Inflammatory Response and Barrier Dysfunction by Different ...
CRP and inflammatory response (2)
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Transcript of CRP and inflammatory response (2)
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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.
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24th European Congress on Surgical Infection, 28th May, Leon.
• 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
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24th European Congress on Surgical Infection, 28th May, Leon.
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
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24th European Congress on Surgical Infection, 28th May, Leon.
• To evaluate the utility of CRP in the early diagnosis of major septic complications after elective colorectal surgery
Objective
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24th European Congress on Surgical Infection, 28th May, Leon.
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
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24th European Congress on Surgical Infection, 28th May, Leon.
• 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
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24th European Congress on Surgical Infection, 28th May, Leon.
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
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24th European Congress on Surgical Infection, 28th May, Leon.
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
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24th European Congress on Surgical Infection, 28th May, Leon.
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
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24th European Congress on Surgical Infection, 28th May, Leon.
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
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24th European Congress on Surgical Infection, 28th May, Leon.
-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.
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24th European Congress on Surgical Infection, 28th May, Leon.
• 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
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24th European Congress on Surgical Infection, 28th May, Leon.
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24th European Congress on Surgical Infection, 28th May, Leon. Thanks to Dr Guirao for giving me the opportunity to collaborate in the study