery performed, albumin concentration (with <3.5 g/dL defining hypoalbuminemia), and ASA score (≤2 vs >2). Postoperative complications were evaluated through multivariable regression analyses adjusted for age, sex, body mass index, and current smoking status. The study population included 48,751 THA and 79,661 TKA patients. On multivariable analyses, both hypoalbuminemia and ASA score were significant (P<.05) predictors of complications such as death, superficial infection, pneumonia, renal insufficiency, reintubation, transfusion, readmission, and reoperation. Furthermore, hypoalbuminemia more robustly predicted deep infection for THA patients, as well as superficial infection for TKA patients. American Society of Anesthesiologists score was otherwise predictive of more postoperative complications than hypoalbuminemia within the TKA group and provided similar predictability within the THA group. Albumin is associated with complications following THA and TKA, and if used in conjunction with ASA score, albumin contributes to enhanced risk stratification. The authors recommend that a preoperative albumin concentration be obtained and efforts made to modify this risk factor prior to elective arthroplasty. [Orthopedics. 2018; 41(6):354-362.].

Albumin, Prealbumin, and Transferrin May Be Predictive of Wound Complications following Total Knee Arthroplasty

Nutritional status has become increasingly important in optimizing surgical outcomes and preventing postoperative infection and wound complications. However, currently, there is a paucity in the orthopaedics literature investigating the relationship between nutritional status and wound complications following total knee arthroplasty (TKA). Therefore, the purpose of this study was to determine the prevalence of (1) postoperative infections, (2) wound complications, (3) concomitant infection with wound (CoIW) complication, and (4) infection followed by wound complication by using (1) albumin, (2) prealbumin, and (3) transferrin levels as indicators of nutritional status. These four different outcome measures were chosen as they are encountered commonly in daily clinical practice. A retrospective review of a national private payer database for patients who underwent TKA with postoperative infections and wound complications stratified by preoperative serum albumin (normal: 3.5-5 g/dL), prealbumin (normal: 16-35 mg/dL), and transferrin levels (normal: 200-360 mg/dL) between 2007 and 2015 was conducted. Patients were identified by Current Procedural Terminology (CPT), International Classification of Disease, ninth revision (ICD-9) codes, and Logical Observation Identifiers Names and Codes (LOINC). Linear regression was performed to evaluate changes over times. Yearly rates of infection, as well as a correlation and odds ratio analysis of nutritional laboratory values to postoperative complications, were also performed. Our query returned a total of 161,625 TKAs, of which 11,047 (7%) had postoperative wound complications, 18,403 (11%) had infections, 6,296 (34%) had CoIW, and 4,877 (4%) patients with infection developed wound complications. Albumin was the most commonly ordered laboratory test when assessing complications (96%). Wound complications, infections, CoIW, and infection with wound complications after were higher in those below the normal range: albumin <3.5 g/dL (9, 14, 6, and 5%), prealbumin <15 mg/dL (20, 23, 13, and 12%), and transferrin <200 mg/dL (12, 17, 6, and 6%). Preoperative albumin, prealbumin, and transferrin values falling below the normal range represented an increased risk for postoperative complications. Those patients who were in the normal range, however, did not have an increased risk. Therefore, our results suggest that preoperative nutritional optimization can play an important role in reducing the risk for postoperative complications.

Value of procalcitonin as a marker of surgical site infection following spinal surgery

AIM

To compare the value of Procalcitonin (PCT) as a marker of surgical site infection to other inflammatory markers, including C-Reactive Protein (CRP), White Cell Count (WCC) and Erythrocyte Sedimentation Rate (ESR) in patients undergoing a number of spinal procedures. This study also aims to describe the biokinetic profile of the above-named markers in patients developing surgical site infection and those remaining infection-free post-operatively.

METHODS

200 patients undergoing four routine elective spinal procedures were included for analysis. All patients had blood specimens taken at baseline, day 1, 2, 3, 4 and 5 post-operatively for analysis of PCT, CRP, ESR and WCC levels. All patients were monitored for early surgical site infection. Patients with other sources of infection in the early postoperative period were excluded.

RESULTS

Procalcitonin was the most sensitive and specific marker for the detection of surgical site infection in the immediate post-operative period with sensitivity and specificity of 100% and 95.2% respectively. Although Procalcitonin is an inflammatory marker, extent of surgical physiological insult did not alter its biokinetics as opposed to the other inflammatory markers making it a valuable marker of infection.

CONCLUSION

Procalcitonin was found to be superior to the other inflammatory markers investigated in this study as a marker for early surgical site infection in patients undergoing spinal surgery.

Preoperative serum albumin as a predictor of complications following total hip replacement in patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis is a chronic inflammatory disease characterized by polyarthritis with progressive articular wear, immunologic abnormalities and increasing physical limitation. Surgical correction with hip replacement comes as a successful solution for patients with advanced articular destruction. Following intervention, surgical site infection (SSI), venous thromboembolism, sepsis, renal and major cardiovascular complications are among the most cited in the literature. No consensus exists as to the detection of preoperative hypoalbuminemia in patients with rheumatoid arthritis.

METHODS

This study retrospectively evaluated the preoperative serum albumin of 75 patients with rheumatoid arthritis and analyzed its relevance in terms of appearance of postoperative complications with a six-month follow-up. Complications in the group of patients with low serum albumin and the group of patients with normal serum albumin were reviewed to identify the effect of each variable. Odds ratio for each variable was calculated (hospital readmission, surgical site infection, renal and cardiac complications, non-infectious wound complications and the presence of residual hip pain), as well as p-value and confidence intervals.

RESULTS

Surgical site infection showed a statistically significant relation with low serum albumin (OR: 6.125, p = 0.018) as did non-infectious wound complications (OR: 3.714, p = 0.026) and residual hip pain (OR: 3.149, p = 0.022).

CONCLUSION

Preoperative low serum albumin has a direct relation with the rate of postoperative complications including SSI, non-infectious wound complications (seroma formation, wound dehiscence) and residual hip pain. Preoperative serum albumin is a reliable marker of nutrition, which may establish preventive strategies to reduce postoperative complications in patients with rheumatoid arthritis.

Is There a Threshold Value of Hemoglobin A1c That Predicts Risk of Infection Following Primary Total Hip Arthroplasty?

BACKGROUND

There remains little evidence to support a perioperative hemoglobin A1c (HbA_1c) level that could serve as a threshold for a significantly increased risk of deep postoperative infection in patients with diabetes mellitus (DM) following total hip arthroplasty (THA).

METHODS

A national administrative database was queried for patients who underwent primary THA with DM. Patients with an HbA_1c level within 3 months of surgery were identified and were stratified based on HbA_1c level in 0.5 mg/dL increments. The incidence of deep infection requiring operative intervention within 1 year for each group was identified and a receiver operating characteristic (ROC) and area under the curve (AUC) analysis was performed to determine a threshold value of the HbA_1c.

RESULTS

A total of 7736 patients who underwent THA with a perioperative HbA_1c level were included. The rate of infection ranged from 0.7% to 5.9%. The inflection point of the ROC curve corresponded to an HbA_1c level between 7.0 and 7.5 mg/dL (P = .001, specificity = 69%, sensitivity = 47%). The AUC for the ROC was 0.68. Patients with an HbA_1c level of 7.5 mg/dL or greater had a significantly higher risk of deep infection compared to patients below this threshold (odds ratio, 2.6; 95% CI, 1.9-3.4; P < .0001).

CONCLUSION

The risk of infection in patients with DM increases as the perioperative HbA_1c increases. However, in the present study, the HbA_1c threshold level calculated demonstrated low discrimination based on our AUC value, suggesting the HbA_1c test is poorly predictive of periprosthetic joint infection following THA in patients with DM.

Comparison of Lavage Techniques for Preventing Incision Infection Following Posterior Lumbar Interbody Fusion

BACKGROUND The main purpose of this study was to compare the effects of various lavage techniques - traditional saline lavage (SL), pulse lavage (PL), closed drainage (CD), and iodine lavage (IL) - on preventing incision-related infection after posterior lumbar interbody fusion. MATERIAL AND METHODS Patients with prolapsed lumbar (intervertebral) discs (PLID) undergoing posterior lumbar interbody fusion surgery (PLIF) over the course of 2 years were included and were randomly allocated into 4 groups: the SL group, the PL group, the CD group, and the IL group. Relevant data were recorded, including preoperative conditions, intraoperative lavage time, lavage fluid volume, incision outlook, pain perception, results of routine blood tests, and postoperative infection rate. RESULTS The PL, CD, and IL groups showed less intraoperative lavage time, lavage volume fluid, effusion, infection rate, and muscle and lower pain perception compared with the SL group (all P<0.05). Significant differences in white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were observed between preoperative and postoperative data in each group (P<0.01). No significant differences in clinical characteristics, postoperative temperature, suture removal time, incision characteristics, WBC, ESR, and CRP were observed among the PL, CD, IL, and SL groups (P>0.05). CONCLUSIONS PL, CD, and IL all showed much better postoperative infection prevention in comparison to SL.

NEW METHOD OF TREATMENT OF PYOINFLAMMATORY SOFT TISSUE COMPLICATIONS IN PATIENTS WITH DIABETES MELLITUS

Our study evaluated the levels of peroxide oxidation of lipids, oxidative modification of proteins, antioxidant protection and dynamic changes in markers of toxicity in patients with diabetes mellitus and purulent-inflammatory complications. In total, 124 patients were enrolled in the study and were divided into two groups according the treatment methods. Study group consisted of 53 patients, who received intravenously ozonized saline in addition to conservative treatment. The control group consisted of 71 patients who received only conventional therapy. The study period was 6-15 days. The results showed that the use of ozone therapy is not accompanied by negative injury responses at the level of hemostasis parameters and blood biochemical characteristics. Furthermore, ozone therapy may have a favorable effect on treatment outcome in patients with purulent-inflammatory complications and daibetes mellitus.

Relationship between preoperative serum rapid turnover proteins and early-stage surgical wound infection after spine surgery

PURPOSE

Malnutrition is one of the important risk factors for postoperative complications. Transferrin, prealbumin, and retinol-binding protein, so-called rapid turnover proteins (RTPs), may be the better indicators for early detection of nutritional deficits. However, few studies have described the impact of serum RTP levels on postoperative surgical site infection (SSI) in spine surgery. The purpose of this study was to investigate the relationship between preoperative serum RTPs and postoperative SSI.

METHODS

The data of 105 patients (64 male, 41 female; average age 64.4 years; age range 20-88 years) who underwent spine surgery in a single institution between 2014 and 2015 were retrospectively analyzed. Preoperative total lymphocyte count, serum albumin, transferrin, prealbumin, retinol-binding protein, pre-and postopeartive C-reactive protein (CRP), white blood cell count (WBC), and total lymphocyte count were evaluated. Postoperative CRP, WBC, and total lymphocyte count were repeated two or three times/week until hospital discharge. A broad spectrum penicillin or second generation cephalosporin was administered as a prophylactic antibiotic to each patient. When repeated CRP elevation or lymphopenia (no more than 10% or 1000/μL) after postoperative day 3 or 4 was observed, possible SSI was diagnosed. Variables between possible SSI group and non-SSI group were compared using Mann-Whitney U or Chi square test. All variables on univariate analysis were included in multiple logistic regression analysis to identify risk factors for possible postoperative SSI.

RESULTS

Thirty-five patients were diagnosed with possible SSI. The mean operative time of possible SSI group was significantly longer (p = 0.036), preoperative total lymphocyte count and serum prealbumin level of possible SSI group were significantly lower (p = 0.002, p = 0.048, respectively) than that of non-SSI group. On univariate analysis, operative time (p = 0.012), preoperative total lymphocyte count (p = 0.041), serum albumin level (p = 0.038), and serum prealbumin level (p = 0.044) were significant contributors to possible SSI, and multiple logistic regression analysis revealed that operative time was the significant contributor to possible SSI (odds ratio 1.008, 95% confidence interval (CI) 1.001-1.015, p = 0.024).

CONCLUSIONS

A low prealbumin level is a possible risk factor for early-stage SSI in spine surgery, though it was not statistically significant; operative time was the most important indicator of SSI on multivariate analysis.

The Human Host Defense Ribonucleases 1, 3 and 7 Are Elevated in Patients with Sepsis after Major Surgery--A Pilot Study

Sepsis is the most common cause of death in intensive care units and associated with widespread activation of host innate immunity responses. Ribonucleases (RNases) are important components of the innate immune system, however the role of RNases in sepsis has not been investigated. We evaluated serum levels of RNase 1, 3 and 7 in 20 surgical sepsis patients (Sepsis), nine surgical patients (Surgery) and 10 healthy controls (Healthy). RNase 1 and 3 were elevated in Sepsis compared to Surgery (2.2- and 3.1-fold, respectively; both p < 0.0001) or compared to Healthy (3.0- and 15.5-fold, respectively; both p < 0.0001). RNase 1 showed a high predictive value for the development of more than two organ failures (AUC 0.82, p = 0.01). Patients with renal dysfunction revealed higher RNase 1 levels than without renal dysfunction (p = 0.03). RNase 1 and 3 were higher in respiratory failure than without respiratory failure (p < 0.0001 and p = 0.02, respectively). RNase 7 was not detected in Healthy patients and only in two patients of Surgery, however RNase 7 was detected in 10 of 20 Sepsis patients. RNase 7 was higher in renal or metabolic failure than without failure (p = 0.04 and p = 0.02, respectively). In conclusion, RNase 1, 3 and 7 are secreted into serum under conditions with tissue injury, such as major surgery or sepsis. Thus, RNases might serve as laboratory parameters to diagnose and monitor organ failure in sepsis.

Poor oncologic outcomes of hepatocellular carcinoma patients with intra-abdominal infection after hepatectomy

AIM: To evaluate the impact of postoperative infectious complications on hepatocellular carcinoma following curative hepatectomy.

METHODS: We performed a retrospective analysis of 200 hepatocellular carcinoma patients who underwent hepatectomy at our institution between September 2003 and June 2011. The patients’ demographics, clinicopathological characteristics and postoperative infectious complications were analyzed. The Clavien-Dindo classification was adopted to assess the severity of complications. The dynamic change in the neutrophil-to-lymphocyte ratio, defined as the absolute neutrophil count divided by the absolute lymphocyte count, after surgery was also investigated. The observation endpoints for this study were recurrence-free survival and overall survival of the patients. Statistical analysis of the survival curves was performed using the Kaplan-Meier method and the log-rank test. The prognostic value of each variable for predicting prognosis was assessed via multivariate Cox proportional hazards regression analysis. The cutoff score for each variable was selected based on receiver operating characteristic curve analysis. All statistical tests were two-sided, and significance was set at P < 0.05.

RESULTS: The median age of the patients was 49 years, and the majority of patients were male (86%) and had been infected with hepatitis B virus (86%). The 30-d postoperative infectious complication rate was 34.0% (n = 68). Kaplan-Meier survival analysis revealed that postoperative infection was significantly correlated with tumor recurrence (P < 0.001). The postoperative intra-abdominal infection group exhibited a worse prognosis than the non-intra-abdominal infection group (P < 0.001). A significantly increased incidence of postoperative intra-abdominal infection was observed in the patients with hepatic cirrhosis (P = 0.028), concomitant splenectomy (P = 0.007) or vascular invasion (P = 0.026). The patients who had an elevated postoperative neutrophil-to-lymphocyte ratio change (> 1.643) clearly exhibited poorer recurrence-free survival than those who did not (P = 0.009), although no significant correlation was observed between overall survival and the change in the postoperative neutrophil-to-lymphocyte ratio. Based on multivariate analysis, hepatitis B surface antigen positivity, Child-Turcotte-Pugh class B, an elevated postoperative neutrophil-to-lymphocyte ratio change and intra-abdominal infection were significant predictors of poor recurrence-free survival. Hepatic cirrhosis, the maximal tumor diameter and intra-abdominal infection were significant predictors of overall survival.

CONCLUSION: Postoperative intra-abdominal infection adversely affected oncologic outcomes, and the change in postoperative neutrophil-to-lymphocyte ratio was a good indicator of tumor recurrence in hepatocellular carcinoma patients after curative hepatectomy.

Pre- and post-operative values of serum CRP in patients undergoing surgery for brain tumour

OBJECTIVE

To determine the concentration of C-reactive protein in pre- and post-operative serum samples of brain tumour patients in order to detect the potential risks of post-operative infections.

METHODS

Serum C-reactive protein was measured on pre- and post-operative Day 1, Day 2 and Day 7 in 18 patients who underwent surgery for brain tumours. The study was performed at the Neurosurgical Ward, Jinnah Postgraduate Medical Centre, Karachi, from May 2007 to April 2008. Mean pre-operative patients and control values were compared using Mann-Whitney or Wilcoxon tests for comparing between pre- and post-operative values. P-value was considered significant at < 0.05.

RESULTS

Five (27.7%) of the 18 pre-operative patients had elevated serum concentrations i.e. > 5.0 mg/L but no statistically significant difference was found when compared with healthy controls, with mean 4.4 +/- 6.6 and 0.9 +/- 0.7, respectively. Significantly raised serum concentrations were observed in all post-operative samples when compared with pre-operative samples. Serum CRP concentrations significantly increased post-operatively on Day 1, with mean value of 102.9 +/- 82.0 mg/L (p < 0.0005), and further increased on Day 2 with mean value of 166.9 +/- 128.1 mg/L (p < 0.0005), but declined on Day 7, with mean value of 42.7 +/- 63.6 mg/L (p < 0.005).

CONCLUSION

Pre-operative serum C-reactive protein concentrations of 28% of the patients were elevated, suggesting an association with brain tumours. Post-operative serum concentrations were significantly higher than those noted before the surgery. Absence of a fall of concentration from peak value on post-operative Day 2 or a secondary rise from post-operative Day 7 could be alarming for inter-current infection.

[The endotoxine aggression in the pathogenesis of postoperative complications in children with Hirsprung disease]

Signs of disseminated intravascular clotting (DIC), which were considered the laboratory sign of the subcompensated endotoxine aggression, were detected in 20 children with the Hirsprung disease, aged 3 months - 11 years. Under the influence of the operation stress the subcompensated DIC transformed to the acute decompensated reaction, which led to early complications, such as anastomosistis with tendency to the insufficiency or stenosis, enterocolitis, etc. The study revealed not only the straight connection between the postoperative complications and endotoxine aggression, but the necessity of preoperative preparation, directed on the decrease of the intestinal endotoxin level and normalization of antiendotoxin immunity.

Is prophylactic Gentamicin associated with acute kidney injury in patients undergoing surgery for fractured neck of femur?

BACKGROUND

Single dose Gentamicin (240 mg) has been shown to reduce postoperative wound infection in patients with fractured neck of femur when used in a combined antibiotic regimen. However, concerns have arisen about the risk of acute kidney injury (AKI) in these patients.

OBJECTIVE

To determine if the use of prophylactic Gentamicin is associated with AKI in fractured neck of femur patients.

METHODS

A historical cohort study. Pre- and post-operative creatinine mmol/l of 100 successive fractured neck of femur patients admitted from September 2010 were compared to a control of 100 age, sex and procedure matched individuals operated upon before the introduction of prophylactic Gentamicin (2005). AKI was defined as an increase in serum creatinine by over 50% of base line. Statistical significance was regarded as p<0.05.

RESULTS

A significant rise in creatinine levels was observed in both control (p=0.005) and study groups (p=0.001). There was neither a significant difference in peak creatinine between groups (p=0.87) nor in rates of AKI (p=0.568) between the 2 groups.

CONCLUSION

Single preoperative doses of Gentamicin (240 mg) have no detrimental impact on renal function in this group. There is, however, a significant rise in creatinine following fractured neck of femur surgery, independent of Gentamicin.

The role of pre-operative and post-operative glucose control in surgical-site infections and mortality

Background and Objective

The impact of glucose control on surgical-site infection (SSI) and death remains unclear. We examined how pre- and post-operative glucose levels and their variability are associated with the risk of SSI or in-hospital death.

Methods

This retrospective cohort study employed data on 13,800 hospitalized patients who underwent a surgical procedure at a large referral hospital in New York between 2006 and 2008. Over 20 different sources of electronic data were used to analyze how thirty-day risk of SSI and in-hospital death varies by glucose levels and variability. Maximum pre- and post-operative glucose levels were determined for 72 hours before and after the operation and glucose variability was defined as the coefficient of variation of the glucose measurements. We employed logistic regression to model the risk of SSI or death against glucose variables and the following potential confounders: age, sex, body mass index, duration of operation, diabetes status, procedure classification, physical status, emergency status, and blood transfusion.

Results

While association of pre- and post-operative hyperglycemia with SSI were apparent in the crude analysis, multivariate results showed that SSI risk did not vary significantly with glucose levels. On the other hand, in-hospital deaths were associated with pre-operative hypoglycemia (OR = 5.09, 95% CI (1.80, 14.4)) and glucose variability (OR = 1.14, 95% CI (1.03, 1.27) for 10% increase in coefficient of variation).

Conclusion

In-hospital deaths occurred more often among those with pre-operative hypoglycemia and higher glucose variability. These findings warrant further investigation to determine whether stabilization of glucose and prevention of hypoglycemia could reduce post-operative deaths.

Graft infection in kidney recipients and its relation to transplanted kidney function

INTRODUCTION

Following kidney transplantation, septic complications are the leading causes of therapeutic failure including recipient death or graft removal. The serum creatinine level is one of the earliest metrics of kidney metabolic function. We examined the influence of graft infection on serum creatinine levels in kidney recipients.

STUDY DESIGN

We analyzed the function of 220 kidneys transplanted in nine centers in Poland. The kidneys were recovered from 146 multiorgan donors. Donor urea and creatinine levels were within the normal range. We investigated the influence of perioperative graft infection incidence on recipient creatinine levels at 1, 2, 3, 7, 14, 30, 90, and 180 days after kidney transplantation. The association of the serum creatinine level with categorical variables was assessed using either Student t test analysis of variance and multivariate techniques. In all analyses P<.05 indicated statistical significance.

RESULTS

There were 25 graft infections revealing a significant relationship with increased recipient serum creatinine level after kidney transplantation (P=.003). Multivariate analysis confirmed the impact of infection.

CONCLUSION

Perioperative kidney graft infection influenced graft funtion in the early and late periods post-transplantation.

Relationship between C-reactive protein levels and wound infections in elective colorectal surgery: C-reactive protein as a predictor for incisional SSI

BACKGROUND/AIMS

Serum C-reactive protein (CRP) is an acknowledged marker of infections. For early detection of postoperative infections, CRP levels may be a useful marker. In this study, the CRP response with respect to wound infections (incisional surgical site infection (SSI)) in elective colorectal surgery was examined to define the role of serum CRP as a predictor of incisional SSI.

METHODOLOGY

One hundred forty-eight patients who underwent elective colorectal resection were identified for inclusion in this study. The outcome of interest was incisional SSI. Twenty-eight patients with incisional SSI were compared to a subgroup of 118 patients with an uneventful postoperative course, and the correlation between postoperative serum CRP levels and incisional SSI in colorectal surgery was investigated.

RESULTS

For uneventful cases, the CRP rose postoperatively to a maximum on the third day, and the concentrations then returned to near normal levels on postoperative day (POD) 7. In incisional SSI cases, persistent elevation or a second rise in CRP concentrations was seen. Although no statistically significant differences in CRP concentrations were seen on POD 1 or 3, the initial rise in CRP of cases with incisional SSI was relatively higher compared to uneventful cases. A deviation became obvious at POD 7. A cut-off level of 36 mg/L on POD 7 was recorded (sensitivity of 71.4% and a specificity of 83.1%) for incisional SSI.

CONCLUSION

Our results suggest that elevated serum CRP levels are correlated with incisional SSI. Persistent CRP elevation is predictive of incisional SSI in colorectal surgery if pneumonia or anastomotic leakage are unlikely or excluded.

[Diagnostics of septic complications after long tubular bones fractures]

Interleukine (IL-1alpha, IL-4) blood levels and lipid peroxidation--antioxidant agents were assessed in 98 patients with fractures of long tubular bones. Using the data, an algorithm was worked out, which permits prediction of septic complications with a high level of accuracy.

[Procalcitonin in diagnosis and monitoring of surgical infections]

The procalcitonin (PCT) is a sensitive and reliable biochemical marker used in diagnosing and monitoring of bacterial infections. The procalcitonin assay allows for effective evaluation of the patient's health status. Elevated PCT serum level is correlated with progression and generalization of the infection. In severe infections, such as sepsis or septic shock, the PCT may reach concentrations even up to 1000 ng/ml (with a normal range below 0.1 ng/ml). High PCT levels in the first hours of the developing infection advocates for the bacterial etiology. Therefore, procalcitonin is used in differential diagnosis of severe bacterial and viral infections. Rapid and accurate diagnosis facilitates introduction of the effective therapy. Rapid decrease in PCT level after applying the therapy confirms its efficacy (control assay may be performed after 24 hours since the therapy has been applied). The usefulness of the PCT is supported by the fact, that in pathologic conditions, such as trauma (including surgery procedures), viral infections or autoimmunologic diseases, the PCT level is only slightly increased or remains in a normal range. The PCT level assay enables the detection of the developing infection already in the latent stadium, before characteristic clinical symptoms appear. Therefore, it is very important to monitor the PCT serum level. Further research will allow to determine the accurate diagnostic value and the clinical application of the PCT level as a marker of infection.

Early prediction of infection after craniotomy for brain tumours

Reliably predicting infection soon after craniotomies would prevent infection and reduce treatment costs and hospitalization expenses. Therefore we analysed potential risk factors and blood count data after craniotomies for brain tumours in order to predict infection as soon as possible after surgery. We analysed 139 patients who underwent craniotomies for brain tumours from January 1997 to December 2001, and divided them into four categories (Types A to D) according to the following: increase in their white blood counts (WBCs) from Day 0 to Day 1, maximum WBC between Day 0 and Day 2, and maximum c-reactive protein (CRP) between Day 0 and Day 4 after surgery. We evaluated potential risk factors and the blood count data for infections via logistic regression analysis. Type D patients had a significantly higher rate of infection (p = 0.0123) than the other Types, while Type B patients had the lowest rate among the four groups (p = 0.0006). When Type A patients suffered CSF leakages, they had a significantly higher possibility of meningitis (p < 0.0001) or scalp infection (p = 0.012). In those Type A or D patients who were male, more than 70 years old, and suffered from metastases from primary lung cancer lesions, the possibility of pneumonia was significantly higher (p = 0.0178). In conclusion, we are able to predict infection within four days after craniotomies for brain tumours according to standard blood count data and certain risk factors. This possibility allows for improved care and better clinical outcomes in patients that undergo craniotomies for brain tumours.

[Effects of autologous and homologous blood transfusion on TNF-alpha levels and survival in an intraabdominal infection model]

BACKGROUND

Autologous blood transfusion is one of the approaches used for prevention of the undesirable immunomodulatory effects of homologous blood transfusion that can cause an increase in cancer recurrence and surgical site infections. On the other hand, the benefits of autologous blood transfusion in that respect are not yet clearly identified. In this experimental study, we investigated the differences in effects of autologous and homologous blood transfusion on tumor necrosis factor (TNF)-alpha levels and survival in an intraabdominal infection model in rats.

METHODS

A total of 92 Sprague-Dawley rats were used in the study. Forty-four of those rats were divided into autologous and homologous transfusion groups, and intraabdominal infection was instituted by cecal ligation puncture method on the 7th day after blood transfusion. Blood samples were taken at the 90th minute and at 6-hour intervals after cecal ligation puncture and were used for measurement of TNF-alpha levels by ELISA method. In the remaining 48 rats, survival was investigated within the first week of cecal ligation puncture.

RESULTS

Our results revealed significantly depressed TNF-alpha levels in the homologous blood transfusion group, but with respect to survival, no difference was detected between the groups.

CONCLUSION

Based on these findings, we concluded that autologous blood transfusion decreases transfusion-related immunomodulation but does not cause a decrease in mortality due to intraabdominal infection.

Alloanti-c in a c-positive, JAL-positive patient

BACKGROUND AND OBJECTIVES

In the Rh blood group system, partial D, C, and e antigens are well-known, but a partial c antigen resulting in the production of alloanti-c in a c+ individual is rare. One example of an alloanti-c in a c+ person was an anti-Rh26, which can appear as anti-c, and another was an alloanti-c in a c+ person with a presumed R(1)r phenotype. The finding of an apparent alloanti-c in a transfused c+ patient initiated this investigation.

MATERIALS AND METHODS

Haemagglutination tests, DNA extraction, polymerase chain reaction (PCR)-based assays (PCR-restriction fragment length polymorphism, allele-specific PCR), reticulocyte mRNA extraction, reverse transcriptase (RT)-PCR and sequencing were performed by standard procedures.

RESULTS

Plasma from a 64-year-old African American woman with a wound infection following a mastectomy contained anti-E, anti-S, anti-K, anti-Fy(a) and anti-Jk(b), reacting by the indirect antiglobulin test. In addition, the patient's plasma gave reactions that were consistent with an anti-c, while her pre-transfusion red blood cells typed c+ with some anti-c reagents. These results are consistent with a partial c antigen. The patient's red blood cells also typed V+(W)VS- and JAL+. Analyses of DNA and Rh-transcripts from this patient showed the presence of the following genes: RHD*D, RHD*DAU0, RHCE*Ce and RHCE*ce(S)(340).

CONCLUSION

The nucleotide 340C>T change in RHCE exon 3 (predicted to encode 114Trp) of the RHCE*ce(S)(340) allele is associated with a JAL+ phenotype and the altered expression of the c, V and VS antigens. This alteration in the c antigen allowed the patient to make an alloanti-c. This case reveals that the RHCE*ce(S)(340) allele encodes a partial c antigen.

C-reactive protein as early predictor for infectious postoperative complications in rectal surgery

BACKGROUND

This study evaluated the role of the acute phase C-reactive protein (CRP) in the postoperative course of a large series of rectal resections on the basis of a prospective database. Main focus of this study was the early identification of complications.

MATERIALS AND METHODS

Three hundred eighty-three rectal resections with primary anastomosis for rectal cancer were screened for infectious postoperative complications. Forty-eight complicated cases were identified and matched with 48 patients with an uneventful postoperative course.

RESULTS

In the postoperative setting, CRP peaked on postoperative day (POD) 2 with a median serum CRP of 140 mg/l and gradually declined thereafter in uncomplicated cases. In complicated cases, CRP elevation generally persisted after POD 2, whereas white blood cells and body temperature were within normal range in the early postoperative period. A cutoff CRP value of 140 mg/dl on PODs 3 and 4 resulted in predictive values of 85.7 and 90.5% (adjusted to the prevalence: 37.6 and 50.3%), sensitivities of 80.0 and 54.3%, and specificities of 81.0 and 92.3% for a complicated postoperative course (P<0.001), respectively.

CONCLUSION

Persistent CRP elevation and elevation of serum CRP above 140 mg/dl on PODs 3-4 are predictive of infectious postoperative complications and should prompt intense clinical search for an inflammatory process, especially for an anastomotic leak if pneumonia and wound infection are unlikely or excluded.

Factors predicting postoperative infectious complications and early induction of inflammatory mediators in ulcerative colitis patients

BACKGROUND

Positive outcomes after restorative proctocolectomy are compromised by a number of specific septic complications. However, there is no useful perioperative marker predicting postoperative infectious complications (PICs) in steroid overdosed patients with ulcerative colitis (UC).

METHODS

To determine factors associated with PICs and their relation to circulating levels of pro- and anti-inflammatory cytokines and neutrophil elastase (NE), we obtained perioperative blood samples from 60 UC patients.

RESULTS

Postoperative infectious complications were identified in 47% of cases. Patients who developed PICs had significantly longer disease duration, had been administered a greater total preoperative dosage of prednisolone, and had a higher body mass index. Logistic regression analysis showed that the total preoperative dosage of prednisolone was independently associated with the development of PICs. These patients showed suppressed systemic inflammation and pro- and anti-inflammatory cytokine induction. An early increase in the NE level was found to be predictive of PICs in the high-dose group, whereas there was no significant difference in neutrophil counts between the high- and low-dose groups.

CONCLUSIONS

Circulating NE levels in the early postoperative period might be a useful predictor of PICs in immune-controlled UC patients who received high doses of steroids.

Nosocomial infections after off-pump coronary artery bypass surgery: frequency, characteristics, and risk factors

We evaluated the frequency, risk factors, and characteristics of infections in 360 patients after off-pump coronary artery bypass grafting (OPCABG). A prospective study was performed during the period June 2004-October 2005 at Henry Dunant Hospital, Athens, Greece. C-reactive protein (CRP) and procalcitonin were assayed from 222 patients preoperatively, and 1-3 days following OPCABG. Variables independently associated with infection were identified by a multivariable logistic regression model. Eighteen of 360 (5%) patients developed postoperative infections; 1.7% developed superficial wound infection, 1.4% pneumonia, 1.1% bacteremia, 0.3% mediastinitis, and 0.3% intra-aortic balloon pump related infection. The mean increase of CRP and procalcitonin levels in the first two or three days, respectively, after surgery was significantly higher (P<0.05) in patients with infection. Independent risk factors of infection (P<0.05) were history of major nervous system disorder, left ventricular heart failure preoperatively, emergent operation, transfusions of red blood cells during ICU stay, and duration of central venous catheter placement. The identification of risk factors for infection in combination with the appropriate evaluation of the increased CRP and procalcitonin values may help clinicians for the early diagnosis of infection after OPCABG.

Pharmacokinetic and pharmacodynamic profiling of cefepime in plasma and peritoneal fluid of abdominal surgery patients

This study was conducted to characterise the pharmacokinetics and pharmacodynamics of cefepime in plasma and peritoneal fluid (PF). One gram of cefepime was administered to eight laparotomy patients and plasma and PF samples were collected at the end of 0.5 h infusion and every hour for 6 h. Drug concentrations were determined, analysed by population pharmacokinetic modelling and used for a Monte Carlo simulation with minimum inhibitory concentration (MIC) data. The maximum concentration in PF was two-thirds of the value in plasma; however, the concentrations were higher in PF than in plasma at 0.68 h post dose. The probabilities of attaining the pharmacodynamic target (65% of the time above the MIC) were 92-99% in plasma (90% fraction unbound) and 93-100% in PF against Escherichia coli, Klebsiella pneumoniae and Enterobacter cloacae with a regimen of 1 g every 12 h. However, 1 g every 8 h or 2 g every 12 h was required for values of 94-95% in plasma and 95-96% in PF against Pseudomonas aeruginosa. These results demonstrate that the pharmacodynamic exposures in PF were almost identical to those estimated from plasma data and provided a pharmacokinetic/pharmacodynamic rationale for the dosing regimen for surgical intra-abdominal infections.

Infection, depression, and immunity in women after coronary artery bypass: a pilot study of cognitive behavioral therapy

CONTEXT

Depression is common after coronary artery bypass graft (CABG) surgery, but little is known about its effect on post-CABG inflammation or infection or about the most effective treatment for post-CABG depression.

OBJECTIVES

(1) To determine ifpost-CABG depression is associated with increased infectious illness and (2) to test effects of cognitive behavioral therapy (CBT) on depressive symptoms, inflammatory biomarkers, and post-CABG infections in depressed post-CABG women.

DESIGN

Randomized, controlled trial.

SETTING

Two urban tertiary care centers.

PATIENTS

Fifteen clinically depressed women in the first month after CABG, along with a comparison group of 37 non-depressed postCABG women, were studied. Inclusion criteria were: < or = 75 years old, English-speaking, undergoing first-time CABG, available for 6 months offollow-up, and without malignancy or autoimmune disorders.

INTERVENTION

Eight weeks of individual home-based CBT.

MAIN OUTCOME MEASURES

(1) Depressive symptoms measured by the Beck Depression Inventory, (2) natural killer cell cytotoxicity (NKCC) measured by 51Cr-release assay, (3) infectious illness episodes measured by the Modified Health Review, (4) interleukin (IL)-6 and C reactive protein (CRP) measured by enzyme immunoabsorbent assay.

RESULTS

Clinically depressed post-CABG women exhibited decreased NKCC and a higher incidence of in-hospital fevers and infectious illness in the first 6 months after CABG. Among depressed women, CBT yielded moderate to large effects for improved NKCC (D=0.67) and decreased IL-6 (D=0.61), CRP (D=0.85), and postoperative infectious illnesses (D=0.93). CBT holds promise for improving depression and immunity and reducing infection and inflammation after CABG.

Is secondary haemorrhage after tonsillectomy in adults an infective condition? Objective measures of infection in a prospective cohort

OBJECTIVES

Traditionally secondary post-tonsillectomy haemorrhage has been thought to be due to post-operative infection and as such is treated with broad-spectrum antibiotics. The aim of this study was to identify clinical evidence of infection in patients with secondary post-tonsillectomy haemorrhage that might justify the use of antibiotics in these patients.

DESIGN

Prospective data collection.

SETTING

Tertiary University Teaching Hospital.

PARTICIPANTS

Adult patients admitted with post-tonsillectomy haemorrhage over a 2-year period.

MAIN OUTCOME MEASURES

Temperature, white cell count, Neutrophil count and C-reactive protein.

RESULTS

47 patients were admitted with secondary post-tonsillectomy haemorrhage. Fifteen out of 47 patients (32%) had an elevated white cell count but in them the other indicators of temperature and C-reactive protein were extremely variable: none of these 15 patients was pyrexial (> 37.6 C). An elevated C-reactive protein was found in 55% of patients but none had an elevated white cell count. The elevated C-reactive protein may have been influenced by the recent surgery rather than infection. Overall there was no clear interrelation between the indicators of infection in the patients and none had the three main indicators of infection (pyrexia, increased white cell count and elevated C-reactive protein).

CONCLUSIONS

Our results suggest that clinical signs of infection are lacking in patients with secondary tonsillectomy bleeding. Correspondingly the routine use of antibiotics should be questioned for secondary tonsillectomy haemorrhage.

Laparoscopic surgery impairs tissue oxygen tension more than open surgery

Background

Wound infection remains a common and serious complication after colonic surgery. Although many colonic operations are performed laparoscopically, it remains unclear whether this has any impact on the incidence of wound infection. Subcutaneous tissue oxygenation is an excellent predictor of surgical wound infection. The impact of open and laparoscopic colonic surgery on tissue oxygenation was compared.

Methods

Fifty-two patients undergoing elective open and laparoscopic left-sided colonic resections were evaluated in a prospective observational study. Anaesthesia management was standardized and intraoperative arterial partial pressure of oxygen was kept at 150 mmHg in both groups. Oxygen tension was measured in the subcutaneous tissue of the right upper arm.

Results

At the start of surgery subcutaneous tissue oxygen tension (Psqo2) was similar in both groups (mean(s.d.) 65·8(17·2) and 63·7(23·6) mmHg for open and laparoscopic operations respectively; P = 0·714). Tissue oxygen remained stable in the open group, but dropped significantly in the laparoscopic group during the course of surgery (Psqo2 after operation 53·4(12·9) and 45·5(11·6) mmHg, respectively; P = 0·012).

Conclusion

Laparoscopic colonic surgery significantly decreases Psqo2, an effect that occurs early in the course of surgery. As tissue oxygen tension is a predictor of wound infection, these results may explain why the risk of wound infection after laparoscopic surgery remains higher than expected.

Procalcitonin and brain natriuretic peptide as parameters in the postoperative course of patients with major pulmonary resection

Postoperative infections and cardiac events are the major morbidity factors after thoracic surgery and dominating causes of death. Therefore, a sensitive blood marker is needed for an early diagnosis of complications. Twenty-two patients admitted with lung cancer were enrolled in this study. Procalcitonin, brain natriuretic peptide, C-reactive peptide and interleukin-6 levels were recorded preoperatively and postoperatively on days 1-5. Laboratory values of patients with cardiac or infectious complications were compared to patients without complications. During postoperative course procalcitonin and brain natriuretic peptide levels elevated in all patients, but both had higher peak levels in patients with infectious or cardiac complication than without these complications. Interleukin-6 levels were increased on day one and showed a slower decrease in case of complications than without complications. In general, brain natriuretic peptide and procalcitonin levels are increased in the postoperative course after major pulmonary resection, but cardiac and infectious complications are associated with higher levels and a slower decrease than without complications. Interleukin-6 levels showed a slower decrease in patients with complications in the postoperative course than without complications. So the combination of procalcitonin, brain natriuretic peptide, and interleukin-6 seems to be useful for an optimized postoperative monitoring.

C-reactive protein as a parameter of surgical trauma: CRP response after different types of surgery in 349 hip fractures

BACKGROUND

Postoperative C-reactive protein (CRP) levels in serum appear to reflect surgical trauma. We examined CRP levels after different types of surgery in hip fractures.

METHODS

We studied the CRP response after 349 operative procedures in proximal femur fractures with a normal postoperative course. 5 different operative techniques were used: 3-4 percutaneous cancellous screws, dynamic hip screw (DHS), proximal femur nail (PFN), hemiarthroplasty (HA), and total hip arthroplasty (THA).

RESULTS

Peak CRP levels were reached on the second postoperative day in each group (medians: screws 8.7, DHS 12, PFN 14, HA 16, THA 16 mg/dL). Significant differences were found between screws and all others, and between DHS and arthroplasties.

INTERPRETATION

CRP levels following surgical trauma can be used to quantify the degree of tissue damage and invasiveness of a procedure and reflect the perioperative stress experienced by the patient.

Neutrophil priming as a surgery-related risk factor for postoperative infectious complications in patients with ulcerative colitis

AIMS

The present study was designed to assess whether preoperative neutrophil priming under surgical stress has causal effects on the postoperative clinical outcomes of ulcerative colitis (UC) patients.

PATIENTS AND METHODS

In 63 consecutive UC patients, perioperative changes in cytokines and neutrophil elastase (NE) were quantified and their relationships to postoperative infectious complications (PICs) were evaluated.

RESULTS

A preoperative increase in NE (high group: Group H) was associated with longer disease duration and greater preoperative total amount of steroids administered. Patients in Group H developed more PICs than those in the low NE group when they underwent surgery >240 min. In Group H, the NE level remained high after longer duration surgery, but decreased rapidly after shorter duration surgery. Multivariate analyses revealed that the total amount of steroids used and preoperative NE level were independent risk factors for predicting PICs in the longer operation group.

CONCLUSION

Preoperative neutrophil activation may become a risk factor for postoperative morbidity when the patients undergo intense surgical stress. The most important procedures for preventing postoperative morbidity in high-risk UC patients may be reducing surgical stress and/or controlling neutrophil activation perioperatively.

Serum C-reactive protein levels correlate with clinical response in patients treated with antibiotics for wound infections after spinal surgery

BACKGROUND CONTEXT

C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been used to diagnose postoperative infections after spinal surgery. However, it has not been demonstrated if resolution of the signs and symptoms of postoperative spinal wound infections in patients who are being treated with intravenous antibiotics correlates with these markers.

PURPOSE

The objective of this study was to determine if improvement of the signs and symptoms of postoperative wound infection after spinal surgery correlates with a decrease in serum CRP and ESR while intravenous antibiotics are administered.

STUDY DESIGN

Retrospective review.

PATIENT SAMPLE

The study consisted of 21 patients (mean age 63.8 years; 13 female, 8 male) with postoperative wound infections after spinal surgery. They were studied for a minimum of 20 weeks.

OUTCOME MEASURES

CRP and ESR were measured at the time of diagnosis and at serial time-points.

METHODS

All patients received intravenous antibiotic therapy for 6-8 weeks. Patients were monitored for clinical signs and symptoms of infection such as fever, drainage, erythema, or a need for continued wound packing at 4, 7, and 20 weeks after being diagnosed with a wound infection.

RESULTS

The average CRP for all 21 patients at time of diagnosis was 11.7+/-9.0 mg/dL (range 1.2 to 37.8 mg/dL). At the 4-week time-point, 16 patients ("early responders") showed clinical improvement with no fevers, no wound drainage, no erythema, and no need for wound packing. The average CRP of this group at the 4-week time-point decreased to 0.3+/-0.5 mg/dL. In contrast, at the 4-week time-point five patients ("late responders") still had signs and symptoms of infection (2 with continuing drainage requiring wound packing; 1 with vertebral osteomyelitis requiring irrigation and debridement; 2 with erythema without fevers). The average CRP for this group was still elevated at the 4-week time-point at 7.3+/-3.5 mg/dL. The CRP value difference was statistically significant between the two groups (p<.05). As treatment continued, at the 20-week time-point the average CRP of the late responders gradually decreased to 0.8+/-0.8 mg/dL, which was not statistically different from that of the early responders (average CRP=0.6+/-1.1 mg/dL). All 21 patients had resolution of infection at the 20-week time-point. The ESR did not correlate well with clinical improvement. At time of diagnosis, the ESR of both early responders (average=57.6+/-27.6 mm/hr) and late responders (average=64.0+/-21.9 mm/hr) was elevated. It remained elevated for both groups from the beginning of the study to the end at all time-points. The final ESR at the 20-week time-point was not different between the early responders and late responders (average=27.6+/-22.3 mm/hr vs. 31.0+/-2.6 mm/hr, respectively; p>.05).

CONCLUSIONS

Our data suggest that CRP may be of value in following the treatment response to antibiotics in wound infections after spinal surgery. The ESR can remain elevated in the presence of a normal CRP despite a resolution of clinical signs and symptoms of postoperative wound infection.

Usefulness of white blood cell differential for early diagnosis of surgical wound infection following spinal instrumentation surgery

STUDY DESIGN

The white blood cell (WBC) count and WBC differential were measured prospectively in patients after spinal instrumentation surgery with or without surgical wound infection. OBJECTIVES.: To investigate the usefulness of WBC differential for early diagnosis of surgical wound infection after spinal instrumentation surgery.

SUMMARY OF BACKGROUND DATA

Renewed elevation of C-reactive protein (CRP) or WBC, gallium scan, and CRP/transthyretin mass concentration ratio were reported for early diagnosis of surgical wound infection.

METHODS

A total of 39 patients were enrolled in this study: 13 patients who developed wound infection within 2 weeks after spinal instrumentation surgery (infection group) and 26 patients who were comparable with those patients included in the infection group with regard to age, sex, and surgical techniques used (control group). The WBC count and WBC differential were determined before and after surgery.

RESULTS

In both groups, WBC and percentage and number of neutrophils showed nearly same change until postoperative 4 days (day 4). However, in the infection group, these parameters had increased after day 4. In both groups, the percentage and number of lymphocytes decreased to 10% or less and 1,000/microL or less on day 1, respectively. These lymphocyte parameters began to gradually normalize on day 4 and returned to the preoperative level 3 weeks after surgery in the control group. On the other hand, these parameters remained 10% or less and 1,000/muL or less until day 11 in the infection group. In patients with infection, the percentage and number of lymphocytes significantly decreased as early as on day 4.

CONCLUSION

Lymphopenia represents immunodepression status, thus indicating the increased susceptibility to infection, which may lead to the development of postoperative infection. If lymphopenia is diagnosed as early as possible, surgical wound infection can be treated promptly without removing the instruments.

Infections following arthroscopic anterior cruciate ligament reconstruction

PURPOSE

Infection after anterior cruciate ligament (ACL) reconstruction is a serious but uncommon complication. Optimal management has not been established. The purpose of our case series was to review our experience and published reports to identify risk factors, evaluate physical and laboratory findings, compare different treatments, and assess clinical outcomes.

METHODS

Retrospective review of all the arthroscopic ACL reconstructions performed at our institution between 1994 and 2002. Patients with intra-articular infections were evaluated and, when available, comparisons were made between patients with extra-articular infections and uncomplicated postoperative ACL reconstructions.

RESULTS

Eleven postoperative infections were identified, all in patients who had hamstring autograft. Previous knee surgery, especially previous ACL reconstruction and tibial ACL graft fixation with a post and washer, was associated with increased infection. Laboratory data revealed elevated erythrocyte sedimentation rate (average, 67), C-reactive protein (average, 14), and intra-articular blood cell count (average, 52,000). All infections were eradicated with serial arthroscopic incision and drainage (average, 2.4 procedures) and intravenous antibiotics (duration, 14 to 42 days). The graft was retained in 10 of 11 patients. At an average follow-up of 22 months, the average Lysholm functional knee score was 71.6 out of 100 points (range, 36-99). Of the 5 patients with fair/poor results, the most common chief complaint was pain and stiffness.

CONCLUSIONS

Long-term goals for treatment of patients with postoperative ACL infections are to protect the articular cartilage and to maintain knee function. Timely initiation of treatment, including joint lavage, debridement, and antibiotics, are essential to treatment. Graft and hardware retention can successfully accomplish these long-term goals. However, if early clinical response is not acceptable, strong consideration should be given to expedient graft and hardware removal. Excellent outcomes can be obtained, but results are usually lower than with uncomplicated cases.

LEVEL OF EVIDENCE

Level IV, case series.

Ghrelin and leptin elevation in postoperative intra-abdominal sepsis

BACKGROUND

Both ghrelin and leptin are important signals in the regulation of food intake and energy balance. Leptin concentrations are elevated in the majority of obese individuals, and its levels usually correlate with adiposity and body mass index. Ghrelin as a new growth hormone (GH)-releasing peptide was discovered in 1999. Ghrelin stimulates food intake and exhibits gastroprotective properties. Many other regulatory effects of both ghrelin and leptin involving cardiovascular, gastrointestinal, renal, and endocrine systems were revealed. New experimental studies show both hormones as new acute phase reactants in animal models of inflammatory reaction. The aim of this study was to characterize the levels of circulating ghrelin and leptin in relation to systemic inflammatory response. We used a postoperative bacterial sepsis after large abdominal surgery as a model of cytokine network hyperstimulation.

PATIENTS AND METHODS

The prospective study was performed on 25 surgical patients with proven postoperative intra-abdominal sepsis after large abdominal surgery. Plasma levels of ghrelin (RIA), leptin, TNF-alpha, IL-1beta, sIL-2R, IL-6 (ELISA analysis), CRP and alpha1-antitrypsin (nephelometric analysis) were analyzed.

RESULTS

Authors demonstrate statistically significant elevation of plasma ghrelin (492.3+/-70.6 ng/l) and leptin (31.6+/-12.2 microg/l) compared with the control group (336.5+/-46,1, p<0.01 for ghrelin, 3.5+/-1.2 microg/l, p<0.001 for leptin). The regression coefficient was the highest for ghrelin and IL-6 (r=0,44, p<0.05), and for ghrelin and TNF (r=0.43, p<0.05) in the sepsis group. In regard to leptin, the regression coefficient was the highest for IL-6 and leptin (r=0.53, p<0.05) and for leptin and CRP (r=0.51, p<0.05). There was no significant correlation between ghrelin and IL-1beta, ghrelin and sIL-2R, and leptin and IL-1beta.

CONCLUSIONS

During postoperative intra-abdominal sepsis, both ghrelin and leptin plasma levels are elevated and positively correlate with both inflammatory cytokines (TNF-alpha, IL-6) and main APP member (CRP). It supports experimental finding that TNF-alpha and IL-6 can be important regulatory factors of their synthesis. This hormonal reaction is not specific to sepsis--the significant increase of both ghrelin and leptin occurs during an uncomplicated postoperative response, although in a lesser extent than was shown in sepsis.

Quantitative analysis of procalcitonin after pediatric cardiothoracic surgery

Procalcitonin appears to be an early and sensitive marker of bacterial infection in a variety of clinical settings. The use of levels of procalcitonin to predict infection in children undergoing cardiac surgery, however, may be complicated by the systemic inflammatory response that normally accompanies cardiopulmonary bypass. The aim of our study was to estimate peri-operative concentrations of procalcitonin in non-infected children undergoing cardiac surgery. Samples of serum for assay of procalcitonin were obtained in 53 patients at baseline, 24, 48, and 72 hours following cardiac surgery. Concentrations were assessed using an immunoluminetric technique. Median concentrations were lowest at baseline at less than 0.5 nanograms per millilitre, increased at 24 hours to 1.8 nanograms per millilitre, maximized at 48 hours at 2.1 nanograms per millilitre, and decreased at 72 hours to 1.3 nanograms per millilitre, but did not return to baseline levels. Ratios of concentrations between 24, 48 and 72 hours after surgery as compared to baseline were 6.15, with 95 percent confidence intervals between 4.60 and 8.23, 6.49, with 95 percent confidence intervals from 4.55 to 9.27, and 4.26, with 95 percent confidence intervals between 2.78 and 6.51, respectively, with a p value less than 0.001. In 8 patients, who had no evidence of infection, concentrations during the period from 24 to 72 hours were well above the median for the group. We conclude that concentrations of procalcitonin in the serum increase significantly in children following cardiac surgery, with a peak at 48 hours, and do not return to baseline within 72 hours of surgery. A proportion of patients, in the absence of infection, had exaggerated elevations post-operatively.