Perioperative Serum Procalcitonin and High-sensitivity C-reactive Protein as Prognostic Markers of Postoperative Outcomes in Surgical Neonates: A Prospective Observational Study.

Abstract

Introduction: Neonatal sepsis is a major cause of morbidity and mortality. Procalcitonin (PCT) and high-sensitivity C-reactive protein (hs-CRP) are increasingly evaluated as early markers of infection. This study assessed the predictive value of PCT and hs-CRP at admission and 24 h postsurgery for adverse outcomes.

Materials and methods: A total of 120 operated neonates admitted to our surgical neonatal intensive care unit were prospectively enrolled. Demographic data, clinical parameters, blood investigations, blood culture results, and biomarker levels were recorded at admission and 24 h postoperatively. Note was also made of any surgical or anesthetic events. Outcomes were assessed at discharge or death and classified as favorable (discharge) or adverse (Clavien-Dindo Grade 4 or death). Receiver operating characteristic curves determined sensitivity, specificity, and optimal cutoffs; Spearman's correlation assessed associations of outcome with biomarkers, total leukocyte count (TLC), and blood culture. Multivariable logistic regression (backward stepwise) was performed to identify independent predictors of adverse outcome, with model fit assessed using the Hosmer-Lemeshow test and Nagelkerke R ².

Results: Of 120 neonates (mean age: 3.5 ± 4.5 days; male = 69, female = 51), 97% had congenital conditions pertaining to the gastrointestinal tract and required either bowel anastomosis or stoma. Culture-proven sepsis was present in 23% of neonates at admission and increased to 39% at 24 h postsurgery (almost 60% rise). Clinically suspected sepsis was observed in 41% of neonates at admission and 57% at 24 h after surgery (about 40% increase). Abnormal TLC was noted in 22.5% at admission, which increased marginally after surgery, while absolute neutrophil count remained comparable across time points. At admission, elevated hs-CRP and PCT were detected in 58% and 54% of neonates, respectively; these incidences increased to 82% and 61.6% at 24 h postsurgery, indicating a 20% postoperative rise in biomarker levels. Adverse outcomes occurred in 59% of neonates, and most of these patients had elevated PCT and hs-CRP (70% and 65%, respectively), which had a correlating trend at admission and 24 h (P < 0.001). Using standard laboratory thresholds, hs-CRP demonstrated a marked increase in sensitivity from 57.7% at admission to 91.5% at 24 h postsurgery (50% increase), while specificity declined marginally from 40.8% to 30.6% for predicting adverse outcomes. In contrast, PCT showed modest improvement in postoperative performance, with sensitivity increasing from 57.7% to 73.2% (35% increase), and specificity remained roughly the same (51.0% to 55.1%). All neonates with intraoperative events suffered poor outcomes, and all of them had high biomarker levels at admission. On multivariable analysis, lower birth weight (odds ratio [OR]: 0.29, 95% confidence interval [CI]: 0.12-0.68, P = 0.004) and blood culture positivity at 24 h (OR: 6.41, 95% CI: 2.18-18.85, P = 0.001) were independent predictors of adverse outcome, while biomarker levels were not independently associated.

Conclusions: More than half of surgical neonates had elevated biomarkers at admission, indicating a high burden of sepsis at admission. Higher values of biomarkers increasingly suggest the likelihood of intraoperative complications and adverse overall outcomes. Hs-CRP emerged as the more sensitive and cost-effective screening and risk-stratification tool as an adjunct to clinical and microbiological data for the prediction of postoperative sepsis or adverse outcomes.