Procalcitonin in the Early Course Post Pediatric Cardiac Surgery

Robert Zant, MD; Christian Stocker, MD, FMH (CH), FCICM; Luregn Jan Schlapbach, MD, FCICM; Sara Mayfield, BHScNurs; Tom Karl, MD, FRACS; Andreas Schibler, MD, FMH (CH), FCICM

Disclosures

Pediatr Crit Care Med. 2016;17(7):624-629.

Conclusions

Procalcitonin levels are elevated after pediatric cardiac surgery reaching a maximum on POD1. Levels of procalcitonin at admission to PICU correlated to duration of CPB, aortic cross-clamp time, and initial serum lactate and were significantly higher in children suffering a MAE. Furthermore, markers of postoperative morbidity (LOS in PICU, length of inotropic, and respiratory support) correlated with procalcitonin levels at admission. Patients with clinical suspicion of infection-associated deterioration in the later postoperative course already had significantly higher procalcitonin levels at admission to PICU.

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Acknowledgments
We thank Florian Zeman, biostatistician (Center for Clinical Studies, University Hospital Regensburg, Germany) for the statistical support.

Table 1. Preoperative Risk Factors of All Included Patients
Preoperative Risk Factor	n (%)
Mechanical ventilation	10 (4)
Myocardial dysfunction	3 (1)
Seizures, stroke, intracranial hemorrhage	6 (3)
Chromosomal/syndromic abnormality	28 (12)
Necrotizing enterocolitis	2 (1)
Renal failure	2 (1)

Table 2. Indications for Cardiac Surgery of All Included Patients
Anatomic Diagnosis	n (%)	Mean Age (mo)	Mean Weight (kg)	Mean Basic Aristotle Complexity Scores	Mean Comprehensive Aristotle Complexity Scores	Mean Risk Adjusted Congenital Heart Surgery Score
Ventricular septal defect	52 (22)	23.6 (0–125)	10.4 (2.5–45.4)	7.4 (4–14.5)	8.6 (5–21)	1,929 (1,913–1,978)
Atrial septal defect	28 (12)	60.4 (6–165)	20.4 (9–41)	3.6 (3–9)	4 (3–9)	1,904 (1,901–1,921)
Coarctation of the aorta	24 (10)	14.7 (0–118)	10.3 (2.5–40)	7.6 (6–10)	9.3 (6–13)	1,934 (1,904–1,971)
Transposition of the great arteries	19 (8)	11.9 (0–145)	4.6 (2.7–15.9)	9.8 (6–12)	11.5 (6–13)	1,955 (1,943–1,991)
Tetralogy of Fallot	17 (7)	19.5 (2–174)	7.1 (3.5–13.6)	8.5 (7.5–11)	10.1 (8–17)	1,926 (1,919–1,947)
Pulmonary regurgitation	12 (5)	175.4 (141–226)	54.8 (38.5–76)	6.7 (6.5–7.5)	9.7 (6.5–12.5)	1,871 (1,609–1,943)
Totally anomalous pulmonary venous drainage	9 (4)	10.4 (0–87)	5.3 (3.1–14.6)	9 (9–9)	12.7 (9–19)	1,933 (1,920–1,961)
Pulmonary atresia	9 (4)	27.3 (0–150)	6.3 (3–10)	7.7 (6.3–9)	12.4 (6.3–16.3)	1,949 (1,943–1,951)
Double outlet right ventricle	8 (3)	18.6 (0–60)	8.7 (3–16)	9.8 (7–14.5)	12.2 (7–19.5)	1,943 (1,919–1,978)
Left ventricular outflow tract obstruction	6 (2)	66 (41–131)	16.5 (10.5–20)	6.6 (6.3–8)	9.7 (6.3–12.8)	1,914 (1,907–1,943)
Pulmonary stenosis	6 (2)	81.5 (2–141)	25.1 (4.9–38.7)	6.5 (6.0–7.0)	6.5 (6.0–7.0)	1,926 (1,909–1,943)
Hypoplastic left heart syndrome	5 (2)	14 (3–53)	7.7 (5.3–13)	7.8 (7–9)	11.3 (9.5–11)	1,934 (1,921–1,946)
Aortic valve stenosis	5 (2)	72.8 (5–201)	41.1 (8.8–69.5)	8.9 (6.3–12.5)	19.4 (6.8–12.5)	1,932 (1,906–1,959)

n = 4: aortic valve regurgitation; n = 3: right ventricular outflow tract obstruction, truncus arteriosus, Ebstein's anomaly, double inlet left ventricle, mitral regurgitation; n = 2: partially anomalous pulmonary venous drainage, vascular ring, tricuspid regurgitation; n = 1: pulmonary artery stenosis, hemitruncus arteriosus, levo: transposition of the great arteries, aortopulmonary window, mitral stenosis, ductus arteriosus, anomalous left coronary artery from the pulmonary artery.

Table 3. Multivariable Analysis (Multiple Linear Regression) of Predictors of Outcome and Preoperative Risk Factors Associated With Procalcitonin at Admission.
Predictors of Outcome	Length of Stay in the PICU		Time on Mechanical Ventilation		Duration of Inotropic Support
Predictors of Outcome	β (95% CI)	p	β (95% CI)	p	β (95% CI)	p
Mechanical ventilation	10.8 (1.9, 19.7)	0.18	222.15 (48.9, 395.4)	0.01	125.8 (53.7, 198.0)	0.01
Myocardial dysfunction	–11.3 (–27.9, 5.3)	0.18	–218.2 (–540.2, 103.8)	0.18	–105.1 (–224.5, 14.3)	0.08
Procalcitonin	2.9 (0.8, 5.1)	0.08	43.5 (1.7, 85.2)	0.04	16.3 (0.9, 31.8)	0.04

Table 4. Area Under the Receiver Operating Characteristic Curve, Cutoff, Significance, Sensitivity, Specificity, Positive and Negative Predictive Values for Procalcitonin at Admission as Predictor of Postoperative Outcome
Procalcitonin at Admission to PICU	Cutoff (ng/mL)	p	Area Under the Receiver Operating Characteristic Curve	Sensitivity (%)	Specificity (%)	Positive Predictive Value (%)	Negative Predictive Value (%)
Major adverse event	0.3	0.04	0.74	60	82	8	99
Postoperative renal failure	0.9	0.01	0.77	60	93	16	99
Length of stay in PICU over 90th percentile (= 9 d)	0.3	<0.0001	0.78	70	86	33	95
Length of mechanical ventilation over 90th percentile (= 118 hr)	0.3	<0.0001	0.79	71	86	40	95
Length of inotropic support over 90th percentile (= 184 hr)	0.3	0.005	0.69	53	83	22	96

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Procalcitonin in the Early Course Post Pediatric Cardiac Surgery

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