Acute and Critical Care

Original Articles

Cardiology
Utility of procalcitonin in diagnosing early postoperative sepsis after pediatric cardiac surgery in Malaysia: Muhammad Yusoff Mohd Ramdzan, Kah Kee Tan, Kok Wai Soo; Acute Crit Care. 2025;40(4):567-573. Published online November 28, 2025; DOI: https://doi.org/10.4266/acc.005016

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Abstract PDF: Background
Systemic inflammation following cardiopulmonary bypass (CPB) can interfere with analysis of routine clinical and biochemical parameters. Procalcitonin (PCT) is a potential biomarker for diagnosing early postoperative sepsis in pediatric patients following cardiac surgery utilizing CPB. This study aimed to evaluate the diagnostic accuracy of PCT compared to other biomarkers, especially C-reactive protein (CRP), in this clinical setting.
Methods
A prospective single-center study was conducted over a 10-month period during the coronavirus disease 2019 (COVID-19) pandemic (2021–2022), enrolling 89 pediatric patients postcardiac surgery. PCT, CRP, and complete blood count were analyzed, and area under the curve (AUC) was employed for statistical analysis.
Results
PCT and CRP demonstrated moderate discriminatory ability with AUCs of 0.678 and 0.635, respectively. White cell count exhibited fair discriminatory power, and platelet count performed poorly in distinguishing septic from nonseptic cases (AUC: white cell count, 0.545; platelet, 0.486).
Conclusions
PCT and CRP hold promise as diagnostic markers for early postoperative sepsis in pediatric cardiac surgery patients. However, these biomarkers are not adequate standalone indicators, emphasizing the continued need for clinical judgment supported by multiple diagnostic parameters.

Immunology
Serum procalcitonin and C-reactive protein as indices of early sepsis and mortality in North Indian pediatric burn injuries: a prospective evaluation and literature review: Nupur Aggarwal, Durga Karki, Rajni Gaind, Monika Matlani, Vamseedharan Muthukumar; Acute Crit Care. 2024;39(3):350-358. Published online August 30, 2024; DOI: https://doi.org/10.4266/acc.2023.00759

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Background
Delays in diagnosing sepsis in children afflicted with thermal injuries can result in high morbidity and mortality. Our study evaluated the role of the biomarkers Procalcitonin (PCT) and C-reactive protein (CRP) as predictors of early sepsis and mortality, respectively, in this group of patients.
Methods
This was a prospective evaluation of 90 pediatric burn cases treated at a tertiary care burn center in Northern India. Patients, aged 1–16 years, presenting within 24 hours of being burned, with >10% body surface area of burn injury were included in the study. Levels of PCT and CRP were measured on days 1, 3, 5, and 7. Patients were followed until discharge, 30th post-burn day, or death, whichever occurred first.
Results
Sepsis was clinically present in 49 of 90 (54.4%) cases with a median 30% total body surface area (TBSA) of burns. Mortality was seen in 31 of 90 (34.4%) cases with a median of 35% TBSA burns. High PCT and CRP were seen in the sepsis group, particularly on days 3, 5, and 7. PCT was also significantly higher in the mortality group (days 1 and 3).
Conclusions
While PCT was a good early predictor of sepsis and mortality in children with burns, CRP was reliable as a predictor of sepsis only. Both markers, however, can serve as adjuncts to culture sensitivity reports for diagnosing early onset sepsis and initiation of antibiotic therapy in appropriate patients.

Citations

Citations to this article as recorded by

Predictive Value of Inflammatory Burden Index for Sepsis in Critically Ill Patients with Extensive Burns: A Decade-Long Cohort Study
Songwei Zhou, Xin He, Yuqun Huang, Wei Zhu, Huapei Song
Journal of Inflammation Research.2026; Volume 19: 1. CrossRef
Research Progress on Immune Inflammatory Response in Severe Burn and the Treatment with Ulinastatin
祺马
Advances in Clinical Medicine.2025; 15(05): 896. CrossRef

CPR/Resuscitation
Association between C-reactive protein-to-albumin ratio and 6-month mortality in out-of-hospital cardiac arrest: Hui Hwan Kim, Ji Ho Lee, Dong Hun Lee, Byung Kook Lee; Acute Crit Care. 2022;37(4):601-609. Published online August 18, 2022; DOI: https://doi.org/10.4266/acc.2022.00542

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Abstract PDF Supplementary Material

Background
The inflammatory response that occurs following cardiac arrest can determine the long-term prognosis of patients who survive out-of-hospital cardiac arrest. We evaluated the correlation between C-reactive protein-to-albumin ratio (CAR) following cardiac arrest and long-term mortality.
Methods
The current retrospective observational study examined patients with post-cardiac arrest syndrome (PCAS) treated with targeted temperature management at a single tertiary care hospital. We measured CAR at four time points (at admission and then 24 hours, 48 hours, and 72 hours after) following cardiac arrest. The primary outcome was the patients’ 6-month mortality. We performed multivariable and area under the receiver operating characteristic curve (AUC) analyses to investigate the relationship between CAR and 6-month mortality.
Results
Among the 115 patients, 52 (44.1%) died within 6 months. In the multivariable analysis, CAR at 48 hours (odds ratio [OR], 1.130; 95% confidence interval [CI], 1.027–1.244) and 72 hours (OR, 1.241; 95% CI, 1.059–1.455) after cardiac arrest was independently associated with 6-month mortality. The AUCs of CAR at admission and 24, 48, and 72 hours after cardiac arrest for predicting 6-month mortality were 0.583 (95% CI, 0.489–0.673), 0.622 (95% CI, 0.528–0.710), 0.706 (95% CI, 0.615–0.786), and 0.762 (95% CI, 0.675–0.835), respectively.
Conclusions
CAR at 72 hours after cardiac arrest was an independent predictor for long-term mortality in patients with PCAS.

Citations

Citations to this article as recorded by

C-reactive protein-to-albumin ratio is associated with mortality after transcatheter tricuspid valve repair
Karl Finke, Laura Marx, Jan Althoff, Thorsten Gietzen, Matthieu Schäfer, Jan Wrobel, Philipp von Stein, Jennifer von Stein, Maria Isabel Körber, Stephan Baldus, Roman Pfister, Christos Iliadis
Clinical Research in Cardiology.2025; 114(7): 892. CrossRef
Biomarkers in Cardiac Arrest: A Narrative Review
Rohin Singla, Chelsey Sidaras, Jignesh K. Patel
Therapeutic Advances in Pulmonary and Critical Care Medicine.2025;[Epub] CrossRef
Association of the blood urea nitrogen to serum albumin ratio and 28-day all-cause mortality in patients with cardiac arrest: a retrospective cohort study using the MIMIC-IV database
Gaosheng Zhou, Yayuan Tan, Xueli Li, Yixun Wang, Dingdeng Wang, Min Liu
Frontiers in Cardiovascular Medicine.2025;[Epub] CrossRef
Associations of C-reactive protein/albumin ratio with frailty and the risk of mortality: An observational study
Yaying Xu, Peng Tian, Ying Xu
Medicine.2025; 104(43): e45329. CrossRef
C-reactive protein-to-albumin ratio as a novel prognostic biomarker for long-term mortality in pericarditis: a real-world study
Lingyu Mi, Ishan Lakhani, Sharen Lee, Wing Tak Wong, Gary Tse, Fang Fang
BMC Cardiovascular Disorders.2025;[Epub] CrossRef
The association between C-reactive protein to albumin ratio and 6-month neurological outcome in patients with in-hospital cardiac arrest
Ji Ho Lee, Dong Hun Lee, Byung Kook Lee, Seok Jin Ryu
World Journal of Emergency Medicine.2024; 15(3): 223. CrossRef
Inflammatory response after out‐of‐hospital cardiac arrest—Impact on outcome and organ failure development
Asser M. J. Seppä, Markus B. Skrifvars, Pirkka T. Pekkarinen
Acta Anaesthesiologica Scandinavica.2023; 67(9): 1273. CrossRef
Comparison of Prognostic Performance between Procalcitonin and Procalcitonin-to-Albumin Ratio in Post Cardiac Arrest Syndrome
Ju Hee Yoon, Woo Sung Choi, Yong Su Lim, Jae Ho Jang
Journal of Clinical Medicine.2023; 12(14): 4568. CrossRef
C-reactive protein-to-albumin ratio as a biomarker in patients with sepsis: a novel LASSO-COX based prognostic nomogram
Xin Zhou, Shouzhi Fu, Yisi Wu, Zhenhui Guo, Wankang Dian, Huibin Sun, Youxia Liao
Scientific Reports.2023;[Epub] CrossRef

Trauma
C-reactive protein-albumin ratio and procalcitonin in predicting intensive care unit mortality in traumatic brain injury: Canan Gürsoy, Güven Gürsoy, Semra Gümüş Demirbilek; Acute Crit Care. 2022;37(3):462-467. Published online August 5, 2022; DOI: https://doi.org/10.4266/acc.2022.00052

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Abstract PDF

Background
Prediction of intensive care unit (ICU) mortality in traumatic brain injury (TBI), which is a common cause of death in children and young adults, is important for injury management. Neuroinflammation is responsible for both primary and secondary brain injury, and C-reactive protein-albumin ratio (CAR) has allowed use of biomarkers such as procalcitonin (PCT) in predicting mortality. Here, we compared the performance of CAR and PCT in predicting ICU mortality in TBI.
Methods
Adults with TBI were enrolled in our study. The medical records of 82 isolated TBI patients were reviewed retrospectively.
Results
The mean patient age was 49.0 ± 22.69 years; 59 of all patients (72%) were discharged, and 23 (28%) died. There was a statistically significant difference between PCT and CAR values according to mortality (P<0.05). The area under the curve (AUC) was 0.646 with 0.071 standard error for PCT and 0.642 with 0.066 standard error for CAR. The PCT showed a similar AUC of the receiver operating characteristic to CAR.
Conclusions
This study shows that CAR and PCT are usable biomarkers to predict ICU mortality in TBI. When the determined cut-off values are used to predict the course of the disease, the CAR and PCT biomarkers will provide more effective information for treatment planning and for preparation of the family for the treatment process and to manage their outcome expectations.

Citations

Citations to this article as recorded by

Performance and accuracy of blood glucose and neutrophil-lymphocyte ratio as predictors of mortality in children and adolescents with traumatic brain injury
José Roberto Tude Melo, Caio Vinicius de Almeida Chaves, Cindy Kawano, Isabela Zampirolli Leal, Maria Antonia Coladeti Fernandes, Stephannie Monaco Bodra, Jean Gonçalves de Oliveira, José Carlos Esteves Veiga
Child's Nervous System.2026;[Epub] CrossRef
Prognostic value of CAR, FIB-4, and procalcitonin in subdural hematoma: associations with mortality and 90-day functional outcomes running title: CAR, FIB-4, and procalcitonin in SDH outcomes
Tamer Tamdoğan, İlke Tamdoğan
Journal of Health Sciences and Medicine.2026; 9(1): 19. CrossRef
One-Year Mortality After Percutaneous Endoscopic Gastrostomy: The Prognostic Role of Nutritional Biomarkers and Care Settings
Nermin Mutlu Bilgiç, Güldan Kahveci, Ekmel Burak Özşenel, Sema Basat
Nutrients.2025; 17(5): 904. CrossRef
Elevation of C-reactive protein and homocysteine levels as reliable biomarkers for assessing injury severity and prognosis in traumatic brain injury
Zi-Yan Wang, Wei Du, Xian-Zhi Liu, Yuan Li, Jun Liu
Scientific Reports.2025;[Epub] CrossRef
Prognostic value of procalcitonin and IL-6 with a composite model in moderate-severe traumatic brain injury
Xin-meng Li, Zi-wei Liu, Wei-yu Liu, Gao-jian Su, Xian-jian Huang
Journal of Clinical Neuroscience.2025; 140: 111516. CrossRef
Development and validation of a prediction model for pulmonary infection in elderly patients with traumatic brain injury
Shuai Tian, Ali Shang, Wenqian Zhou, Zhen Xu, Yunpeng Kou, Zhenyu Guo, Fan Chen, Peigang Ji, Yulong Zhai, Wenjian Zhao, Yang Jiao, Zhipeng Song, Shunnan Ge, Yuan Wang, Liang Wang, Shaochun Guo
Neurochirurgie.2025; 71(6): 101733. CrossRef
Albuminemia as a Potential Predictor of Clinical Outcomes in Patients with Severe Traumatic Brain Injury (TBI)
Luka Stepanovic, Usha Govindarajulu, George Agriantonis, Navin D. Bhatia, Jasmine Dave, Shalini Arora, Zahra Shafaee, Kate Twelker, Jennifer Whittington, Bharti Sharma
Journal of Clinical Medicine.2025; 14(21): 7499. CrossRef
Research Advances in CAR, NLR, and S100β for Assessing Neurological Functional Prognosis in Traumatic Brain Injury Patients
明隆陈
Advances in Clinical Medicine.2025; 15(10): 2518. CrossRef
Symptoms and Functional Outcomes Among Traumatic Brain Injury Patients 3- to 12-Months Post-Injury
Kathryn S. Gerber, Gemayaret Alvarez, Arsham Alamian, Victoria Behar-Zusman, Charles A. Downs
Journal of Trauma Nursing.2024; 31(2): 72. CrossRef
Association of C-reactive protein/albumin ratio with mortality in patients with Traumatic Brain Injury: A systematic review and meta-analysis
Yuyang Liu, Yaheng Tan, Jun Wan, Qiwen Chen, Yuxin Zheng, Wenhao Xu, Peng Wang, Weelic Chong, Xueying Yu, Yu Zhang
Heliyon.2024; 10(13): e33460. CrossRef

Meta-analysis
Associations between systemic inflammation and intestinal permeability with Onodera's prognostic nutritional index in critically ill patients: Seyed Hossein Ardehali, Ghazaleh Eslamian, Shirin Malek; Acute Crit Care. 2021;36(4):361-368. Published online November 26, 2021; DOI: https://doi.org/10.4266/acc.2021.00178

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Abstract PDF

Background
Malnutrition is a potentially costly problem in critically ill patients admitted to the intensive care unit (ICU). The aim of this study is to evaluate the relationships between the Onodera’s prognostic nutritional index (OPNI) and intestinal permeability and between OPNI and systemic inflammation in critically ill patients.
Methods
This was a cross-sectional study conducted in the general ICU of a university-affiliated hospital. A total of 162 ICU-hospitalized adult patients admitted between May 2018 and December 2019, was included in the study sample. The OPNI was calculated at admission and categorized as ≤40 or >40. We assessed plasma endotoxin and zonulin concentrations as markers of intestinal permeability as well as serum interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP) as markers of systemic inflammation upon admission under stringent conditions. The relationships between these markers and OPNI were assessed after adjusting for potential confounders through estimation of a binary logistic regression model.
Results
Median (interquartile range) hs-CRP, IL-6 zonulin, and endotoxin were significantly greater in the low OPNI subgroup than in the high OPNI subgroup (all P<0.05). Multivariate analyses showed significant association between serum IL-6 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.64–0.96), serum hs-CRP (OR, 0.77; 95% CI, 0.53–0.92), plasma endotoxin (OR, 0.81; 95% CI, 0.72–0.93), and plasma zonulin (OR, 0.83; 95% CI, 0.75–0.98) levels with OPNI in the overall population.
Conclusions
Our results provide evidence that higher plasma endotoxin, zonulin, IL-6, and hs-CRP levels are associated with progressively lower OPNI in mixed ICU populations, particularly in surgical ICU patients.

Citations

Citations to this article as recorded by

Recent Insights into the Evolving Role of the Gut Microbiome in Critical Care
Seoho Lee, Paul E. Wischmeyer, Cyrus D. Mintz, Mara A. Serbanescu
Critical Care Clinics.2025; 41(2): 379. CrossRef
Machine learning-based predictive model for enteral nutrition-associated diarrhea in ICU patients and its nursing applications
Xiaoying Liao, Chunhua Li, Qunyan Liu, Wang Xia, Zhenglin Liu, Jiamao Zhu, Wei Hu, Qionghua Hong
Frontiers in Nutrition.2025;[Epub] CrossRef
Association of malnutrition status with 30-day mortality in patients with sepsis using objective nutritional indices: a multicenter retrospective study
Moon Seong Baek, Young Suk Kwon, Sang Soo Kang, Daechul Shim, Youngsang Yoon, Jong Ho Kim
Acute and Critical Care.2024; 39(1): 127. CrossRef
Practical parameters that can be used for nutritional assessment in patients hospitalized in the intensive care unit with the diagnosis of chronic obstructive pulmonary disease
Ramazan Baldemir, Mustafa Özgür Cirik
Medicine.2022; 101(24): e29433. CrossRef
Nutritional Status, Body Composition, and Inflammation Profile in Older Patients with Advanced Chronic Kidney Disease Stage 4–5: A Case-Control Study
Mar Ruperto, Guillermina Barril
Nutrients.2022; 14(17): 3650. CrossRef

The Utility of Serum Procalcitonin Levels in the Management of Systemic Inflammatory Response Syndrome in the Emergency Department: Kyung Hye Park, Kang Hyun Lee, Kyoung Chul Cha, Hyun Kim, Sung Oh Hwang; Korean J Crit Care Med. 2012;27(1):10-15.; DOI: https://doi.org/10.4266/kjccm.2012.27.1.10

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Abstract PDF: BACKGROUND
The aim of this study was to investigate whether obtaining serum procalcitonin (PCT) levels in patients with systemic inflammatory response syndrome (SIRS) helps the differential diagnosis between sepsis and non-sepsis and predicts disease severity in the emergency department (ED).
METHODS
This prospective study enrolled 132 consecutive adult patients with SIRS who visited the ED. Serum C-reactive protein (CRP) levels and serum PCT levels were compared between sepsis and non-sepsis groups upon ED admission. Sequential Organ Failure Assessment (SOFA), Multiple Organ Dysfunction Score (MODS), and Acute Physiology and Chronic Health Evaluation (APACHE) III scores were calculated, and their correlations with CRP and PCT levels were evaluated. The PCT and CRP levels were assessed to predict sepsis in terms of comparing receiver operating characteristic (ROC) curves.
RESULTS
Eighty patients were included in the sepsis group. The levels of PCT and CRP in the sepsis group were significantly higher. In the sepsis group, the initial serum PCT correlated with the SOFA and MODS scores, and this also correlated in the non-sepsis group, but CRP did not. No differences were found when the PCT and CRP ROCs were compared.
CONCLUSIONS
Correlation between PCT and severity in the non-sepsis group is considered to be clinically meaningless because of low levels. Additionally, PCT levels had similar diagnostic value for sepsis as CRP levels. PCT is recommended for prediction of severity in sepsis patients in ED, but not for differential diagnosis between sepsis and non-sepsis.

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