Changes and its influencing factors of procalcitonin in pediatric cardiac surgery under cardiopulmonary bypass_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LI Xia ,  WANG Xu , YANG Juxian , ZHOU Yuzi , YANG Fan

Department of Pediatric Intensive Care Unit, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, 100037, P. R. China;

Corresponding author：

WANG Xu, Email: fwpicu@163.com

Keywords：

Congenital heart disease; cardiac surgery; cardiopulmonary bypass; postoperative infection; procalcitonin

DOI：

10.7507/1007-4848.202101011

Video：

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Objective To explore the natural changes of procalcitonin (PCT) in the early period after pediatric cardiac surgery with cardiopulmonary bypass (CPB).Methods A prospective and observational study was done on patients below 3 years of age, who underwent cardiac surgery involving CPB, with the risk adjustment of congenital heart surgery (RACHS) score of 2 to 5 and free from active preoperative infection or inflammatory disease. Blood samples for measurement of PCT, C-reactive protein (CRP) and white blood cell (WBC) were taken before surgery and daily for 7 days in postoperative period. Infections and complications within 7 days after operation were investigated. According to the presence or absence of infection and complications within 7 days after operation, the enrolled children were divided into an infection+complications group, a simple infection group, a simple complication group, and a normal group.Results Finally, 429 children with PICU stay≥ 4 days were enrolled, including 268 males and 161 females, with a median age of 8.0 (0.7, 26.0) months. There were 145 children in the simple infection group, 38 children in the simple complication group, 230 children in the normal group and 16 children in the infection+complications group. The levels of PCT, CRP and WBC were significantly higher after CPB. CRP and WBC peaked on the second postoperative day (POD) and remained higher than normal until POD7. PCT peaked on POD1 and would generally decrease to normal on POD5 if without infection and complications. Age, body weight, RACHS scores, the duration of CPB and aortic cross-clamping time were correlated with PCT level. There was a statistical difference in PCT concentration between the simple infection group and the normal group on POD 3-7 (P<0.01) and a statistical difference between the simple complication group and the normal group on POD 1-7 (P<0.01). A statistical difference was found between the simple infection group and the simple complication group in PCT on POD 1-5 (P<0.05).Conclusion WBC, CRP and PCT significantly increase after CPB in pediatric cardiac surgery patients. The factors influencing PCT concentration include age, weight, RACHS scores, CPB and aortic cross-clamping time, infection and complications.

Citation： LI Xia, WANG Xu, YANG Juxian, ZHOU Yuzi, YANG Fan. Changes and its influencing factors of procalcitonin in pediatric cardiac surgery under cardiopulmonary bypass. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(1): 106-112. doi: 10.7507/1007-4848.202101011 Copy

1.	Ó Maoldomhnaigh C, Drew RJ, Gavin P, et al. Invasive meningococcal disease in children in Ireland, 2001-2011. Arch Dis Child, 2016, 101(12): 1125-1129.
2.	Schrag SJ, Farley MM, Petit S, et al. Epidemiology of invasive early-onset neonatal sepsis, 2005 to 2014. Pediatrics, 2016, 138(6): e20162013.
3.	Kalich BA, Maguire JM, Campbell-Bright SL, et al. Impact of an antibiotic-specific sepsis bundle on appropriate and timely antibiotic administration for severe sepsis in the emergency department. J Emerg Med, 2016, 50(1): 79-88.
4.	Wallgren UM, Antonsson VE, Castrén MK, et al. Longer time to antibiotics and higher mortality among septic patients with non-specific presentations—A cross sectional study of emergency department patients indicating that a screening tool may improve identification. Scand J Trauma Resusc Emerg Med, 2016, 24: 1.
5.	Weiss SL, Fitzgerald JC, Balamuth F, et al. Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis. Crit Care Med, 2014, 42(11): 2409-2417.
6.	Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med, 2001, 345(19): 1368-1377.
7.	Harbarth S, Holeckova K, Froidevaux C, et al. Diagnostic value of procalcitonin, interleukin-6, and interleukin-8 in critically ill patients admitted with suspected sepsis. Am J Respir Crit Care Med, 2001, 164(3): 396-402.
8.	Claeys R, Vinken S, Spapen H, et al. Plasma procalcitonin and C-reactive protein in acute septic shock: Clinical and biological correlates. Crit Care Med, 2002, 30(4): 757-762.
9.	Lecharny JB, Khater D, Bronchard R, et al. Hyperprocalcitonemia in patients with perioperative myocardial infarction after cardiac surgery. Crit Care Med, 2001, 29(2): 323-325.
10.	Dörge H, Schöndube FA, Dörge P, et al. Procalcitonin is a valuable prognostic marker in cardiac surgery but not specific for infection. Thorac Cardiovasc Surg, 2003, 51(6): 322-326.
11.	Prat C, Ricart P, Ruyra X, et al. Serum concentrations of procalcitonin after cardiac surgery. J Card Surg, 2008, 23(6): 627-632.
12.	Kallel S, Abid M, Jarraya A, et al. Kinetics, diagnostic and prognostic value of procalcitonin after cardiac surgery. Ann Biol Clin (Paris), 2012, 70(5): 567-580.
13.	Laffey JG, Boylan JF, Cheng DC. The systemic inflammatory response to cardiac surgery: Implications for the anesthesiologist. Anesthesiology, 2002, 97(1): 215-252.
14.	Delannoy B, Guye ML, Slaiman DH, et al. Effect of cardiopulmonary bypass on activated partial thromboplastin time waveform analysis, serum procalcitonin and C-reactive protein concentrations. Crit Care, 2009, 13(6): R180.
15.	Jensen JU, Heslet L, Jensen TH, et al. Procalcitonin increase in early identification of critically ill patients at high risk of mortality. Crit Care Med, 2006, 34(10): 2596-2602.
16.	Jenkins KJ, Gauvreau K, Newburger JW, et al. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg, 2002, 123(1): 110-118.
17.	Calandra T, Cohen J,. The international sepsis forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med, 2005, 33(7): 1538-1548.
18.	El Oakley RM, Wright JE. Postoperative mediastinitis: Classification and management. Ann Thorac Surg, 1996, 61(3): 1030-1036.
19.	Society of Critical Care Medicine Consensus Conference Committee, American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med, 1992, 20: 864-874.
20.	Arkader R, Troster EJ, Lopes MR, et al. Procalcitonin does discriminate between sepsis and systemic inflammatory response syndrome. Arch Dis Child, 2006, 91(2): 117-120.
21.	Crespo-Marcos D, Rey-Galán C, López-Herce-Cid J, et al. Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery. An Pediatr (Barc), 2010, 73(4): 162-168.
22.	Minami E, Ito S, Sugiura T, et al. Markedly elevated procalcitonin in early postoperative period in pediatric open heart surgery: A prospective cohort study. J Intensive Care, 2014, 2(1): 38.
23.	Hammer S, Loeff M, Reichenspurner H, et al. Effect of cardiopulmonary bypass on myocardial function, damage and inflammation after cardiac surgery in newborns and children. Thorac Cardiovasc Surg, 2001, 49(6): 349-354.
24.	Beghetti M, Rimensberger PC, Kalangos A, et al. Kinetics of procalcitonin, interleukin 6 and C-reactive protein after cardiopulmonary-bypass in children. Cardiol Young, 2003, 13(2): 161-167.
25.	Celebi S, Koner O, Menda F, et al. Procalcitonin kinetics in pediatric patients with systemic inflammatory response after open heart surgery. Intensive Care Med, 2006, 32(6): 881-887.
26.	Adamik B, Kübler-Kielb J, Golebiowska B, et al. Effect of sepsis and cardiac surgery with cardiopulmonary bypass on plasma level of nitric oxide metabolites, neopterin, and procalcitonin: Correlation with mortality and postoperative complications. Intensive Care Med, 2000, 26(9): 1259-1267.
27.	Kerbaul F, Guidon C, Lejeune PJ, et al. Hyperprocalcitonemia is related to noninfectious postoperative severe systemic inflammatory response syndrome associated with cardiovascular dysfunction after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth, 2002, 16(1): 47-53.
28.	Meisner M, Rauschmayer C, Schmidt J, et al. Early increase of procalcitonin after cardiovascular surgery in patients with postoperative complications. Intensive Care Med, 2002, 28(8): 1094-1102.
29.	Aouifi A, Piriou V, Blanc P, et al. Effect of cardiopulmonary bypass on serum procalcitonin and C-reactive protein concentrations. Br J Anaesth, 1999, 83(4): 602-607.
30.	Boeken U, Feindt P, Petzold T, et al. Diagnostic value of procalcitonin: The influence of cardiopulmonary bypass, aprotinin, SIRS, and sepsis. Thorac Cardiovasc Surg, 1998, 46(6): 348-351.
31.	Li X, Wang X, Li S, et al. Diagnostic value of procalcitonin on early postoperative infection after pediatric cardiac surgery. Pediatr Crit Care Med, 2017, 18(5): 420-428.

1. Ó Maoldomhnaigh C, Drew RJ, Gavin P, et al. Invasive meningococcal disease in children in Ireland, 2001-2011. Arch Dis Child, 2016, 101(12): 1125-1129.
2. Schrag SJ, Farley MM, Petit S, et al. Epidemiology of invasive early-onset neonatal sepsis, 2005 to 2014. Pediatrics, 2016, 138(6): e20162013.
3. Kalich BA, Maguire JM, Campbell-Bright SL, et al. Impact of an antibiotic-specific sepsis bundle on appropriate and timely antibiotic administration for severe sepsis in the emergency department. J Emerg Med, 2016, 50(1): 79-88.
4. Wallgren UM, Antonsson VE, Castrén MK, et al. Longer time to antibiotics and higher mortality among septic patients with non-specific presentations—A cross sectional study of emergency department patients indicating that a screening tool may improve identification. Scand J Trauma Resusc Emerg Med, 2016, 24: 1.
5. Weiss SL, Fitzgerald JC, Balamuth F, et al. Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis. Crit Care Med, 2014, 42(11): 2409-2417.
6. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med, 2001, 345(19): 1368-1377.
7. Harbarth S, Holeckova K, Froidevaux C, et al. Diagnostic value of procalcitonin, interleukin-6, and interleukin-8 in critically ill patients admitted with suspected sepsis. Am J Respir Crit Care Med, 2001, 164(3): 396-402.
8. Claeys R, Vinken S, Spapen H, et al. Plasma procalcitonin and C-reactive protein in acute septic shock: Clinical and biological correlates. Crit Care Med, 2002, 30(4): 757-762.
9. Lecharny JB, Khater D, Bronchard R, et al. Hyperprocalcitonemia in patients with perioperative myocardial infarction after cardiac surgery. Crit Care Med, 2001, 29(2): 323-325.
10. Dörge H, Schöndube FA, Dörge P, et al. Procalcitonin is a valuable prognostic marker in cardiac surgery but not specific for infection. Thorac Cardiovasc Surg, 2003, 51(6): 322-326.
11. Prat C, Ricart P, Ruyra X, et al. Serum concentrations of procalcitonin after cardiac surgery. J Card Surg, 2008, 23(6): 627-632.
12. Kallel S, Abid M, Jarraya A, et al. Kinetics, diagnostic and prognostic value of procalcitonin after cardiac surgery. Ann Biol Clin (Paris), 2012, 70(5): 567-580.
13. Laffey JG, Boylan JF, Cheng DC. The systemic inflammatory response to cardiac surgery: Implications for the anesthesiologist. Anesthesiology, 2002, 97(1): 215-252.
14. Delannoy B, Guye ML, Slaiman DH, et al. Effect of cardiopulmonary bypass on activated partial thromboplastin time waveform analysis, serum procalcitonin and C-reactive protein concentrations. Crit Care, 2009, 13(6): R180.
15. Jensen JU, Heslet L, Jensen TH, et al. Procalcitonin increase in early identification of critically ill patients at high risk of mortality. Crit Care Med, 2006, 34(10): 2596-2602.
16. Jenkins KJ, Gauvreau K, Newburger JW, et al. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg, 2002, 123(1): 110-118.
17. Calandra T, Cohen J,. The international sepsis forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med, 2005, 33(7): 1538-1548.
18. El Oakley RM, Wright JE. Postoperative mediastinitis: Classification and management. Ann Thorac Surg, 1996, 61(3): 1030-1036.
19. Society of Critical Care Medicine Consensus Conference Committee, American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med, 1992, 20: 864-874.
20. Arkader R, Troster EJ, Lopes MR, et al. Procalcitonin does discriminate between sepsis and systemic inflammatory response syndrome. Arch Dis Child, 2006, 91(2): 117-120.
21. Crespo-Marcos D, Rey-Galán C, López-Herce-Cid J, et al. Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery. An Pediatr (Barc), 2010, 73(4): 162-168.
22. Minami E, Ito S, Sugiura T, et al. Markedly elevated procalcitonin in early postoperative period in pediatric open heart surgery: A prospective cohort study. J Intensive Care, 2014, 2(1): 38.
23. Hammer S, Loeff M, Reichenspurner H, et al. Effect of cardiopulmonary bypass on myocardial function, damage and inflammation after cardiac surgery in newborns and children. Thorac Cardiovasc Surg, 2001, 49(6): 349-354.
24. Beghetti M, Rimensberger PC, Kalangos A, et al. Kinetics of procalcitonin, interleukin 6 and C-reactive protein after cardiopulmonary-bypass in children. Cardiol Young, 2003, 13(2): 161-167.
25. Celebi S, Koner O, Menda F, et al. Procalcitonin kinetics in pediatric patients with systemic inflammatory response after open heart surgery. Intensive Care Med, 2006, 32(6): 881-887.
26. Adamik B, Kübler-Kielb J, Golebiowska B, et al. Effect of sepsis and cardiac surgery with cardiopulmonary bypass on plasma level of nitric oxide metabolites, neopterin, and procalcitonin: Correlation with mortality and postoperative complications. Intensive Care Med, 2000, 26(9): 1259-1267.
27. Kerbaul F, Guidon C, Lejeune PJ, et al. Hyperprocalcitonemia is related to noninfectious postoperative severe systemic inflammatory response syndrome associated with cardiovascular dysfunction after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth, 2002, 16(1): 47-53.
28. Meisner M, Rauschmayer C, Schmidt J, et al. Early increase of procalcitonin after cardiovascular surgery in patients with postoperative complications. Intensive Care Med, 2002, 28(8): 1094-1102.
29. Aouifi A, Piriou V, Blanc P, et al. Effect of cardiopulmonary bypass on serum procalcitonin and C-reactive protein concentrations. Br J Anaesth, 1999, 83(4): 602-607.
30. Boeken U, Feindt P, Petzold T, et al. Diagnostic value of procalcitonin: The influence of cardiopulmonary bypass, aprotinin, SIRS, and sepsis. Thorac Cardiovasc Surg, 1998, 46(6): 348-351.
31. Li X, Wang X, Li S, et al. Diagnostic value of procalcitonin on early postoperative infection after pediatric cardiac surgery. Pediatr Crit Care Med, 2017, 18(5): 420-428.

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