Serum procalcitonin leveles in patients undergoing open heart surgery and its relation to mortality and morbidity

Our study was conducted on a total of 76 adult patients; 29 female and 47 male who underwent CABG with cardiopulmonary bypass, LVAD implantation and cardiac valve surgery by cardiovascular surgery clinic in 2015, after receiving the approval of Akdeniz University Medical Faculty Ethics Committee. The patients were divided into 3 groups according to types of surgery. 37 patients in CABG with cardiopulmonary bypass, 21 patients in LVAD implantation and cardiac valve replacement surgery 18 patients. The patients who were excluded from this study were off-pump CABGs, patients who received both cardiac valve and big vessel surgery at the same time , emergency surgery patients, patients who underwent surgery due to congenital defects, transplantation surgery, pediatric patients, patients who did not consent to this study, patients who were haemodinamically unstable before surgery and patients who were brought to operating romm with an ECMO. The cases underwent standart monitoring with pulse-oximeter and a 3-lead ECG involving DII and V5 derivations. A 16G cannula was inserted into periferic veins under aseptic conditions. After the administration of a local anesthetic, a 20G cannula was inserted into radial artery for invasive arterial blood pressure monitorization. The haemodynamic datas, ABG values, IOAVE, AS, CKS, and cardiopulmonary bypass times were recorded each time, at induction, start and end of CPB, during and after aortic cross clamping and after operation. The CRP and serum procalcitonin values of the patients were measured preoperatively, before induction, 24 hours post-operatively, 48 hours post-operatively and every time a complication arise. While the patients were receiving 100% oxygen, 0,07–0,1 mg/kg midazolam, 3–7 mg/kg thiopental, 2–20 µg/kg fentanyl and 0,6 mg/kg rocuronium were administered for induction of anesthesia. Following orotracheal intubation, patients were mechanically ventilated (Dräger Fabius GS Premium, Drägerwerk AG & Co.) under IPPV mode with 50% FiO2, 12/minute respiratory rate, 5 cm-H2O PEEP, Pmax:30 cm-H2O and 6-8 ml/kg tidal volume values. All patients were operated under intratracheal general anesthesia. After the intubation, the bladder was catheterised to monitor the urine output, prophylactic antibiotics were administered and both nasopharyngeal and rectal temperature probes were inserted for temperature monitorisation. During the operation, the anesthesia was maintained with 025 µg/kg/minute remifentanyl infusion and 1 MAC sevoflurane. Intravenous fluids were given. Under aseptic conditions, a central venous pressure catheter (Certofix® trio, B.Braun Melsungen AG) was inserted into the vena jugularis interna or a swan-ganz catheter was inserted when indicated. Central venous pressure and pulmonary artery pressure values were collected. When off-pump, a mean arterial pressure of 65-100 mmHg and heart rate of 60-100 beat per minute were maintained. Erythrocyte suspension was given to maintain a hematocrit value of at least 21%. Fresh frozen plasma was given whenever needed depending on CVP value, heart rate, arterial pressure and the amount of hemorrhage from the operation site. Heamodynamically stable, normothermic patients with no evident arrhythmia, with acceptable levels of drainage from chest tubes, good muscle power, good consciousness, normal oxygen and carbondioxide values in ABG's were weaned and appropriate patients were extubated. There were no meaningful statistical difference on the demographics of patients such as weight, height, BMI. The difference between EF, age and sex of the three groups was evaluated. At least one of the groups differed in terms of age and EF. The average age of the groups I and II were higher than group III. The average EF values of group I and II were found to be higher than group III. The differences were evaluated in every group for preoperative procalcitonin, postoperative 24 hour procalcitonin and postoperative 48 hour procalcitonin levels. The procalcitonin levels for group I were the lowest in preoperative measurement and highest in postoperative 24 hour measurement. The procalcitonin levels showed a decline in group I postoperative 48 hour measurement in contrast to postoperative 24 hour measurement. In group II procalcitonin levels showed an increase in postoperative 24 and 48 hours relative to preoperative levels while there was no difference between postoperative 24 hour and 48 hour measurements. In group III, like group II, procalcitonin levels were the lowest in preoperative measurement and highest in postoperative 24 hours while postoperative 48 hour measurement showed a decrease relative to postoperative 24 hour measurement. The difference between post-operative mechanical ventilation duration, post-operative inotrope dependency duration, ICU stay time and hospitalisation times were evaluated for patients with postoperative 24 hour procalcitonin levels below 0.5 and over 0.5 . The only significant difference between patients with P1PCT levels higher and lower than 0.5 were ICU stay time with higher procalcitonin levels correlating with higher ICU stay duration. There was no difference between post-operative mechanical ventilation duration, post-operative inotrope dependency duration and hospitalisation times between patients whose procalcitonin levels were higher or lower than 0.5 The difference between post-operative mechanical ventilation duration, post-operative inotrope dependency duration, ICU and hospital stay times were evaluated for patients with postoperative 48 hour procalcitonin levels below 0.5 and over 0.5. Patients with higher than 0.5 P2PCT measurements were found to have longer ICU stay times, postoperative mechanical ventilation durations and hospitalisation times. There was no difference between patients with P2PCT levels below and over 0.5 regarding postoperative inotrope dependency durations. The difference between groups in 24 hour and 48 hour postoperative procalcitonin levels, postoperative mechanical ventilation duration, postoperative inotrope dependency times, ICU and hospital stay times were studied. No difference was found between preoperative procalcitonin levels. The P1PCT levels of at least one group was found to be different while group III s P1PCT levels were found to be higher than group I during pairwise comparisons. The P2PCT levels of at least one group was found to be different while group I s P2PCT levels were found to be lower than group II and group III during pairwise comparisons. No difference was observed between postoperative mechanical ventilation durations between the groups. The post-operative inotrope dependency times of at least one group was found to be different while during pairwise comparison, group I s post operative inotrope dependency duration was found to be lower than group II and group III. The ICU stay time of at least one group was found to be different while during pairwise comparison, group III s ICU stay time was found to be higher than Group I and II. Similarly, hospitalisation time of at least one group was found to be different while during pairwise comparison, group III s hospitalisation time was found to be higher than Group I and II. For all 3 groups, the relation of IOAVE time, anesthesia time, cross clamp time and CPB time to CRP was studied. According to the results, only the postoperative 48 hour measurement of CRP was found to be significantly positively correlated to the period when lungs were not ventilated. No other correlation between measurements was found. The relation between PCT levels and IOVA time, PS, cross clamp time and AS measurements were studied. According to correlation test that were done, there was found to be a positive correlation between Group II s P1PCT levels and IOAVE time, PS and AS measurements. Again, a positive correlation between Group II s P2PCT levels and AS measurements were observed. The correlation of patients PCT levels and postoperative complications was studied. According to the correlation test that were done, no correlation between a specific complication and procalcitonin level was observed. It was only observed that a correlation exists between P2PCT levels and general complication risk. Key words: Open heart surgery, Procalcitonin, Mortality, Morbidity.