Clinical Study Of Procalcitonin After Cardiopulmonary Bypass In Pediatric Cardiac Surgery Children

Objective1.To explore the natural changes of procalcitonin(PCT)in the early period after pediatric cardiac surgery with cardiopulmonary bypass(CPB).2.To evaluate the diagnostic value of PCT levels on early postoperative infection after pediatric cardiac surgery with CPB.MethodsA prospective and observational study done to patients who were 3 years of age and below,underwent cardiac surgery involving CPB,the RACHS score was 2 to 5 and free from active preoperative infection or inflammatory disease.Blood samples for measurement of PCT,C-reactive protein(CRP)and white blood cell(WBC)were taken before surgery and daily for 7 days in postoperative period.Patients were divided into four groups according to the postoperative infection and complications within 7 days after surgery.Postoperative infections were defined as pneumonia,deep sternal wound infection and mediastinitis and sepsis according to American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference.The final diagnosis of postoperative infection was determined by two independent experts in regard to the complete medical chart.Dynamic trend of PCT expressed by PCT variation and PCT variation was defined by the equation([(PCTPODn-PCTPODl)/PCTPOD1]×100%.PCTPOD1 is PCT concentration on POD1;PCTPODn is blood PCT concentration measured at POD2 to POD7.Measurements and Main Results1.To explore the natural changes and influencing factors of PCT in the early stage after pediatric cardiac surgery with CPB,the final subjects were children with PICU?4 days,429 patients were included,including 145 infection children,38 children with complication,230 children in normal group and 16 children with infection and complication at the same time.PCT,CRP and WBC were significantly higher after CPB.CRP and WBC peaked on the second postoperative day(POD)and remained higher than normal until POD7.PCT peaked on POD1 and would generally decreas to normal on POD5 if without infection and complications.Age,body weight,RACHS scores,the durations of CPB and AXC were correlated with PCT level.There was a significant difference in PCT concentration between the infection group and the normal group on POD3-7(P<0.01)and a significant difference between the complication group and normal group on POD 1-7(P<0.01).A significant difference was found between infection group and complication group on POD1-5(P<0.05).2.To evaluate the value of PCT levels on early postoperative infection after pediatric cardiac surgery with CPB,combined with the results of the PCT influencing factors,further select the children with age?1 year old and single disease(anatomical deformity for transposition of great arteries,switch operation)no complications for research.There were 11 children in the infection group and 16 in the normal group.Significant differences were found in PCT on POD4-7 and PCT variation on POD3-7 between the two groups.Among the 11 infection patients,5 patients kept a high level of PCT(>lng/ml)within 7 days after operation,and the rest patients had a second increase in PCT.The diagnostic value of PCT was significantly higher than that of CRP and WBC.Best ROC curves AUC were obtained for PCT variation on POD3(AUCROC=0.91,sensitivity 80%,specificity 87%).No correlation was found between timing of infection and the absolute value of PCT(R2=0.034,P=0.922),but significant correlation was found in PCT variation(R2=0.625,P=0.004).Conclusions1.WBC.CRP and PCT were significantly increased after CPB in pediatric cardiac surgery patients.The factors influencing PCT concentration included age,weight,PACHS grade,CPB and AXC time,infection and complications.2.Compared with WBC and CRP,PCT has a higher diagnostic value to predict postoperative infection,and the dynamic change of PCT is more important than the absolute value of PCT.After excluding the influence of complications,the maintenance of a high level(PCT>1.0ng/ml)within 7 days after surgery and/or a second increase in PCT could be used as an indicator of postoperative infection.Objective1.To describe the postoperative course and outcomes of cardiac surgery in children with perioperative viral respiratory infection(VRI)2.to evaluate optimal surgical timing for preoperative VRI patients3.to define risk stratification.Methods1.Retrospective study of children undergoing cardiac surgery.Children were tested using a multiplex Polymerase Chain Reaction(respiratory virus polymerase chain reaction,RespPCR)panel capturing seven respiratory viruses.RespPCR testing was routinely performed in patients under 2 years old.Those with negative results yet highly suspected of VRI after surgeries would be tested again.2.Patients: Children admitted between January 1,2016 and December 31,2018 to perform RespPCR testing and cardiac surgery were included.Measurements and Main Results1.A total of 2,831 patients had RespPCR testing,and vimses were detected in 91 patients(3.2%),including 35 preoperative and 56 postoperative.of the 35 preoperative VRI patients,there were 29 VRI-Resolved(patients for whom surgery was postponed until resolution of VRI symptoms and negative RespPCR)and 6 VRI-Unresolved(who underwent cardiac surgery before resolution of symptoms and clearance of carriage)patients.Furthermore,there were seven deaths,including 1 in the preoperative VRIUnresolved group and 6 in the postoperative VRI group.2.Commonly detected viruses included respiratoiy syncytial vinas(RSV,60.4%),para-influenza virus ?(36.3%)and influenza A(3.3%).Of all viruses,RSV patients had higher mortality(12.7% vs 0,p=0.026)and longer duration of MV(median 296 h,IQR 7-936 h vs median 139 h,IQR 4-376h;p =0.035).3.A propensity score matching(PSM)was performed to correct the selection bias and identify the comparable patient groups.Compared to their matched non-VRI patients,VRIResolved patients had similar duration of MV(median 22 h,interquartile range(IQR)1-124 h vs median 20 h,IQR l-212h;p=0.268),PICU(median 3d,IQR l-8d vs median 3d,IQR l-17d;p=0.785)and hospital LOS(median 12 d,IQR 8-16 d vs median 12 d,IQR 7-25d;p=0.872),while VRI-Unresolved patients had longer durations of postoperative MV(256h vs 72 h,p=0.033),PICU(18d vs 9d,p=0.028)and hospital LOS(27±7.5 vs 16±7.3d,p=0.010),and postoperative VRI patients had significantly longer duration of MV(372h vs 18 h,p<0.001),PICU LOS(22d vs 3d,p<0.001),hospital LOS(34d vs 12 d,p<0.001)and higher mortality(11.1% vs 1.42%,p<0.001).4.The unmatched analysis between VRI-Resolved and VRI-Unres?]ved patients indicated that those who underwent surgery during virus infection was associated with unfavorable outcomes in terms of MV(288h vs 22 h,p<0.001),PICU LOS(20d vs 3d,p<0.001),hospital LOS(29d vs 12 d,p<0.001),need of HFOV/ECMO(33.3% vs 0,p=0.001), bacteria/fungal co-infection(66.7% vs 6.9%,p<0.001)and in-hospital mortality(16.7% vs 0,p=0.026).5.Earlier diagnosis of postoperative VRI was associated with longer MV duration(r2 =0.422.p <0.001).Univariate analysis showed that death was associated with type of operation(p <0.001),type of VRI(p =0₀40)and diagnostic timing of VRI.However,Palliative cardiac surgery was the only variable significantly associated with mortality in multivariate analysis(OR 12.0,95% Cl 1.6,87.5;p =0.014).The mortality rate in biventricular repairs and palliations in patients with VRI was respectively 3.8% and 37.5%with a p value of <0.001.Conclusions1.The preoperative-unresolved and postoperative VRI were associated with prolonged postoperative recovery,increased severity and mortality in children with cardiac surgeries.2.The optimal surgical timing may be after the resolution of VRI symptoms and carriage,unless the perceived benefits of early surgery outweigh the risk of death,prolonged ventilation and PICU LOS.3.Factors for risk stratification include type of operation,type of VRI and diagnostic timing of VRI.Palliative surgeries were associated with increasing mortality.