Procalcitonin in the Early Course Post Pediatric

Cardiac Surgery
Robert Zant, MD1,2; Christian Stocker, MD, FMH (CH), FCICM1,3;
Luregn Jan Schlapbach, MD, FCICM1,3,4; Sara Mayfield, BHScNurs1,3; Tom Karl, MD, FRACS5,6;
Andreas Schibler, MD, FMH (CH), FCICM1,3

Objective: Procalcitonin has emerged as a promising infection

marker, but previous reports from small-sized studies suggest
nonspecific elevation of procalcitonin after pediatric heart surgery.
As procalcitonin is increasingly used as a marker for infection in
the PICU, the aim of this study was to identify factors associated
with postoperative procalcitonin elevation and to investigate the
role of procalcitonin as an early marker of outcome after cardiac
surgery.
Design: Prospective observational study.
Setting: Single, tertiary referral PICU.
Patients: Patients aged 016 years following cardiac surgery with
or without cardiopulmonary bypass.
Interventions: Procalcitonin was measured in all patients at admission to PICU, and on postoperative day 1 and 2. Outcome variables
included major adverse event, length of stay in PICU, postoperative renal failure requiring temporary dialysis, duration of mechanical
ventilation and duration of inotropic support. A major adverse event
was defined as cardiac arrest, need for postoperative extracorporeal life support or death within 3 months of cardiac surgery.
Measurements and Main Results: In 221 included patients who
underwent 232 operations, procalcitonin at admission to PICU
was significantly associated with mechanical ventilation prior

Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, QLD, Australia.
2
University Childrens Hospital Regensburg, Regensburg, Germany.
3
Paediatric Intensive Care Unit, Lady Cilento Childrens Hospital, Brisbane, QLD, Australia.
4
Department of Pediatrics, Inselspital, University of Bern, Bern, Switzerland.
5
Department of Surgery, University of Queensland, Brisbane, QLD, Australia.
6
Heart Institute, Johns Hopkins All Childrens Hospital, St. Petersburg, FL.
Dr. Schiblers institution received grant support from NHMRC, ANZ
Trustee, QEMRF, and the Preston James Fund. The remaining authors
have disclosed that they do not have any potential conflicts of interest.
Address requests for reprints to: Robert Zant, MD, KUNO University Childrens Hospital Regensburg, Franz-Josef-Strau-Allee 11 93053 Regensburg, Germany. E-mail: robert.zant@ukr.de
Copyright 2016 by the Society of Critical Care Medicine and the World
Federation of Pediatric Intensive and Critical Care Societies
DOI: 10.1097/PCC.0000000000000751
1

to surgery (p = 0.001), preoperative myocardial dysfunction

(p = 0.002), duration of cardiopulmonary bypass (p < 0.001),
intraoperative cross-clamp time (p=0.015), and serum lactate at
admission (p < 0.001). Patients suffering a major adverse event
and patients with postoperative renal failure had significantly
higher procalcitonin levels at admission to PICU (p = 0.04 and
0.01, respectively). Furthermore, procalcitonin levels at admission correlated significantly with the length of stay in the PICU
(p=0.005), time on mechanical ventilation (p=0.03), and duration of inotropic support (p=0.02).
Conclusions: Elevated levels of procalcitonin in the early phase
after pediatric cardiac surgery are a marker for increased risk
for major adverse events and postoperative renal failure and
increased postoperative morbidity. (Pediatr Crit Care Med 2016;
17:624629)
Key Words: cardiac surgery; cardiopulmonary bypass;
extracorporeal membrane oxygenation; major adverse event;
pediatric cardiac surgery; procalcitonin

he immediate postoperative phase after cardiac surgery

is affected by bypass-induced systemic inflammatory
response syndrome (SIRS), which is difficult to differentiate from with microorganism-induced SIRS. Procalcitonin, has emerged recently as a marker of infection in PICU.
As with many other inflammatory markers, procalcitonin has
been shown to be non specifically elevated in the absence of
infection after uncomplicated pediatric open heart surgery (1),
reaching a maximum level within 24 hours postoperatively (2).
In adults, high procalcitonin levels after cardiac surgery have
been shown to correlate with several severity of illness scoring systems, including the acute physiology and chronic health
evaluation II and the simplified acute physiology score. Nonsurvivors were more likely to have high levels (36). There is
a limited number of publications based on small sample size
describing the postoperative changes of procalcitonin in children after cardiac surgery (1, 7).
In view of the increasing use of procalcitonin as a sepsis
marker in children, including postoperative patients, better

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Cardiac Intensive Care

knowledge on the course of procalcitonin post cardiac surgery

is required. The aim of this study was to investigate the factors
associated with high procalcitonin levels and to investigate the
role of procalcitonin as a prognostic marker for outcome after
surgery in a large cohort of infants and children undergoing
surgery for congenital heart disease.

MATERIALS AND METHODS

Study Design
This was a prospective single-center observational study performed at Queenslands referral center for pediatric cardiac
surgery located at the Mater Children`s Hospital, Brisbane,
Australia. Patients were aged 016 years and were included following cardiac surgery between January 1, 2013, and December 31, 2013. The study was approved by the local Institutional
Review Board (Mater Health Services; HREC 2013_02). Waiver
of informed consent was approved by the institutional review
board.
Preoperative risk factors and risk assessment scores were
prospectively assessed using Basic/Comprehensive Aristotle
Complexity and Risk Adjusted Congenital Heart Surgery
Scores (8). Further preoperative risk factors were defined as
mechanical ventilation prior to surgery, myocardial dysfunction, seizures, stroke or intracranial hemorrhage, necrotizing
enterocolitis, and renal failure. In addition, cardiopulmonary
bypass (CPB) time, aortic cross clamp time, and serum lactate
at admission were prospectively collected.
All children were routinely treated for 24 hours post bypass
surgery with cefazolin (25mg/kg 8 hourly). Procalcitonin was
measured in all patients at admission from operating theater
to PICU, and on postoperative day 1 and 2 (POD0, POD1, and
POD2, respectively) as long as the children remained in PICU.
All blood samples were taken from the arterial line. Quantitative
measurements of procalcitonin were performed with the Advia
Centaur BRAHMS PCT-test kit (B-R-A-H-M-S AG Hennigsdorf,
Germany and Siemens Medical Solutions, NY). The analytic
sensitivity of this assay is 0.01ng/mL (range, 0.0175ng/mL).
As procalcitonin is physiologically elevated in the first 48 hours
after birth, the tests adult reference range applies from day 3
after birth (9). The results of the procalcitonin levels were not
known to the treating clinicians during the stay in PICU.
Outcome Data
A major adverse event (MAE) was defined as cardiac arrest,
need for postoperative extracorporeal life support or death
within 3 months of cardiac surgery. MAE were prospectively
recorded as a part of internal quality control requirements.
Further outcome variables included length of stay (LOS) in
PICU, postoperative renal failure requiring temporary dialysis,
duration on mechanical ventilation, and duration of inotropic
support.

for testing influence variables on procalcitonin, for testing

differences in procalcitonin clearance, and for assessment of
procalcitonin as a predictor of outcome. Multiple linear regression analysis was performed to determine which associations
are unique to procalcitonin. Receiver operating characteristic
(ROC) curves were additionally calculated to evaluate the discriminative power of procalcitonin values at admission as a
predictor of outcome. Optimal cutoff values were determined
by the Youden index. Mean and range and median and interquartile range are reported. All analyses were performed with
IBM SPSS Statistics for Windows, version 21.0 (IBM, Armonk,
NY).

RESULTS
Baseline Characteristics
A total of 221 patients who as a group had undergone 232 operations were included. The median age of the study group was
44 months (range, 1 d to 16.9 yr). Preoperative mean Basic, and
Comprehensive Aristotle Complexity Scores were 7.4 (314.5)
and 9.4 (321); the preoperative mean Risk Adjusted Congenital Heart Surgery Score in our cohort was 1,928 (1,609
1,991). Preoperative risk factors were present in 43 (19%) of all
included patients (Table 1). Eight patients (3%) had more than
one preoperative risk factor. Indications for cardiac surgery are
summarized in Table 2. Five of 221 patients (2%) suffered a
MAE: one patient had a cardiac arrest, one patient required
emergency extracorporeal life support, and three patients died
within 3 months of cardiac surgery.
Overview Procalcitonin Levels
The median procalcitonin level of all patients after cardiac
surgery was 0.01ng/mL (0.3) at admission to PICU, reaching the postoperative peak of 0.8ng/mL (2.1) at POD1 with
a decline to 0.7ng/mL (2.2) on POD2. Simultaneously measured median levels for serum lactate were 1.4 mmol/L (0.9)
at admission, 1.4 mmol/L (0.7) for POD1, and 1.1 mmol/L
(0.7) for POD2. The procalcitonin values at admission and
on POD1 were not associated with age (p=0.52 and 0.38,
respectively) (Fig. 1). Preoperative risk factors associated
with procalcitonin elevation at admission were mechanical
ventilation prior to surgery (p=0.001) and myocardial dysfunction (p=0.002). There was no significant difference in
Table 1. Preoperative Risk Factors of All
Included Patients
n (%)

Preoperative Risk Factor

Mechanical ventilation

10 (4)

Myocardial dysfunction

3 (1)

Seizures, stroke, intracranial hemorrhage

6 (3)

Chromosomal/syndromic abnormality

Statistical Analyses
Linear regression models in interval scaled variables and
Mann-Whitney U tests in nominal-scaled variables were used
Pediatric Critical Care Medicine

28 (12)

Necrotizing enterocolitis

2 (1)

Renal failure

2 (1)
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Zant et al

Table 2.

Indications for Cardiac Surgery of All Included Patients

Anatomic Diagnosis

n (%)

Mean
Age (mo)

Mean
Weight (kg)

Mean Basic
Aristotle
Complexity
Scores

Ventricular septal defect 52 (22)

23.6 (0125)

10.4 (2.545.4)

7.4 (414.5)

Atrial septal defect

28 (12)

60.4 (6165)

20.4 (941)

3.6 (39)

Coarctation of the aorta

24 (10)

14.7 (0118)

10.3 (2.540)

Transposition of the
great arteries

19 (8)

Tetralogy of Fallot

17 (7)

Pulmonary regurgitation

12 (5)

Mean
Comprehensive
Aristotle
Complexity
Scores

Mean Risk
Adjusted
Congenital
Heart Surgery
Score

8.6 (521)

1,929 (1,9131,978)

4 (39)

1,904 (1,9011,921)

7.6 (610)

9.3 (613)

1,934 (1,9041,971)

11.9 (0145)

4.6 (2.715.9) 9.8 (612)

11.5 (613)

1,955 (1,9431,991)

19.5 (2174)

7.1 (3.513.6) 8.5 (7.511)

10.1 (817)

1,926 (1,9191,947)

175.4 (141226) 54.8 (38.576)

Totally anomalous
pulmonary venous
drainage

9 (4)

10.4 (087)

5.3 (3.114.6)

Pulmonary atresia

9 (4)

27.3 (0150)

6.3 (310)

Double outlet right

ventricle

8 (3)

18.6 (060)

8.7 (316)

Left ventricular outflow

tract obstruction

6 (2)

Pulmonary stenosis

6 (2)

81.5 (2141)

Hypoplastic left heart

syndrome

5 (2)

14 (353)

Aortic valve stenosis

5 (2)

72.8 (5201)

66 (41131)

16.5 (10.520)

6.7 (6.57.5)
9 (99)

1,871 (1,6091,943)

12.7 (919)

1,933 (1,9201,961)

7.7 (6.39)

12.4 (6.316.3)

1,949 (1,9431,951)

9.8 (714.5)

12.2 (719.5)

1,943 (1,9191,978)

6.6 (6.38)

25.1 (4.938.7) 6.5 (6.07.0)

7.7 (5.313)

9.7 (6.512.5)

7.8 (79)

41.1 (8.869.5) 8.9 (6.312.5)

9.7 (6.312.8)

1,914 (1,9071,943)

6.5 (6.07.0)

1,926 (1,9091,943)

11.3 (9.511)

1,934 (1,9211,946)

19.4 (6.812.5)

1,932 (1,9061,959)

n = 4: aortic valve regurgitation; n = 3: right ventricular outflow tract obstruction, truncus arteriosus, Ebsteins 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.

procalcitonin values at admission in patients with and without chromosomal/syndromic abnormality (p=0.57). Procalcitonin concentrations at admission were not associated with
any specific cardiac condition (Fig. 2).

Figure 1. Procalcitonin values at admission to PICU and on postoperative

day 1 in relation to age.

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Procalcitonin and CPB

In patients with CPB, the median procalcitonin level at admission was 0.01ng/mL (0.3) and on POD1 was 0.8ng/mL (1.9)
(p=0.24). In patients without CBP, the procalcitonin level at
admission was 0.01 (0.1) and on POD1 was 0.5ng/mL (1.3).
Levels of procalcitonin at admission correlated significantly
with the duration of CPB (p < 0.001), cross-clamp time
(p=0.015), and serum lactate at admission (p < 0.001). No
significant difference in procalcitonin levels between patients
operated with or without CBP was found for POD0, POD1,
and POD2 (p=0.24, 0.41, and 0.52, respectively).
Procalcitonin and Outcome
The median procalcitonin level at admission of the five
patients suffering a MAE was significantly higher, 0.3ng/mL
(0.8), than patients without a MAE with a median level of
0.01ng/mL (0.19) (p=0.04). The area under the ROC curve
for procalcitonin at admission as a predictor for MAE was 0.74
(95% CI, 0.520.96), compared with the AUC ROC for lactate at admission of 0.72 (95% CI, 0.540.92). Furthermore,
procalcitonin levels at admission correlated significantly with
the LOS in the PICU (p=0.005), time on mechanical ventilation (p=0.03), and duration of inotropic support (p=0.02).
procalcitonin at admission was significantly correlated with
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Cardiac Intensive Care

preoperative disease severity and intraoperative variables

(cross-clamp time and duration on CBP). Linear regression
adjusting for mechanical ventilation and cardiac dysfunction
preoperatively confirmed that higher procalcitonin was independently predictive for both time on mechanical ventilation
and duration of inotropic support (Table 3). The median procalcitonin levels at admission in patients with postoperative
renal failure requiring temporary dialysis was with 1ng/mL
(1.7), which was significantly higher than in patients without
postoperative renal failure (p=0.01). In the early phase after
cardiac surgery, procalcitonin clearance from POD1 to POD2
was not significantly different in patients with and without
postoperative renal failure (p=0.16). Table 4 summarizes
procalcitonin at admission as a prognostic parameter, including MAE, postoperative renal failure requiring temporary
dialysis and values above the 90th percentile for LOS in the
PICU, time on mechanical ventilation and inotropic support.

Figure 2. Procalcitonin values at admission to PICU in relation to indication

for surgery. The broken line indicates a cut-off level of 0.3 ng/mL. ASD = atrial
septal defect, AoS: aortic valve stenosis, coarctation = coarctation of the aorta,
DORV = double outlet right ventricle, HLH = hypoplastic left heart syndrome,
LVOTO = left ventricular outflow tract obstruction, PA = pulmonary atresia,
PR = pulmonary regurgitation, PS = pulmonary stenosis, TAPVD = totally
anomalous pulmonary venous drainage, TGA = transposition of the great
arteries, ToF = Tetralogy of Fallot; VSD = ventricular septal defect..

Exploratory Analyses in Patients With Postoperative

Infections
In nine patients (3.9%), invasive infection was suspected
in the first three postoperative days, prompting initiation of
broad-spectrum antibiotics. Compared with the entire study

Table 3. Multivariable Analysis (Multiple Linear Regression) of Predictors of Outcome and

Preoperative Risk Factors Associated With Procalcitonin at Admission.
Length of Stay in the PICU

Time on Mechanical Ventilation

Duration of Inotropic Support

Predictors of
Outcome

(95% CI)

(95% CI)

(95% CI)

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

Area Under the

Receiver Operating
Characteristic
Curve

Sensitivity
(%)

Specificity
(%)

0.3

0.04

0.74

60

82

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 (= 118hr)

0.3

< 0.0001

0.79

71

86

40

95

Length of inotropic support

over 90th percentile
(= 184hr)

0.3

0.005

0.69

53

83

22

96

Procalcitonin at
Admission to PICU

Cutoff
(ng/
mL)

Major adverse event

Pediatric Critical Care Medicine

Positive
Predictive
Value (%)

Negative
Predictive
Value (%)

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Zant et al

cohort, these patients with suspected infection had already

significantly higher procalcitonin levels at admission to PICU
(p=0.003) with a median level of 1.0ng/mL (1.7). In only two
patients with assumed infection growth of either Staphylococcus hominis (ascites) or Moraxella catarrhalis (endotracheal
aspirate) was demonstrated.

DISCUSSION
In this prospective study of children requiring surgery for
congenital heart disease, we observed higher than normal
procalcitonin levels postoperatively. Higher procalcitonin following surgery for congenital heart disease was predictive of
MAEs and was highly correlated with postoperative renal failure, length of PICU stay, duration of mechanical ventilation,
and duration of inotropic support. Procalcitonin at admission
remains a significant risk factor for duration of mechanical
ventilation and duration of inotropic support when accounting for the preoperative risk factors that are associated with
postoperative procalcitonin elevation.
Over the past years, several studies have been published to
assess the diagnostic and prognostic value of procalcitonin
after cardiac surgery in adults and have identified variables
other than infection having an impact on procalcitonin levels
(10). However, studies in pediatric patients have been limited, due to a small sample size. The association of elevated
procalcitonin levels at admission with the LOS in PICU and
duration of both inotropic and respiratory support confirms
data of previous studies conducted in children (1, 7). In our
cohort, procalcitonin levels at admission were significantly
higher in children suffering a postoperative MAE and the
ROC AUC of procalcitonin was slightly superior to lactate,
which is a well-established marker of impaired oxygen delivery to end organs (11).
Aortic cross clamp time, duration of CPB, and duration of
surgery were the intraoperative factors associated with a postoperative increase in procalcitonin (1, 3, 7). We suspect that
the source of procalcitonin production could be triggered
by nonspecific cytokine liberation from the injured tissue
damage-associated molecular patterns or insufficient tissue
oxygenation including the liver as the main producer of procalcitonin (2, 1214). The latter thesis is supported by the fact
that in our cohort high levels of procalcitonin were significantly
associated with serum lactate levels at admission. Similarly,
it is known that procalcitonin is significantly increased after
pediatric cardiac arrest (15). Indeed, a number of studies have
shown that procalcitonin is a marker of poor outcome in different scenarios including cardiac surgery, post cardiopulmonary resuscitation, shock, and pediatric liver transplantation
(1, 7, 13, 1518).
This study was not designed to investigate performance of
procalcitonin in postoperative infections, and the prevalence of
such infections was low. We observed that the patients with the
clinical suspicion of infection had already significantly higher
procalcitonin values at admission to PICU. Attending clinicians did not have knowledge of the results of the procalcitonin levels during the entire stay in PICU. In only two patients,
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an infectious agent was isolated. In both cases, very high levels

of procalcitonin in the early phase after surgery were observed.
Larger prospective studies are needed to define sensitivity and
specific of procalcitonin to diagnose invasive infections in children post cardiac surgery.
Early risk assessment after cardiac surgery might play a
key role in reducing postoperative complications and death.
Procalcitonin, which is increasingly used for routine postoperative infection monitoring, may in addition to lactate help
in the early risk stratification of patients after cardiac surgery.
It thereby may provide additional early information on the
degree of inflammation and tissue damage (19). Because no
defined postoperative cutoff levels are available yet, our study
may support clinicians classifying elevated procalcitonin levels
after cardiac surgery in children (10).

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.

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

REFERENCES

1. Celebi S, Koner O, Menda F, et al: Procalcitonin kinetics in pediatric

patients with systemic inflammatory response after open heart surgery. Intensive Care Med 2006; 32:881887
2. Meisner M: Pathobiochemistry and clinical use of procalcitonin. Clin
Chim Acta 2002; 323:1729
3. Meisner M, Rauschmayer C, Schmidt J, et al: Early increase of procalcitonin after cardiovascular surgery in patients with postoperative
complications. Intensive Care Med 2002; 28:10941102
4. Aouifi A, Piriou V, Bastien O, et al: Usefulness of procalcitonin for
diagnosis of infection in cardiac surgical patients. Crit Care Med
2000; 28:31713176
5. Sablotzki A, Dehne MG, Friedrich I, et al: Different expression of cytokines in survivors and non-survivors from MODS following cardiovascular surgery. Eur J Med Res 2003; 8:7176
6. Loebe M, Locziewski S, Brunkhorst FM, et al: Procalcitonin in
patients undergoing cardiopulmonary bypass in open heart surgeryfirst results of the Procalcitonin in Heart Surgery study (ProHearts).
Intensive Care Med 2000; 26(Suppl 2):S193S198
7. Beghetti M, Rimensberger PC, Kalangos A, et al: Kinetics of procalcitonin, interleukin 6 and C-reactive protein after cardiopulmonarybypass in children. Cardiol Young 2003; 13:161167
8. Jacobs ML, Jacobs JP, Jenkins KJ, et al: Stratification of complexity:
The Risk Adjustment for Congenital Heart Surgery-1 method and the
Aristotle Complexity Scorepast, present, and future. Cardiol Young
2008; 18 Suppl 2:163168
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Unauthorized reproduction of this article is prohibited

Cardiac Intensive Care

9. Assumma M, Signore F, Pacifico L, et al: Serum procalcitonin concentrations in term delivering mothers and their healthy offspring:
A longitudinal study. Clin Chem 2000; 46:15831587
10. Sponholz C, Sakr Y, Reinhart K, et al: Diagnostic value and prognostic
implications of serum procalcitonin after cardiac surgery: A systematic review of the literature. Crit Care 2006; 10:R145
11. Seear MD, Scarfe JC, LeBlanc JG: Predicting major adverse events after
cardiac surgery in children. Pediatr Crit Care Med 2008; 9:606611
12. Meisner M, Mller V, Khakpour Z, et al: Induction of procalcitonin and
proinflammatory cytokines in an anhepatic baboon endotoxin shock
model. Shock 2003; 19:187190
13. Zant R, Melter M, Schlitt HJ, et al: High levels of procalcitonin in the
early phase after pediatric liver transplantation indicate poor postoperative outcome. Hepatogastroenterology 2014; 61:13441349
14. Miki T, Iba T: Kinetics of circulating damage-associated molecular
patterns in sepsis. J Immunol Res 2015; 2015:424575

Pediatric Critical Care Medicine

15. Los Arcos M, Rey C, Concha A, et al: Acute-phase reactants after

paediatric cardiac arrest. Procalcitonin as marker of immediate outcome. BMC Pediatr 2008; 8:18
16. Jensen JU, Heslet L, Jensen TH, et al: Procalcitonin increase in early
identification of critically ill patients at high risk of mortality. Crit Care
Med 2006; 34:25962602
17. Hatherill M, Tibby SM, Turner C, et al: Procalcitonin and cytokine
levels: Relationship to organ failure and mortality in pediatric septic
shock. Crit Care Med 2000; 28:25912594
18. Zant R, Melter M, Knoppke B, et al: Kinetics of interleukin-6, procalcitonin, and C-reactive protein after pediatric liver transplantation.
Transplant Proc 2014; 46:35073510
1 9. Mimoz O, Benoist JF, Edouard AR, et al: Procalcitonin and
C-reactive protein during the early posttraumatic systemic
inflammatory response syndrome. Intensive Care Med 1998;
24:185188

www.pccmjournal.org

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