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J Pediatr Intensive Care 2023; 12(03): 203-209
DOI: 10.1055/s-0041-1731432
Original Article

Troponin I as an Independent Biomarker of Outcome in Children with Systemic Inflammatory Response

Heitor P. Leite 
1   Discipline of Nutrition and Metabolism, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil
,
Rodrigo Medina
2   Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
,
Emilio L. Junior
1   Discipline of Nutrition and Metabolism, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil
,
Tulio Konstantyner
1   Discipline of Nutrition and Metabolism, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil
3   Department of Pediatrics, Hospital Geral de Itapecerica da Serra—HGIS, Itapecerica da Serra, São Paulo, Brazil
› Author Affiliations Funding R.M received a grant for scientific initiation from CNPQ, Conselho Nacional de Desenvolvimento Cientifico e Tecnológico (National Council for Scientific and Technological Development).
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Abstract

Cardiac troponin-I (cTnI) is a biomarker of myocardial injury with implications for clinical outcomes. May other contributing factors that could affect outcomes have not been uniformly considered in pediatric studies. We hypothesized that there is an association between admission serum cTnI and outcomes in critically ill children taking into account the magnitude of the acute systemic inflammatory response syndrome (SIRS), serum lactate concentrations, and nutritional status. Second, we tested for potential factors associated with elevated serum cTnI. This was a prospective cohort study in 104 children (median age: 21.3 months) consecutively admitted to a pediatric intensive care unit (PICU) of a teaching hospital with SIRS and without previous chronic diseases. Primary outcome variables were PICU-free days, ventilator-free days, and 30-day mortality. Exposure variables were serum cTnI concentration on admission, revised pediatric index of mortality (PIM2), pediatric logistic organ dysfunction (PELOD-2), hypotensive shock, C-reactive protein, procalcitonin, and serum lactate on admission, and malnutrition. Elevated cTnI (>0.01 μg/L) was observed in 24% of patients, which was associated with the reduction of ventilator-free days (β coefficient = − 4.97; 95% confidence interval [CI]: −8.03; −1.91) and PICU-free days (β coefficient = − 5.76; 95% CI: −8.97; −2.55). All patients who died had elevated serum cTnI. The increase of 0.1 μg/L in cTnI concentration resulted in an elevation of 2 points in the oxygenation index (β coefficient = 2.0; 95% CI: 1.22; 2.78, p < 0.001). The PIM2 score, hypotensive shock in the first 24 hours, and serum lactate were independently associated with elevated cTnI on admission. We conclude that elevated serum cTnI on admission is independently associated with adverse outcomes in children with SIRS and without associated chronic diseases.

Keywords

troponin - septic shock - intensive care unit - pediatric - lactate - children - outcomes

Note

This work was performed in the Department of Pediatrics of Universidade Federal de São Paulo. The data were collected from patients admitted to the intensive care unit of Hospital Geral de Itapecerica da Serra, São Paulo, Brazil.




Publication History

Received: 24 January 2021

Accepted: 17 May 2021

Article published online:
22 June 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
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  • References

  • 1 Rudd KE, Johnson SC, Agesa KM. et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet 2020; 395 (10219): 200-211
    CrossrefPubMedGoogle Scholar
  • 2 Tan B, Wong JJ, Sultana R. et al. Global case-fatality rates in pediatric severe sepsis and septic shock: a systematic review and meta-analysis. JAMA Pediatr 2019; 173 (04) 352-362
    CrossrefPubMedGoogle Scholar
  • 3 Feltes TF, Pignatelli R, Kleinert S, Mariscalco MM. Quantitated left ventricular systolic mechanics in children with septic shock utilizing noninvasive wall-stress analysis. Crit Care Med 1994; 22 (10) 1647-1658
    CrossrefPubMedGoogle Scholar
  • 4 Kumar A, Haery C, Parrillo JE. Myocardial dysfunction in septic shock. Crit Care Clin 2000; 16 (02) 251-287
    CrossrefPubMedGoogle Scholar
  • 5 Sanfilippo F, Corredor C, Fletcher N. et al. Diastolic dysfunction and mortality in septic patients: a systematic review and meta-analysis. Intensive Care Med 2015; 41 (06) 1004-1013
    CrossrefPubMedGoogle Scholar
  • 6 Fenton KE, Parker MM. Cardiac function and dysfunction in sepsis. Clin Chest Med 2016; 37 (02) 289-298
    CrossrefPubMedGoogle Scholar
  • 7 Domico M, Allen M. Biomarkers in pediatric cardiac critical care. Pediatr Crit Care Med 2016; 17 (8, suppl 1) S215-S221
    CrossrefPubMedGoogle Scholar
  • 8 Katus HA, Scheffeld T, Remppis A. et al. Proteins of the troponin complex. Lab Med 1992; 23: 311-317
    CrossrefPubMedGoogle Scholar
  • 9 Bessière F, Khenifer S, Dubourg J, Durieu I, Lega JC. Prognostic value of troponins in sepsis: a meta-analysis. Intensive Care Med 2013; 39 (07) 1181-1189
    CrossrefPubMedGoogle Scholar
  • 10 Mair J, Morandell D, Genser N, Lechleitner P, Dienstl F, Puschendorf B. Equivalent early sensitivities of myoglobin, creatine kinase MB mass, creatine kinase isoform ratios, and cardiac troponins I and T for acute myocardial infarction. Clin Chem 1995; 41 (09) 1266-1272
    CrossrefPubMedGoogle Scholar
  • 11 Adams III JE, Schechtman KB, Landt Y, Ladenson JH, Jaffe AS. Comparable detection of acute myocardial infarction by creatine kinase MB isoenzyme and cardiac troponin I. Clin Chem 1994; 40 (7 Pt 1): 1291-1295
    CrossrefPubMedGoogle Scholar
  • 12 Fenton KE, Sable CA, Bell MJ, Patel KM, Berger JT. Increases in serum levels of troponin I are associated with cardiac dysfunction and disease severity in pediatric patients with septic shock. Pediatr Crit Care Med 2004; 5 (06) 533-538
    CrossrefPubMedGoogle Scholar
  • 13 Wilson C, Sambandamoorthy G, Holloway P, Ramnarayan P, Inwald DP. Admission plasma troponin I is associated with mortality in pediatric intensive care. Pediatr Crit Care Med 2016; 17 (09) 831-836
    CrossrefPubMedGoogle Scholar
  • 14 Oliveira NS, Silva VR, Castelo JSA, Elias-Neto J, Pereira FE, Carvalho WB. Serum level of cardiac troponin I in pediatric patients with sepsis or septic shock. Pediatr Crit Care Med 2008; 9 (04) 414-417
    CrossrefPubMedGoogle Scholar
  • 15 Chong D, Chua YT, Chong SL, Ong GY. What raises troponins in the paediatric population?. Pediatr Cardiol 2018; 39 (08) 1530-1534
    CrossrefPubMedGoogle Scholar
  • 16 Bai Z, Zhu X, Li M. et al. Effectiveness of predicting in-hospital mortality in critically ill children by assessing blood lactate levels at admission. BMC Pediatr 2014; 14: 83
    CrossrefPubMedGoogle Scholar
  • 17 de Souza Menezes F, Leite HP, Koch Nogueira PC. Malnutrition as an independent predictor of clinical outcome in critically ill children. Nutrition 2012; 28 (03) 267-270
    CrossrefPubMedGoogle Scholar
  • 18 Schuetz P, Birkhahn R, Sherwin R. et al. Serial procalcitonin predicts mortality in severe sepsis patients: results from the Multicenter Procalcitonin MOnitoring SEpsis (MOSES) study. Crit Care Med 2017; 45 (05) 781-789
    CrossrefPubMedGoogle Scholar
  • 19 Korff S, Katus HA, Giannitsis E. Differential diagnosis of elevated troponins. Heart 2006; 92 (07) 987-993
    CrossrefPubMedGoogle Scholar
  • 20 Park KC, Gaze DC, Collinson PO, Marber MS. Cardiac troponins: from myocardial infarction to chronic disease. Cardiovasc Res 2017; 113 (14) 1708-1718
    CrossrefPubMedGoogle Scholar
  • 21 Rosenberg DI, Moss MM. American Academy of Pediatrics Section on Critical Care, American Academy of Pediatrics Committee on Hospital Care. Guidelines and levels of care for pediatric intensive care units. Pediatrics 2004; 114 (04) 1114-1125
    CrossrefPubMedGoogle Scholar
  • 22 Brierley J, Carcillo JA, Choong K. et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37 (02) 666-688
    CrossrefPubMedGoogle Scholar
  • 23 Davis AL, Carcillo JA, Aneja RK. et al. American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med 2017; 45 (06) 1061-1093
    CrossrefPubMedGoogle Scholar
  • 24 Schoenfeld DA, Bernard GR. ARDS Network. Statistical evaluation of ventilator-free days as an efficacy measure in clinical trials of treatments for acute respiratory distress syndrome. Crit Care Med 2002; 30 (08) 1772-1777
    CrossrefPubMedGoogle Scholar
  • 25 Slater A, Shann F, Pearson G. Paediatric Index of Mortality (PIM) Study Group. PIM2: a revised version of the paediatric index of mortality. Intensive Care Med 2003; 29 (02) 278-285
    CrossrefPubMedGoogle Scholar
  • 26 Leteurtre S, Duhamel A, Salleron J, Grandbastien B, Lacroix J, Leclerc F. Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP). PELOD-2: an update of the PEdiatric logistic organ dysfunction score. Crit Care Med 2013; 41 (07) 1761-1773
    CrossrefPubMedGoogle Scholar
  • 27 Thomas NJ, Shaffer ML, Willson DF, Shih MC, Curley MA. Defining acute lung disease in children with the oxygenation saturation index. Pediatr Crit Care Med 2010; 11 (01) 12-17
    CrossrefPubMedGoogle Scholar
  • 28 Collinson PO, Gaze DC, Stubbs PJ. et al. Diagnostic and prognostic role of cardiac troponin I (cTnI) measured on the DPC Immulite. Clin Biochem 2006; 39 (07) 692-696
    CrossrefPubMedGoogle Scholar
  • 29 World Health Organization. The WHO Child Growth Standards. Accessed May 31, 2021 at: https://www.who.int/tools/child-growth-standards
    PubMedGoogle Scholar
  • 30 Gurkan F, Alkaya A, Ece A. et al. Cardiac troponin-I as a marker of myocardial dysfunction in children with septic shock. Swiss Med Wkly 2004; 134 (39–40): 593-596
    PubMedGoogle Scholar
  • 31 Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr 2008; 27 (01) 5-15
    CrossrefPubMedGoogle Scholar
  • 32 Gaies MG, Gurney JG, Yen AH. et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med 2010; 11 (02) 234-238
    CrossrefPubMedGoogle Scholar
  • 33 Guest TM, Ramanathan AV, Tuteur PG, Schechtman KB, Ladenson JH, Jaffe AS. Myocardial injury in critically ill patients. A frequently unrecognized complication. JAMA 1995; 273 (24) 1945-1949
    CrossrefPubMedGoogle Scholar
  • 34 Shekerdemian L, Bohn D. Cardiovascular effects of mechanical ventilation. Arch Dis Child 1999; 80 (05) 475-480
    CrossrefPubMedGoogle Scholar
  • 35 Weiss SL, Zhang D, Bush J. et al. Persistent mitochondrial dysfunction linked to prolonged organ dysfunction in pediatric sepsis. Crit Care Med 2019; 47 (10) 1433-1441
    CrossrefPubMedGoogle Scholar
  • 36 Kraut JA, Madias NE. Lactic acidosis: current treatments and future directions. Am J Kidney Dis 2016; 68 (03) 473-482
    CrossrefPubMedGoogle Scholar
  • 37 Kraut JA, Madias NE. Treatment of acute metabolic acidosis: a pathophysiologic approach. Nat Rev Nephrol 2012; 8 (10) 589-601
    CrossrefPubMedGoogle Scholar
  • 38 Onorati F, Cristodoro L, Caroleo S. et al. Troponin I and lactate from coronary sinus predict cardiac complications after myocardial revascularization. Ann Thorac Surg 2007; 83 (03) 1016-1023
    CrossrefPubMedGoogle Scholar
  • 39 Giannitsis E, Katus HA. Cardiac troponin level elevations not related to acute coronary syndromes. Nat Rev Cardiol 2013; 10 (11) 623-634
    CrossrefPubMedGoogle Scholar