Red Blood Cell Distribution Width as a Predictive Biomarker for Postoperative Infections in Children Who Underwent Cardiac Surgery: A Single-Center Retrospective Study - Cureus

Red humor compartment organisation width (RDW) reflects the size and saltation of mature erythrocytes successful peripheral blood, and it is routinely reported successful the implicit humor number sheet with a mean scope of 11.5%-14.5% [1]. An summation successful RDW of much than 14.5% is suggestive of greater than mean saltation successful reddish humor compartment (RBC) size. It is utilized successful the differential diagnosis of antithetic types of anemia [2]. Recently, galore studies person shown a correlation betwixt higher RDW and adverse outcomes, including sepsis, cardiovascular events, and cerebrovascular events including wide mortality [3-5].

Elevated RDW conferred 1.73 times accrued hazard of all-cause mortality and 2.49 times accrued hazard of cardiovascular illness (CVD)-specific mortality successful adults. Some explained mechanisms are that oxidative accent and inflammation whitethorn play a relation fixed that some tin trim RBC endurance [6,7], starring to much mixed populations of RBCs successful circulation, which thereby results successful higher RDW levels that tin beryllium observed successful conditions specified arsenic Down syndrome [8], mediocre pulmonary relation [9], and dialysis [10]. Wang et al. recovered a correlation betwixt RDW and renal compartment carcinoma people and signifier astatine the clip of diagnosis, defining precocious illness with an RDW cut-off worth of 13.15% [11]. Similarly, Li et al. and Periša et al. concluded that the RDW cut-off levels of 14.15% and 14.5%, respectively, person been utilized arsenic autarkic predictors of mediocre endurance successful ovarian crab [12] and lymphocytic leukemia [13].

Most important publications to day item the relation betwixt RDW values and coronary artery disease, bosom failure, coronary artery ectasia, stroke, atrial peripheral occlusive artery disease, and fibrillation. Furthermore, RDW was suggested arsenic a biomarker of complications successful these patients [14]. The worth of RDW arsenic a prognostic predictor successful pediatrics was besides discussed. In a survey including 404 pediatric intensive attraction portion (PICU) patients, RDW was linked to intensive attraction portion (ICU) morbidity and mortality [15].

Li et al. person established that RDW and C-reactive proteins might be autarkic predictive values of mortality successful non-cardiac pediatric intensive attraction portion (PICU) setups, arsenic abnormal changes successful these values were associated with higher rates of mortality; however, the objective reliability and potency of RDW person not yet been afloat understood [16,17]. Another retrospective survey explored the correlation betwixt RDW values and prognosis oregon severity of the illness among newborns admitted with sepsis. Remarkable variabilities successful RDW values were recovered betwixt consequent groups: the sepsis radical had a mean RDW worth of 16.59, the terrible sepsis radical had a mean RDW worth of 18.88, and the septic daze radical had a mean RDW worth of 19.71. The survey besides showed a affirmative correlation betwixt mortality and RDW values [18]. The levels of RDW were recovered to beryllium remarkably precocious astatine the clip of late-onset sepsis successful infants, specifically successful those infected with gram-negative bacteria [19]. There is simply a cognition spread successful measuring the RDW level arsenic a prognosis predictor for pediatric sepsis.

Thus, further studies are required to find the level of value of RDW values arsenic a predictive biomarker for postsurgical complications [20]. This survey aims to measure the worth of RDW arsenic a predictor for bloodstream infections (BSI), ventilator-associated pneumonia (VAP), urinary tract infections (UTIs), and surgical tract infections (SSIs) successful children admitted to the pediatric cardiac intensive attraction portion (PCICU) aft cardiac surgery.

This survey was approved by King Abdullah International Research Medical Center with an support fig SP-20-261-R and was conducted successful the PCICU of the Cardiac Center astatine King Abdulaziz Medical City (KAMC). A non-interventional retrospective cohort attack was utilized to measurement the incidence of postsurgical infections successful narration to RDW levels.

All pediatric patients aged 0 to 14 years aged who underwent cardiac country betwixt 2017 and 2018 were enrolled successful this study. Patients on extracorporeal membrane oxygenation (ECMO) and those who were diagnosed with Down syndrome, terrible anemia (Hb<7 g/dL), oregon known hematological diseases were excluded. The demographic characteristics, surgical records, objective outcomes, and laboratory findings from the clip of admittance to discharge of the survey subjects were collected by each the investigators done physics charts (BestCare System, Seoul National University Hospital, Seoul, South Korea). The survey was approved by the Institutional Review Board (IRB H-01-R-005). Due to the quality of the study, informed consent was waived.

The obtained information were analyzed wrong a 95% assurance interval utilizing Statistical Package for Social Science (SPSS), mentation 23.0 (International Business Machines Corporation (IBM), New York, USA). Categorical variables were presented arsenic frequencies and percentages, and continuous variables were presented arsenic the mean ± modular deviation. Data were checked for normality utilizing the Shapiro-Wilk trial and were recovered to beryllium non-normally distributed.

The narration betwixt RDW levels, ICU stay, and duration of mechanical ventilation was analyzed by a elemental linear regression test. The narration betwixt RDW levels and BSI, UTI, and VAP was assessed by the Mann-Whitney U test. Lastly, the narration betwixt RDW levels and SSI was established by the Kruskal-Wallis H test.

A full of 355 pediatric cases were included, and among them 186 (52.4%) were male. The median value was 5.64 kg, and the median property was six months. About 96.6% of cases had nary syndromes, and 83.7% of cases had nary erstwhile infections astatine the clip of admission. BSI was observed successful 8.2% of cases, UTI was observed successful 9.0% of cases, VAP was observed successful 10.1% of cases, and SSI was observed successful 3.7% of cases (Table 1). The mean mechanical ventilation duration was 5.7 ± 10.4 days, and the mean PCICU enactment was 14.8 ± 24.1 days (Table 2).

The narration betwixt RDW levels and BSI, UTI, VAP, and SSI was assessed. Significantly higher postoperative RDW levels were seen successful cases with bloodstream infections. The p-value for postoperative time 3 RDW was 0.028, the p-value for postoperative time 5 RDW was 0.041, and the p-value for postoperative time 7 RDW was 0.042. Patients who developed VAP had higher RDW levels some pre- and postoperatively (p-value<0.050). For UTI cases, lone preoperative RDW levels (p<0.001) and postoperative time 3 RDW (p-value=0.049) were importantly higher. For patients with SSI, RDW levels preoperative and postoperative connected days 3 and 5 were recovered to beryllium importantly higher (p-value<0.050) (Tables 3, 4).

Simple linear regression investigation showed that determination is simply a important narration betwixt preoperative RDW and magnitude of ICU enactment (95% CI 0.685-3.221, p-value=0.003, R2=0.104).

Similarly, precocious preoperative RDW levels importantly correlated with longer mechanical ventilation duration (95% CI 0.549-1.938, p-value=0.001, R2=0.102). However, the magnitude of ICU enactment and mechanical ventilation was not related to postoperative RDW levels (Tables 5, 6). Finally, preoperative and postoperative RDW levels and their relation with mortality were not important (Table 7).

There is emerging grounds of the worth of RDW levels successful big patients with bosom failure, myocardial infarction, paroxysmal atrial fibrillation, pulmonary embolism, and chronic obstructive pulmonary illness (COPD) [21]. Several studies person shown that a precocious RDW tin beryllium utilized arsenic a strong, autarkic predictor of accrued mortality and morbidity [22,23]. It has, therefore, go a invaluable instrumentality utilized to measure patients with cardiac diseases for immoderate imaginable complications. However, astir of the published probe has lone concentrated connected the worth of RDW levels successful adults undergoing cardiac country and critically sick children. 

There is paucity successful the lit considering the worth of RDW arsenic a biomarker predictor for postoperative infections, peculiarly successful children. To our knowledge, this is the archetypal study nationally discussing the prognostic value of RDW, astatine some pre- and postoperative levels, successful predicting complications successful pediatric patients undergoing cardiac surgery. RDW is believed to beryllium a important marker of cardiovascular illnesses owed to the publication of inflammation and oxidative accent to the progression of cardiovascular disease. Although the nonstop mechanics of this accusation has not been afloat identified yet, hypotheses relating to oxidative accent and inflammatory responses person led the mode successful respective examples of applicable research. Erythrocytes are much susceptible to the effects of oxidative harm owed to their greater antioxidant capability. Oxidative accent and chronic inflammation trim erythropoietin accumulation and exacerbate the demolition process of erythrocytes, resulting successful inefficient reddish humor compartment formation, harm to erythrocytes, a simplification successful the beingness rhythm of disposable erythrocytes, and the introduction of the immature cells into the systemic circulation, frankincense expanding levels of RDW [24].

In this study, pre- and post-operative RDW levels were assessed and recovered to beryllium higher preoperatively successful patients who developed UTIs, peculiarly with gram-negative bacteria (6.8%) aft surgery. Although, successful this group, determination was nary important elevation successful RDW values aft the surgery. Fungal VAP was recovered to beryllium of higher incidence successful patients who had elevated RDW levels earlier and aft surgery. Controversially, Sachdev et al. reported nary relation betwixt RDW levels astatine admittance and the occurrence of infections during hospitalization [25].

Moreover, successful this contiguous study, accrued preoperative RDW levels were recovered to beryllium associated with an accrued magnitude of PCICU stays. This content is strengthened by the aforesaid reflection by Sachdev et al., who intelligibly stated that higher RDW levels astatine admittance were correlated with prolonged PICU stays successful critically sick children [25,26]. Wang et al. besides looked astatine big patients who underwent coronary artery bypass grafts and recovered that those with higher RDW levels had prolonged infirmary stays [27]. It was besides observed successful this existent survey that patients with precocious RDW levels upon admittance person had prolonged mechanical ventilation enactment during their enactment successful the PCICU. However, the relation betwixt preoperative RDW levels and the duration of mechanical ventilation was not recovered successful the literature. Several studies connected some pediatrics and adults person reported that persistently precocious RDW is associated with a higher in-hospital mortality complaint [23,27]. However, this relation was not observed successful this study, arsenic some pre- and post-operative RDW levels were not a important origin successful determining in-hospital mortality successful children who underwent cardiac surgery. A beardown nexus was besides recovered betwixt precocious RDW readings connected the third, fifth, and seventh days post-surgery and the beingness of BSI. This is successful keeping with the results reported by Ahmed et al., who recovered that RDW levels were importantly higher successful neonates who developed sepsis during their ICU enactment [28].

In addition, the relation betwixt elevated RDW aft country and the beingness of SSI was recovered to beryllium important successful this existent study. This uncovering was besides observed by Kumar et al., who looked astatine children’s betterment aft correction of Tetralogy of Fallot and recovered that patients with accrued postoperative RDW levels had much predominant SSIs [29].

Limitations 

There are a fewer limitations to this study. First, it was a single-centered study. Second, astir of the subjects of involvement underwent aggregate antithetic non-cardiac procedures; consequently, the studied patients were unified by including lone those who underwent cardiac surgeries that were included successful the risk-adjusted classification for the congenital bosom country class (RACHS-1) [30].