C-reactive protein kinetics after major surgery.

BACKGROUND: Diagnosis of sepsis in the postoperative period is a challenge. Measurements of inflammatory markers, such as C-reactive protein (CRP), have been proposed in medical patients, but the interpretation of these values in surgical patients is more difficult. We evaluated the changes in blood CRP levels and white blood cell count in postoperative patients with and without infection. METHODS: All patients admitted to our 34-bed Department of Intensive Care after major (elective or emergency) cardiac, neuro-, vascular, thoracic, or abdominal surgery during a 4-month period were prospectively included. Patients were screened daily and characterized as infected or noninfected. CRP levels and white blood cell counts were recorded daily in all patients for up to 7 days after the surgical intervention. RESULTS: Of the 151 patients enrolled, 115 underwent elective surgery and 36 emergency surgery; cardiac surgery was performed in 49 patients, neurosurgery in 65, abdominal surgery in 25, vascular surgery in 7, and thoracic surgery in 5. In noninfected patients (n = 117), mean CRP values increased from baseline to postoperative day (POD) 3 (P < 0.0001, estimated mean difference [EMD] = 99.7 mg/L [95% confidence interval, 85.6-113.8]) and then decreased until POD 7 but remained higher than the level at baseline (P < 0.0001, EMD = 49.2 mg/L [95% confidence interval, 27.1-71.2]). Postoperative infection occurred in 20 patients (13.2%). In these patients, CRP values were already higher on POD 1 than in noninfected patients (P = 0.0054). CONCLUSIONS: CRP levels increase in the first week after major surgery but to a much larger extent in infected than in noninfected patients. Persistently high CRP levels after POD 4, especially when >100 mg/L, suggest the presence of a postoperative infection.

Statins in the critically ill.

The use or misuse of statins in critically ill patients recently attracted the attention of intensive care clinicians. Indeed, statins are probably the most common chronic treatment before critical illness and some recent experimental and clinical data demonstrated their beneficial effects during sepsis, acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), or after aneurismal subarachnoidal hemorrhage (aSAH). Due to the heterogeneity of current studies and the lack of well-designed prospective studies, definitive conclusions for systematic and large-scale utilization in intensive care units cannot be drawn from the published evidence. Furthermore, the extent of statins side effects in critically ill patients is still unknown. For the intensive care clinician, it is a matter of individually identifying the patient who can benefit from this therapy according to the current literature. The purpose of this review is to describe the mechanisms of actions of statins and to synthesize the clinical data that underline the relevant effects of statins in the particular setting of critical care, in an attempt to guide the clinician through his daily practice.