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\def\makelabel##1{\upshape ##1}}% } {\end{list}\end{raggedright}} \newenvironment{specHead}[2]% {\vspace{20pt}\hrule\vspace{10pt}% \phantomsection\label{#1}\markright{#2}% \pdfbookmark[2]{#2}{#1}% \hspace{-0.75in}{\bfseries\fontsize{16pt}{18pt}\selectfont#2}% }{} \def\TheFullDate{2019 2019-01-15 (revised: 4 Year 2019 15 January 2019)} \def\TheID{\makeatother } \def\TheDate{2019 2019-01-15} \title{Predictors of Systemic Inflammatory Response Syndrome Following Percutaneous Nephrolithotomy} \author{}\makeatletter \makeatletter \newcommand*{\cleartoleftpage}{% \clearpage \if@twoside \ifodd\c@page \hbox{}\newpage \if@twocolumn \hbox{}\newpage \fi \fi \fi } \makeatother \makeatletter \thispagestyle{empty} \markright{\@title}\markboth{\@title}{\@author} \renewcommand\small{\@setfontsize\small{9pt}{11pt}\abovedisplayskip 8.5\p@ plus3\p@ minus4\p@ \belowdisplayskip \abovedisplayskip \abovedisplayshortskip \z@ plus2\p@ \belowdisplayshortskip 4\p@ plus2\p@ minus2\p@ 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\setlength{\parindent}{0pt}\raggedright \textcolor{GJMediumGrey}{\rule{\textwidth}{2pt}} \vskip16pt \textcolor{GJBlue}{\large\bfseries\abstractname\space} }{% \vskip8pt \textcolor{GJMediumGrey}{\rule{\textwidth}{2pt}} \vskip16pt } \usepackage[absolute,overlay]{textpos} \makeatother \usepackage{lineno} \linenumbers \begin{document} \author[1]{Durga Prasad} \author[2]{Rahul Devraj} \author[3]{Kiran Golimi} \author[4]{Rahul Nair} \author[5]{ S.Vidyasagar} \author[6]{Ch. Ram Reddy} \renewcommand\Authands{ and } \date{\small \em Received: 15 December 2018 Accepted: 5 January 2019 Published: 15 January 2019} \maketitle \begin{abstract} Introduction and Objectives: Sepsis remains one of the dreaded complications of percutaneous nephrolithotomy (PCNL). To analyze prospectively the preoperative and intraoperative factors that predict the occurrence of systemic inflammatory response syndrome (SIRS) in patients undergoing PCNL so that we can aggressively manage those patients from the preoperative period itself and avert the dangerous complications. Materials and Methods: A prospective study was carried out between Septembser 2016 and April 2018 including all patients who underwent PCNL. Patients with infected collecting system, synchronous ureteric stones, stents, or percutaneous nephrostomy drainage were excluded from the study. Patients were evaluated with physical examination, urine analysis, urine culture and sensitivity, complete blood count, renal function test, X-ray kidney, ureter, and bladder (KUB), and plain and contrast-enhanced computerized tomography KUB. Patients who developed any two or above of the following in the postoperative period were considered to have developed SIRS. (1) Temperature >100.4°F (38°C) or < 96.8°F (36°C). (2) Pulse rate > 90/min. (3) Respiratory rate > 20/min. (4) White blood cell count > 12,000/ml or < 4000/ml. Materials and Methods:A prospective study was carried out between Septembser 2016 and April 2018 including all patients who underwent PCNL. Patients with infected collecting system, synchronous ureteric stones, stents, or percutaneous nephrostomy drainage were excluded from the study. Patients were evaluated with physical examination, urine analysis, urine culture and sensitivity, complete blood count, renal function test, X-ray kidney, ureter, and bladder (KUB), and plain and contrast-enhanced computerized tomography KUB. Patients who developed any two or above of the following in the postoperative period were considered to have developed SIRS. \end{abstract} \keywords{percutaneous nephrolithotomy, post PCNL complications, systemic inflammatory response syndrome.} \begin{textblock*}{18cm}(1cm,1cm) % {block width} (coords) \textcolor{GJBlue}{\LARGE Global Journals \LaTeX\ JournalKaleidoscope\texttrademark} \end{textblock*} \begin{textblock*}{18cm}(1.4cm,1.5cm) % {block width} (coords) \textcolor{GJBlue}{\footnotesize \\ Artificial Intelligence formulated this projection for compatibility purposes from the original article published at Global Journals. However, this technology is currently in beta. \emph{Therefore, kindly ignore odd layouts, missed formulae, text, tables, or figures.}} \end{textblock*} \let\tabcellsep& \section[{Introduction}]{Introduction}\par ercutaneous nephrolithotomy (PCNL) is considered the standard of care in the management of renal calculous disease. In the early days, the procedure had considerable morbidity and at times mortality.\par With advances in technology and improved surgical technique, the mortality is very low and morbidity has come down. Sepsis remains one of the dreaded complications of the procedure. We need factors to predict who all are more likely to develop sepsis so that we can aggressively manage those patients from the preoperative period itself and avert the dangerous complications from occurring.\par In this endeavor, analysis of both preoperative and intraoperative factors is essential to identify the risk factors since both can play a role in the development of sepsis. \hyperref[b0]{[1,}\hyperref[b6]{7]} \section[{a) Aim and objective}]{a) Aim and objective}\par To analyze prospectively the preoperative and intraoperative factors that predict the occurrence of systemic inflammatory response syndrome (SIRS) in patients undergoing PCNL for renal calculus disease. \section[{II.}]{II.} \section[{Materials and Methods}]{Materials and Methods} \section[{E. Exclusion criteria:}]{E. Exclusion criteria:}\par ? Patients with infected collecting system.\par ? Patients with synchronous ureteric stones.\par ? Patients with stents or percutaneous nephrostomy drainage. \section[{a) Method of study}]{a) Method of study}\par All patients who presented to our department with renal stone disease were evaluated with physical examination, urine analysis, urine culture and sensitivity, complete blood count, renal function test, X-ray KUB, and plain and contrast-enhanced computerized tomography.\par All patients were subjected to percutaneous nephrolithotomy after obtaining anesthetic fitness.\par All patients were administered 1 g of ceftriaxone and 500 mg of amikacin as a standard antibiotic P prophylaxis for a period of 3 days including one preoperative dose. Patients with preoperative serum creatinine <1.4 were not administered amikacin.\par All patients underwent PCNL under general anesthesia. Patients were placed in lithotomy position, and a 5 Fr ureteric catheter was introduced. Contrast was used to identify the collecting system and to select the calyx for puncture. After prone positioning with adequate padding, the posterior calyceal puncture was done under fluoroscopic guidance. The level of puncture was decided as per the location of stone to ensure complete clearance.\par Puncture was done using 18 G three part needle, and a guide wire was placed within the system. Guide rod was introduced and serial coaxial dilatation of tract was done with co-axial metal dilators. Access sheath was placed. Using 26 Fr nephroscope and pneumatic lithotriptor stone fragmentation was done.\par After fragments were evacuated, antegrade 4 Fr ureteric stent is placed. A 20 Fr nephrostomy tube is also placed.\par Intraoperative parameters such as operative time, no of access tracts used, and need for blood transfusion were recorded. Pelvic urine collected on puncture and stone were sent for culture and sensitivity.\par Patients were followed up in postoperative period with daily complete blood count including white blood cell (WBC) count, serial pulse rate, temperature, and respiratory rate monitoring.\par Postprocedure check X-ray KUB was taken before removing the nephrostomy tube in the 1 st postoperative day. Ureteric stent was removed after 14 days.\par Patients who developed any two or above of the following in the postoperative period were considered to have developed SIRS.\par 1. Temperature >100.4°F (38°C) or <96.8°F (36°C). 2. Pulse rate >90/min. 3. Respiratory rate >20/min. 4. WBC count >12,000/ml or <4000/ml. \section[{b) Statistical analysis of the study}]{b) Statistical analysis of the study}\par For discrete data, proportion is computed, and the mean and standard deviation are computed for the continuous data. The Chi-square test was applied to compare the proportions between the groups. To examine the association between the outcome (SIRS) and several variables, logistic regression analysis was done. All analyses were two-tailed, and P < 0.05 was considered statistically significant. \section[{III.}]{III.} \section[{Observation and Results}]{Observation and Results} \section[{a) Descriptive statistics}]{a) Descriptive statistics}\par A total of 250 patients underwent PCNL in our institute during the study period. All the patients were evaluated both preoperatively and postoperatively as described above. Of these 250 patients, 51 (20.4\%) of them developed features of SIRS in the postoperative period.\par The patient characteristics are as shown in Tables 1, 2 and Figure {\ref 1}.\par Univariate analysis showed a significant association between age of the patient, blood transfusion, stone size, number of access tracts, operative time, pelvic urine culture \hyperref[b1]{[2]} showing growth, and stone culture showing growth as predictors of SIRS [Table \hyperref[tab_3]{3}].\par On multivariate regression analysis, stone size, no of access tracts, operative time, and stone culture were found to be statistically significant [Table \hyperref[tab_4]{4}] with regard to the occurrence of SIRS. \section[{Discussion}]{Discussion}\par Renal stone disease is a common urological problem. Medical management may not be possible in all situations. In certain situations like increasing stone burden or in specific type of stones like infective stones, surgical management is warranted. Moreover, medical management is more useful to prevent recurrences following surgical removal rather than as primary therapy.\par Surgical management as described includes both open and endourological procedures. In the modern era of minimally invasive surgery, renal calculous surgery is no exception.\par The procedure of PCNL has gained widespread acceptance and is the standard of care to treat renal calculous disease.\par The procedure when attempted initially was time-consuming, tedious for both patient and treating surgeon, and with considerable morbidity and some mortality.\par With advances in imaging, optics, and improved understanding of the pathology behind the considerable morbidity, the procedure has been standardized.\par Initially obtaining an access was considered a vital step in the success of the procedure.\par With good preoperative imaging particularly reconstructed computerized tomography, it paved the way for better localization and defining the extent of calculi. Moreover, better delineation of pelvicalyceal anatomy has helped us in obtaining an access to the pelvicalyceal system with ease. Further understanding of the way of obtaining an access with both fluoroscopic and ultrasonographic guidance has helped us in successfully creating a tract into the pelvicalyceal system.\par Even though both antegrade and retrograde techniques of access are available, the most commonly practiced access is through the antegrade access.\par Developments in creating a tract sufficient for the procedure have also lend a helping hand in the success of the procedure. Various methods of tract dilatation such as coaxial Alken dilators, Amplatz Advances in optics and miniaturization of endo instruments have also reduced the morbidity and improved the success rate. Introduction of flexible instruments has also greatly improved access to all the parts of collecting system without a need for additional tracts.\par Advances in intracorporeal lithotripters have also improved the success rate of PCNL. Smaller size lithotripter probes and efficient retrieval of stone fragments have improved the outcome of the procedure.\par In spite of all the advances and resultant improvements, certain morbidities of the procedure continue to affect the patients. Even though the procedure is being done under standard antibiotic prophylaxis, still patients develop a postoperative fever. \hyperref[b3]{[4]}\hyperref[b4]{[5]}\hyperref[b5]{[6]} The procedure is usually done after sterilizing the urine in patients with preoperative urine culture showing growth. Still 15-30\% of patients develop postoperative SIRS of which 1-2\% of patients develop sepsis. The likelihood of patients developing sepsis cannot be predicted as of now.\par However, the likelihood of developing SIRS in patients undergoing PCNL can be determined by identifying certain preoperative and intraoperative factors associated with the patients.\par Our study comprising of 250 patients who underwent PCNL showed that 51 (20.4\%) of them developed SIRS postoperatively. A study by Korets et al. \hyperref[b2]{[3]} showed SIRS incidence of 9.8\%. Another study by {\ref Chen et al. [9]} showed SIRS incidence of 23.4\%.\par On analysis of data collected before, during, and after surgery, it showed certain factors associated significantly in developing SIRS.\par Univariate analysis showed a significant association between age of the patient (>42 years), need for blood transfusion, stone size (>2.893 cm), number of access tracts (1 or >1), operative time (>70 min), pelvic urine culture showing growth, and stone culture \hyperref[b7]{[8]} showing growth.\par With regard to gender distribution, diabetes mellitus, bladder urine culture showing growth, and raised serum creatinine, the association was found to be statistically insignificant.\par On multivariate analysis, only stone size, number of access tracts, operative time, and stone culture were found to be statistically significant in predicting the occurrence of SIRS postoperatively. \section[{V.}]{V.} \section[{Conclusion}]{Conclusion}\par In patients undergoing PCNL, the following factors were found on analysis to be significantly associated with developing SIRS and thereby helping to identify those likely to develop sepsis.\par ? Univariate analysis showed a significant association between, blood transfusion, stone size, number of access tracts, operative time. ? Multivariate analysis showed stone size, number of access tracts, operative time, and stone culture as statistically significant in predicting the occurrence of SIRS postoperatively. In this study, no statistically significant association was found between gender, diabetes mellitus, bladder urine culture, and stone culture and pelvic urine culture raised serum creatinine in developing SIRS postoperatively. \section[{Financial support and sponsorship}]{Financial support and sponsorship} \section[{Nil.}]{Nil.} \section[{Conflicts of interest}]{Conflicts of interest}\par There are no conflicts of interest. \begin{figure}[htbp] \noindent\textbf{1} \par \begin{longtable}{P{0.10132450331125828\textwidth}P{0.11258278145695365\textwidth}P{0.19701986754966885\textwidth}P{0.14635761589403973\textwidth}P{0.16887417218543044\textwidth}P{0.123841059602649\textwidth}} \tabcellsep Age (years)\tabcellsep Serum creatinine (mg/ml)\tabcellsep Stone size (cm)\tabcellsep Operative time (min)\tabcellsep Number of tracts\\ Mean\tabcellsep 42.18\tabcellsep 1.196\tabcellsep 2.893\tabcellsep 70.32\tabcellsep 1.10\\ Minimum\tabcellsep 18\tabcellsep 0.6\tabcellsep 2.2\tabcellsep 40\tabcellsep 1\\ Maximum\tabcellsep 65\tabcellsep 3.4\tabcellsep 5.1\tabcellsep 125\tabcellsep 2\end{longtable} \par \caption{\label{tab_1}Table 1 :}\end{figure} \begin{figure}[htbp] \noindent\textbf{2} \par \begin{longtable}{P{0.3782967032967033\textwidth}P{0.29423076923076924\textwidth}P{0.06538461538461539\textwidth}P{0.046703296703296704\textwidth}P{0.06538461538461539\textwidth}} Year 2019\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\ 2\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\ Volume XIX Issue I Version I\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\ D D D D )\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\ (\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\ Medical Research\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\ Global Journal of\tabcellsep Sex\tabcellsep No SIRS\tabcellsep SIRS\tabcellsep Total\\ \tabcellsep Male\tabcellsep 121\tabcellsep 27\tabcellsep 148\\ \tabcellsep Female\tabcellsep 78\tabcellsep 24\tabcellsep 102\\ \tabcellsep Total\tabcellsep 91\tabcellsep 29\tabcellsep 250\\ \tabcellsep \multicolumn{2}{l}{SIRS: Systemic inflammatory response syndrome}\tabcellsep \tabcellsep \end{longtable} \par \caption{\label{tab_2}Table 2 :}\end{figure} \begin{figure}[htbp] \noindent\textbf{3} \par \begin{longtable}{P{0.45031914893617025\textwidth}P{0.09404255319148935\textwidth}P{0.3056382978723404\textwidth}} Parameter\tabcellsep P\tabcellsep Statistical significance\\ Gender\tabcellsep 0.829\tabcellsep Not significant\\ Diabetes mellitus\tabcellsep 0.062\tabcellsep Not significant\\ BloodurineC/S\tabcellsep 0.200\tabcellsep Not significant\\ Bloodtransfusion\tabcellsep 0.009\tabcellsep significant\\ Number ofaccesstracts\tabcellsep 0.001\tabcellsep significant\\ Pelvicurineculture\tabcellsep 0.3\tabcellsep Not significant\\ Stoneculture\tabcellsep 0.4\tabcellsep Not significant\\ Serumcreatinine\tabcellsep 0.340\tabcellsep Not significant\\ Stone size\tabcellsep 0.004\tabcellsep significant\\ Pre op pyelocaliectasis\tabcellsep 0.005\tabcellsep significant\\ Operative time\tabcellsep 0.829\tabcellsep significant\\ \multicolumn{3}{l}{SIRS: Systemic inflammatory response syndrome, C/S: Culture and sensitivity}\end{longtable} \par \caption{\label{tab_3}Table 3 :}\end{figure} \begin{figure}[htbp] \noindent\textbf{4} \par \begin{longtable}{P{0.2195462478184991\textwidth}P{0.07862129144851658\textwidth}P{0.07713787085514834\textwidth}P{0.08158813263525305\textwidth}P{0.01780104712041885\textwidth}P{0.09048865619546247\textwidth}P{0.08455497382198952\textwidth}P{0.11273996509598605\textwidth}P{0.08752181500872601\textwidth}} \tabcellsep B\tabcellsep SE\tabcellsep Wald\tabcellsep df\tabcellsep Significant\tabcellsep Exp (B)\tabcellsep \multicolumn{2}{l}{95.0\% CI for Exp (B)}\\ \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Lower\tabcellsep Upper\\ Diabetes mellitus\tabcellsep 0.481\tabcellsep 0.598\tabcellsep 0.647\tabcellsep 1\tabcellsep 0.421\tabcellsep 1.618\tabcellsep 0.501\tabcellsep 5.229\\ Bladder urine C/S\tabcellsep 0.364\tabcellsep 0.531\tabcellsep 0.469\tabcellsep 1\tabcellsep 0.493\tabcellsep 1.439\tabcellsep 0.508\tabcellsep 4.077\\ Blood transfusion\tabcellsep 1.368\tabcellsep 0.764\tabcellsep 3.202\tabcellsep 1\tabcellsep 0.074\tabcellsep 3.927\tabcellsep 0.878\tabcellsep 17.564\\ Pelvic urine C/S\tabcellsep ?0.086\tabcellsep 0.561\tabcellsep 0.024\tabcellsep 1\tabcellsep 0.878\tabcellsep 0.917\tabcellsep 0.305\tabcellsep 2.756\\ Stone C/S\tabcellsep ?0.958\tabcellsep 0.658\tabcellsep 2.120\tabcellsep 1\tabcellsep 0.345\tabcellsep 0.384\tabcellsep 0.106\tabcellsep 1.393\\ Serum creatinine\tabcellsep 0.385\tabcellsep 0.756\tabcellsep 0.259\tabcellsep 1\tabcellsep 0.611\tabcellsep 1.470\tabcellsep 0.334\tabcellsep 6.471\\ Age distribution\tabcellsep 0.842\tabcellsep 0.604\tabcellsep 1.944\tabcellsep 1\tabcellsep 0.163\tabcellsep 2.321\tabcellsep 0.711\tabcellsep 7.582\\ Stone size\tabcellsep 1.498\tabcellsep 0.509\tabcellsep 8.672\tabcellsep 1\tabcellsep 0.003\tabcellsep 4.473\tabcellsep 1.650\tabcellsep 12.124\\ Operative time\tabcellsep 1.268\tabcellsep 0.542\tabcellsep 5.475\tabcellsep 1\tabcellsep 0.019\tabcellsep 3.552\tabcellsep 1.228\tabcellsep 10.271\\ Number of tracts\tabcellsep 3.238\tabcellsep 0.650\tabcellsep 24.828\tabcellsep 1\tabcellsep 0.000\tabcellsep 0.039\tabcellsep 1.332\tabcellsep 11.112\end{longtable} \par {\small\itshape [Note: SE: Standard error, C/S: Culture and sensitivity, CI: Confidence interval IV.]} \caption{\label{tab_4}Table 4 :}\end{figure} \footnote{© 2019 Global JournalsPredictors of Systemic Inflammatory Response Syndrome Following Percutaneous Nephrolithotomy} \backmatter \begin{bibitemlist}{1} \bibitem[Gabay and Kushner ()]{b6}\label{b6} ‘Acute-phase proteins and other systemic responses to inflammation’. 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