Chest
Volume 134, Issue 1, July 2008, Pages 101-108
Journal home page for Chest

Original Research
Critical Care Medicine
Prognostic Role of Clinical and Laboratory Criteria To Identify Early Ventilator-Associated Pneumonia in Brain Injury*

https://doi.org/10.1378/chest.07-2546Get rights and content

Background

We investigated the role of the clinical pulmonary infection score (CPIS), serum levels of procalcitonin (PCT), C-reactive protein (CRP), and serum amyloid A (SAA) in the detection of patients with early ventilator-associated pneumonia (VAP).

Methods

Observational study in a university hospital. In 58 patients with severe brain injury receiving mechanical ventilation, CPIS, PCT, CRP and SAA were evaluated at ICU entry and at days 3 to 4 of hospital stay for VAP diagnosis (confirmed by endotracheal aspirate or BAL cultures).

Results

We found the following: (1) PCT at entry was increased in patients who later had early VAP develop (25 patients) compared to no VAP (median, 1.4 ng/mL; 25–75 percentiles, 0.14–0.78; vs median, 0.2 ng/mL; 25–75 percentiles, 0.76–2.4, p < 0.001; sensitivity, 76%; and specificity, 75%); (2) CPIS increased at the day of VAP diagnosis, compared to entry (median, 6.6 ± 1.1 vs 1.5 ± 1.1, p < 0.001; sensitivity, 97%; specificity, 100%), while other serum inflammatory markers did not change; and (3) deterioration in oxygenation and changes in tracheal secretions were the main determinants of CPIS changes.

Conclusions

PCT may be a useful marker to predict which patients subsequently have early VAP. The CPIS could help as an early way to detect the patients with early VAP and who need further diagnostic testing.

Section snippets

Patient Selection

Sixty-seven brain-injured patients admitted to the ICU of the Servizio Anestesia B, Ospedale di Circolo e Fondazione Macchi, Insubria University, Varese, Italy were identified over a 1-year period. The study was approved by the Ethical Committee of the Hospital and performed in accordance with the precepts established by Helsinki Declaration. Inclusion criteria were as follows: (1) severe brain injury, defined as a Glasgow coma scale (GCS) score at hospital entry ≤ 8, due to isolated brain

Clinical Characteristics and Acute-Phase Inflammatory Markers at Entry

We screened a total of 101 patients. We excluded 2 patients due to age < 18 years, 3 patients due to extrahospital cardiac arrest or brain death, and 29 patients due to severe multiple trauma.

We included 67 patients with severe brain injury, but 9 patients were further excluded from the analysis due to positive culture finding of the endotracheal aspirate or BAL at entry. The remaining 58 brain-injured patients fulfilling the inclusion criteria were admitted into the study. The diagnosis of

Discussion

This is the first study investigating the role of PCT and the CPIS for early detection of patients with early VAP in the setting of brain injury. In severe brain-injured patients, the most frequent medical complication is respiratory dysfunction, with an increased mortality and worse neurologic outcome.18, 19, 20, 21, 22 In this study we investigated changes in CRP,23 SAA,24, 25 PCT, and leukocytes. Serum concentrations of PCT have been reported to be markedly increased in a variety of clinical

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    This study was performed at the Ospedale di Circolo e Fondazione Macchi, Varese, Italy.

    This study was not supported by any financial support, and all the authors declare disclosure of any personal or financial support or financial interest in the subject matter or any actual or potential conflict of interest.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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