RESUMO
We reviewed the use of the levels of C-reactive protein, lactate and procalcitonin and/or the Sequential Organ Failure Assessment score to determine their diagnostic accuracy for predicting surgical complications in critically ill general post-surgery patients. Included were all studies published in PubMed from inception to July 2013 that met the following inclusion criteria: evaluation of the above parameters, describing their diagnostic accuracy and the risk stratification for surgical complications in surgical patients admitted to an intensive care unit. No difference in the Sequential Organ Failure Assessment scores was seen between patients with or without complications. The D-lactate levels were significantly higher in those who developed colonic ischemic complications after a ruptured abdominal aortic aneurysm. After gastro-intestinal surgery, contradictory data were reported, with both positive and negative use of C-reactive protein and procalcitonin in the diagnosis of septic complications. However, in trauma patients, the C-reactive protein levels may help to discriminate between those with and without infectious causes. We conclude that the Sequential Organ Failure Assessment score, lactate concentration and C-reactive protein level have no significant predictive value for early postoperative complications in critically ill post-surgery patients. However, procalcitonin seems to be a useful parameter for diagnosing complications in specific patient populations after surgery and/or after trauma.
Assuntos
Proteína C-Reativa/análise , Calcitonina/sangue , Estado Terminal , Unidades de Terapia Intensiva , Escores de Disfunção Orgânica , Complicações Pós-Operatórias/diagnóstico , Precursores de Proteínas/sangue , Biomarcadores/sangue , Peptídeo Relacionado com Gene de Calcitonina , Previsões , Humanos , Ácido Láctico/sangue , PubMed , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Procalcitonin (PCT) is a relatively new, promising indirect parameter for infection. In the intensive care unit (ICU) it can be used as a marker for sepsis. However, in the ICU there is a need for reliable markers for clinical deterioration in the critically ill patients. This study determines the clinical value of PCT concentrations in recognizing surgical complications in a heterogeneous group of general surgical patients in the ICU. MATERIAL AND METHODS: We prospectively collected PCT concentration data from April 2010 to June 2012 for all general surgical patients admitted to the ICU. Both the relationships between PCT levels and events (diagnostic and therapeutic interventions) as well as between PCT levels and surgical complications (abscesses, bleeding, perforation, ischemia, and ileus) were studied. RESULTS: PCT concentrations were lower in patients who developed complications than those who did not develop complications on the same day, although not significant (P = 0.27). A 10% increase in PCT levels resulted in a 2% higher complication odds, but again this was not significant (odds ratio [OR], 1.020; 95% confidence interval [CI], 0.961-1.083; P = 0.51). Even a 20% or 30% increase in PCT concentrations did not result in higher complication probability (OR, 1.039; 95% CI, 0.927-1.165 and OR, 1.057; 95% CI, 0.897-1.246). Furthermore, an increase in PCT levels did not show an increase or a reduction in the number of diagnostic and therapeutic interventions. CONCLUSIONS: An increase in PCT levels does not help to predict surgical complications in critically ill surgical patients.
Assuntos
Calcitonina/sangue , Precursores de Proteínas/sangue , Sepse/metabolismo , Infecção da Ferida Cirúrgica/metabolismo , Abscesso/diagnóstico , Abscesso/metabolismo , Abscesso/mortalidade , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Peptídeo Relacionado com Gene de Calcitonina , Estado Terminal , Feminino , Mortalidade Hospitalar , Humanos , Íleus/diagnóstico , Íleus/metabolismo , Íleus/mortalidade , Unidades de Terapia Intensiva , Isquemia/diagnóstico , Isquemia/metabolismo , Isquemia/mortalidade , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/diagnóstico , Hemorragia Pós-Operatória/metabolismo , Hemorragia Pós-Operatória/mortalidade , Prognóstico , Estudos Prospectivos , Sepse/diagnóstico , Sepse/mortalidade , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/mortalidadeRESUMO
BACKGROUND: The purpose of this study is first to assess the clinical value of lactate concentrations by comparison with clinical scoring systems, and second to determine the value of lactate levels in clinical decisions as ordering diagnostic and therapeutic (re)interventions in the population of critically ill surgical patients on the intensive care unit (ICU). MATERIALS AND METHODS: From April 2010 to June 2011, the L-lactate concentrations, Sequential Organ Failure Assessment (SOFA) score and Acute Physiological and Chronic Health Evaluation II (APACHE II) score were prospectively collected in surgical patients (n = 174) admitted into the ICU. The L-Lactate and scoring systems were related to events defined as performing computed tomography-scans, laparotomy, ultrasonography, and flexible endoscopy. Furthermore, all surgical complications were also registered. RESULTS: For SOFA scores above four points, mean lactate concentrations increased 4.5% for each point increase in SOFA score (P < 0.0005). In APACHE II scores above 16 points, mean lactate concentrations increased 2.9% for each point increase in APACHE II score (P < 0.0005). Each 10% increase in lactate concentration showed a 3.3% higher odds for a first event (OR 1.033; P = 0.26). Lactate levels did not correspond with more complications (OR 0.968; P = 0.52). CONCLUSIONS: There is a significant positive relationship between lactate concentrations, high SOFA scores, and APACHE II scores. However, the important outcome is that lactate seems to be a poor predictor for surgical complications in the critically ill surgical patient in the ICU.
Assuntos
Cuidados Críticos , Unidades de Terapia Intensiva , Lactatos/sangue , Complicações Pós-Operatórias/epidemiologia , APACHE , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Complicações Pós-Operatórias/sangue , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de RiscoRESUMO
INTRODUCTION: C-reactive Protein (CRP) is used next to clinical scoring systems to recognize critically ill patients prone to develop complications on the Intensive Care Unit (ICU). The purpose of this study is to assess the predictive value of CRP as parameter for clinical deterioration and/or clinical decision making as ordering diagnostic procedures or performing (re)interventions. Also, we wanted to determine the value of CRP in early detection of surgical complications in the critically ill general surgical patient in the ICU and its interpretation in adjunct to a clinical scoring system, the Sequential Organ Failure Assessment Score. MATERIALS AND METHODS: In our prospective observational study, 174 general surgical patients admitted into the Intensive Care Unit were included. We evaluated the Sequential Organ Failure Assessment Score (SOFA) and daily measured the C-reactive protein (CRP) concentrations. All events (diagnostic or therapeutic interventions) and surgical complications were registered. Then the relationship between SOFA score, CRP concentrations, events and complications were studied. RESULTS: Each 10% increase in CRP resulted in a 3.5% increase in the odds of an event (odds ratio 1.035, 95% CI: 1.004-1.068; pâ=â0.028). However, an increase in CRP levels did not lead to a higher odds of complication (OR 0.983, 95% CI: 0.932-1.036; pâ=â0.52). When adjusting for the SOFA score the effect of CRP on the probability of a first event remained significant (OR 1.033, 95% CI: 1.001-1.065; pâ=â0.046), and again did not significantly affect the complication probability (OR 0.980, 95% CI: 0.929-1.035; pâ=â0.46). CONCLUSIONS: An increase in C-reactive protein is a poor parameter for early detection of complications in the critically ill surgical patient in the ICU by means of diagnostic procedures or therapeutic (re)-interventions.
Assuntos
Proteína C-Reativa/metabolismo , Estado Terminal , Tomada de Decisões , Unidades de Terapia Intensiva , Insuficiência de Múltiplos Órgãos/sangue , Insuficiência de Múltiplos Órgãos/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Complicações Pós-OperatóriasRESUMO
CASE PRESENTATION: This report describes the presentation of three critically ill patients with non-traumatic acute abdominal pain and increased concentrations of the biomarkers C-reactive protein (CRP) and lactate. In these three patients an exploratory laparotomy was carried out. Remarkably, the laparotomy showed no intra-abdominal abnormalities. We discuss the usefulness of these biomarkers in practice and their influence on establishing a diagnose and making a decision to perform an intervention. CONCLUSION: We conclude that biomarkers lactate and CRP in patients with acute abdominal pain should only be used in adjunct to the history and clinical findings, as they are not specific and can be misleading in establishing a diagnosis. In addition, relying on these biomarkers may contribute to more diagnostic examinations and/or unnecessary invasive interventions (for example laparotomy).