CRP and inflammatory response (2)

24th European Congress on Surgical Infection, 28th May, Leon.

A suficient decrease of C-reactive protein (CRP) after elective

colorectal surgery is a good marker of uneventful outcome.

Montserrat Juvany, Xavier Guirao, Sara Amador, Ruben Hernando, Guzmán Franch*,

Miquel Casal, Josep Maria Badia.

Hospital General de Granollers, Barcelona. *Hospital Universitario de Salamanca,

Salamanca.

Spain.


• 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 to 25%)

o Delayed diagnosis and treatment might be associated with a worse prognosis

o Previous observations have demonstrated that clinical parameters of SIRS are not so useful as they are in communitary organ-space infections

Introduction

Complications in colo-rectal surgery


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

Introduction


• To evaluate the utility of CRP in the early diagnosis of major septic complications after elective colorectal surgery

Objective


Material and methods

• Prospective

• Elective colo-rectal surgery with primmary anastomosis

• 33 months (January 07-Sept 09)

• Analysis

– CRP: 2nd and 5th po days

• Data: mean ± SD

• Statistics:

– Student-t test

– Receiver operative curve (ROC) test


• Main variable: MAJOR SURGICAL SITE INFECTIONS

Material and methods

Major Minor

Surgical site

infections (SSI)

• Deep wound

infection

• Organ-space

infection

• Superficial

wound infection

No Surgical site

infections (no SSI)

• Cardiac arrest

• Pneumonia

• Urinary infection

• Phlebitis

• Ileus


n=208

Age (y) 68.3 ± 11.4

Gender (%) M: 61

F: 39

ASA (%) - I: 4

- II: 59

- III: 33

- IV: 4

IQ (%) - Right colect: 34

- Sigmoidect: 27

- Rectum res: 22

- Left colect: 9

- Hartmann rev: 6

- Subtotal colect: 2

Aproach (%) Open: 50

Laparoscopic: 50

Results


n=208

n=95 complics

n=113 no complics

n=38 minor

n=57 major

n=48 SSI

n=9 no SSI

NO MAJOR

COMPLICATIONS

(n=151)

MAJOR

COMPLICATIONS

(n=48)

EARLY

<5th PO day

(n=10)

EXCLUDED

LATE ≥5th

PO day

(n=38)

Results


CRP values on the 2nd postoperative day are higher in early complicated patients in comparison to non-complicated patients

Early complicated

(n=10)

Non-complicated

(n=151)

CRP at the 2nd

PO day (mg/L)

241 109 156 76 p<0.005

The best cut-off point in the ROC curve test is a CRP on the 2nd PO day higher than:

201 mg/L

NPV=0.98

Results


CRP at the 2nd and the 5th PO days is higher in late complicated

patients (vs non-complicated) and the fall down is lower (D% CRP 2-5)

Late complicated

(n=38)

Non-complicated

(n=151)

D % CRP 2-5 8 52 % -63 24% P<0.0001

0

50

100

150

200

250

300

350

D0 D2 D5

CR

P (

mg

/L)

217 79

157 48

218 94

57 48

Results

Late-complicated

Non-complicated


-39 % PPV=0.62

NPV=0.97

ROC curve (n=189)

Results

¿Which is the best cut off point of D% CRP 2-5?

¿Are there any differences considering the approach of the surgery?

Open (n=92)

-36% PPV=0.77

NPV=0.96

Laparoscopic (n=97)

-48% PPV=0.44

NPV=1

Laparoscopic approach produces lower levels of CRP (less surgical stress and contraregulation response) and because of this it is necessary a bigger falling down of the CRP to be able to

exclude major complications.


• A decrease of CRP between the 2nd and the 5th postoperative days higher than 36% in open surgery and 48% in laparoscopic are useful to exclude major septic complications and to discharge patients safely.

Conclusion


24th European Congress on Surgical Infection, 28th May, Leon. Thanks to Dr Guirao for giving me the opportunity to collaborate in the study

Health & Medicine

CRP and inflammatory response (2)