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TSIS 2010, March 12, Munich
Insufficient decrease of C-reactive protein after elective colorectal
surgery predicts major septic post-operative complications
Montserrat Juvany, Xavier Guirao, Sara Amador, Ruben Hernando, Guzmán Franch, Josep Maria Badía
Hospital General de Granollers, Barcelona. Spain
TSIS 2010, March 12, Munich
Complications in colorectal surgery
• Surgical site infection (SSI):
– Wound
– Organ-space
o Anastomotic leakage is the main cause (2-24%)
o It is associated with a postoperative mortality (7-25%)
o Delayed diagnosis and treatment might be associated with a worse prognosis
o Previous observations have demonstrated that clinical parameters of SIRS are scarcely present on the postoperative period
TSIS 2010, March 12, Munich
C- reactive protein (CRP)
• IL-6 dependent protein produced in the liver
• Appears in blood at 4 hour after the inflammatory stimulus
• Peaks at 48 hours
100
200
300
400
CRP (mg/L)
24h 120h 240h Preop 48h
0
TSIS 2010, March 12, Munich
OBJECTIVE
• To evaluate the value of C-reactive protein (CRP) as an early predictor marker of major septic complications after elective colorectal surgery
TSIS 2010, March 12, Munich
• Prospective study during 30 months (from August 2006 to March 2009)
• Inclusion criteria – Elective colorectal surgery
– Intestinal anastomosis
• Exlusion criteria
– Emergency colorectal surgery
– No intestinal anastomosis
– Intrabdominal infection at surgery
• Major septic complications
– Deep wound SSI
– Organ-space SSI
– Pneumonia
MATERIALS AND METHODS
EARLY (<5th PO day)
LATE (≥ 5th PO day)
TSIS 2010, March 12, Munich
• Analysis:
– CRP
• 2nd PO
• 5th PO
– SIRS parameters
• During the first 5 days of PO
• Data: mean SD.
• Statistics
– Student-t test
– Receiver operative curve (ROC) test
SIRS (Systemic inflammatory response
syndrome) parameters:
• Temperature (T) >38ºC or < 36ºC
• Heart rate (HR) > 90 bpm
• Breath rate (BR) > 20 bpm
• White count cell (WCC) >12000 /cc or <
4000 / cc.
SIRS criteria (2 or more SIRS parameters).
MATERIALS AND METHODS
TSIS 2010, March 12, Munich
Organ-space SSI
3 19
Deep wound SSI
0 4
Pneumonia 2 8
n=151
36 major septic complications
RESULTS
Age (y) 68 11
Sex (%) M (67)
F (33)
ASA (%) I (1)
II (60)
III (35)
IV (4)
Diagnosis (%) Benign (12)
Malign (88)
Type of surgery (%)
Sigmoidectomy (30)
Right colectomy (29)
Rectum anterior res (24)
Left colectomy (8)
Hartmann 2nd time (7)
Subtotal colectomy (2)
Access route
(%)
Open (51)
Laparoscopic (49)
5 early 31 late
TSIS 2010, March 12, Munich
CRP (mg/L)
Complicated
(n=31)
Non complicated
(n=115)
2nd PO 200 67* 163 77 p<0.05
5th PO 213 100* 65 59 p<0.05
Complicated vs. non complicated patients (late complications:≥ 5 PO day)
RESULTS
TSIS 2010, March 12, Munich
SIRS parameters
Complicated
(n=31)
Non complicated
(n=115)
HR (bpm)
2nd PO 90 14* 82 14 p<0.05
5th PO 96 24* 82 14 p<0.05
WCC (leu/cc)
2nd PO 9448 3029 8791 2683
5th PO 7476 3641* 6304 2103 p<0.05
RR (bpm)
2nd PO 20 2 21 2
5th PO 22 5 21 3
T (ºC) 2nd PO 36.8 0.6 36.7 0.5
5th PO 36.7 0.7 36.6 0.3
Complicated vs. non complicated patients (late complications:≥ 5 PO day)
TSIS 2010, March 12, Munich
Early vs late complicated on the 2nd PO day
RESULTS
Early complicated
(n=5)
Late complicated
(n=31)
CRP (mg/L) 348 70.8 * 200 67 p<0.05
RR (bpm) 28 11* 20 2 p<0.05
HR (bpm) 106 23* 90 14 p<0.05
WCC (L/cc) 10223 4083 9448 3029
T (ºC) 36.5 0.8 36.8 0.5
TSIS 2010, March 12, Munich
Complicated
Non complicated
Changes in CRP values as a percentage between 2nd-5th postoperative day
RESULTS
D CRP % = CRP (5nd) - CRP (2th)
CRP (2nd)
X 100
TSIS 2010, March 12, Munich
ROC curve. Cut off point of D% CRP (2-5): decrease of 36%
RESULTS
• AUC=0.929
•IC=0,87-0,97
•Se= 28/31 (0.9)
• Sp= 99/115 (0.86)
TSIS 2010, March 12, Munich
Complicated Non complicated
Non ↓ > 36% 28 16 44
↓ > 36% 3 99 102
31 115 146
• Se= 28/31 (0.9)
• Sp= 99/115 (0.86)
• PPV= 28/44 (0.64)
• NPV = 99/102 (0.97)
Comparison complicated vs non complicated (late)
RESULTS
Out of 31 patients with complications, 28 did not
have the decrease of > 36% (sens of 90%)
Out of 102 patients who had the decrease >
36%, 99 did not have complications (NPV of 97%)
16 patients (out of 44) with insufficient
decrease, did not have major complications
TSIS 2010, March 12, Munich
CONCLUSIONS
• An insufficient decrease (less than 36%) of CRP values between the 2nd-5th PO days is likely to be a good tool for predicting major septic complications
• A decrease of more than 36 % can help surgeons to safely discharge patients by the 5th PO day
• Levels of CRP more than 300 mg/L on the 2nd PO day might indicate early major septic complications
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