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