Correlation Of Procalcitonin To The Severity Of Injury, Complications And Outcome Of Simple Brain Trauma Patients

BackgroundsSevere trauma is associated with a high incidence of septic complications and multiple organ dysfunction syndrome (MODS), which markedly influence patient outcomes. Pivotal errors that cause serious posttraumatic complications are the wrong timing of secondary surgical interventions and the late recognition of forthcoming infection attributable to an insufficient definition of the inflammatory status of the injured patient. Standard clinical and laboratory markers typical for systemic inflammation, such as fever, leukocytosis, C-reactive protein, and serum levels of proinflammatory cytokines (interleukin-6), are unspecific and do not allow the differentiation between infectious and noninfectious systemic inflammatory response syndrome (SIRS). Moreover, these markers are often increased during ongoing infection, but they have not been found to be predictive for injured patients at risk.There is mounting evidence that procalcitonin is a useful marker in acute inflammatory reaction, with its high sensitivity and specificity in diagnosis of systemic bacterial infection compared with other traditional inflammation markers. Procalcitonin has been shown to be striking raised in systemic inflammation reaction of bacterial or fungi infection, however, its concentrations are normal or mild-moderate elevated in some non-infectious SIRS such as trauma or surgery.In2003, scholars come from Germany found that brain injury played no role in the procalcitonin increasing after trauma. Another foreign researchers investigated that there was a statistically non-significant increase in serum PCT levels from no SIRS to SIRS to sepsis and a similar trend noted in patients with mild, moderate and severe head injury.At present there have been many studies found that procalcitonin, C-reactive protein and other biological molecules rise in early phase of trauma similar to the early stage of postoperative of elective surgery, without sepsis or infection. And there is no report of procalcitonin and C-reactive protein used in the brain trauma patients so far. Therefore we choose this population to design a prospective observational study, aim to explore the correlation of procalcitonin to the severity of injury, complications, and outcome of simple brain trauma patients. MethodsA total of120patients with simple brain trauma admitted to Intensive care unit of Huashan Hospital, Fudan University from June2011to February2012were evaluated in a prospective observational study, with30cases of healthy people (normal group) as comparison. The serum levels of procalcitonin and C-reactive protein were measured at1,2,3,5,7and10days respectively after the admission. During the following ten days after admission, the clinical data of patients with simple brain trauma were recorded, such as sex, age, temperature, the glasgow coma scale, the sepsis-related organ failure assessment score, and the acute physiology and chronic health evaluation II score, complication, the total days of the ICU, the culture of pathogenic microorganism, and follow-up the28-day survival of patients. We assessed the relationship between initial PCT and the severity of injury, complications, prognosis of brain trauma patients using spearman relevant analysis. Kaplan-Meier survival curves were used to investigate the relationship between PCT level and survival rate. Univariate and multivariateor analysis of COX regression model were used to identify the prognosis factors for survival. The predictive value for prognosis by initial PCT level was evaluated with an ROC curve.ResultsThe serum levels of PCT and CRP in patients with brain trauma were higher after injury compared with the normal group (p<0.05). There was a statistically significant increase in serum PCT levels from mild(0.21ng/ml) to severe(0.41ng/ml) head injury and a similar trend noted in patients without surgery to surgery. There was a statistically significant different between the group with high PCT level (≥0.5ng/ml) after admission and the group with lower PCT level (<0.5ng/ml) after admission in the GCS score, APACHEII score, SOFA score, the duration of ICU, the incidence of infections and28-d mortality. There was no significant difference of C-reaction protein in such group. The short-term prognosis of the group with high PCT level (≥0.5ng/ml) after admission was not good. The28-day mortality in the group of high or lower PCT level after admission were16.7%,2.5%respectively, Kaplan-Meier survival analysis showed that the28days survival between the two group was statistically significant (p<0.001). Spearman related analysis showed that the serum level of PCT after admission was related to the GCS score, SOFA score, APACHEII score, infection, surgery (p<0.01), with the correlation coefficient-0.529,0.457,0.535,0.424,0.213respectively. Univariate analysis of COX regression showed that the duration of ICU, GCS score, APACHEII score, SOFA score, infection, and PCT level of admission were significantly related to28days mortality. Multifactor COX regression analysis revealed that the duration of ICU (HR=0.638,95%CI0.512to0.795, p=0.000), GCS score (HR=0.803,95%CI0.668to0.965, p=0.019), APACHEII score (HR=1.109,95%CI1.026to1.199, p=0.009), infection (HR=50.704,95%CI2.229to1153.338, p=0.014), admission level of PCT (HR=1.451,95%CI1.071to1.967, p=0.016) were independent risk factors of28days mortality. The area under the ROC curves of APACHEII score, PCT level after admission and GCS score were0.785(p<0.001),0.79(p<0.001),0.18(p<0.001) respectively in prediction of28days mortality. The APACHEII score and PCT level of admission had a good sensitivity and specificity in prediction of28days mortality.ConclusionIn patients with brain trauma, only moderate trauma-related increase of PCT are induced and its peaked appeared at day1-2after trauma, the concentrations rapidly declining thereafter. CRP ubiquitously increased and its kinetics were much slower. The PCT level provides more information than the CRP level. More severity of injury, complications such as sepsis, infection, prolonged intensive care unit treatment, and poor outcome were more frequent in patients with initially high PCT (>0.5ng/ml), whereas increases of CRP showed no positive correlation. The initially PCT level was independent risk factors of28days mortality, the higher of PCT level, the higher28days mortality. The initially PCT level had a good sensitivity and specificity in prediction of28days mortality.