Do you think procalcitonin is a useful tool for early discovering the post-traumatic septic complications? Has anyone ever tried to assess the increase in plasma current day / day before?
Some data has been presented in the paper (Critical care medicine 05/2009; 37(6):1845-9) that you can download to my profile.
Very important is
ProCT level usefulness for sepsis associated with severe SIRS secondary to trauma ?
A very good debate.
Admission ProCT in case of multiple and severe trauma is higher in case of visceral trauma (Maier et al J Trauma 2009) and secondary sepsis or septic shock. Thus, we need to have a cutoff value with high sensitivity and high predictive negative value to rule-out secondary sepsis. Unfortunately, studies focused on admission or the first two days values. For instance, Castelli et al (CCM 2009) reported an admission ProCT cutoff values of 1.09 ng/ml, but PCT values for patients without secondary sepsis (0.4 – 4.8 ng/ml) overlapped largely with those who developed sepsis (2.9 -25). Furthermore, PCT time course in case of severe visceral trauma is not yet documented.
As PCT levels increase when sepsis develops, for clinical practice, we should focus on PCT subsequent changes or a PCT ratio (to be evaluated) instead of a controversial cutoff level such as 2 or 3ng/ml. If we used the 10ng/ml value proposed by Menaar et al (Critical care Research and Practice 2011), Castelli et al would have missed all their septic cases…
Kinetic ProCT could be useful, in view of the literature
I confirm and agree the best approach is not a cut-off value but the subsequent change of PCT in the case debated here. Dynamic is always better than just a value.
Hello
in my opinion, with no trauma experience but a good general internal medicine one, I have to agree it is not the actual value bUT it'seems dynamic. Some authors tend to use a high PCT value to predict bactériemia.
Our experience in critically ill children with trauma is similar to Castelli. In patients with trauma or other non infectious SIRS, PCT kinetics is a valuable tool for the diagnosis of sepsis. After the initial 24 h increase due to non infectious SIRS, PCT will decrease to values < 1 ng/mL if the evolution is favorable. In case of a septic event, PCT will increase again, usually to higher values than previous caused by trauma SIRS. PCT short half-life of less than 24 h permits early trends changes that give us useful information about the evolution of the patients.
again, as my forespeakers, i would like to highlight theimportance of s e r i a l pct measurements in the trauma patient. The extent of pct secretion of the first 24 - 48 hr is likely to be related to the extent of trauma itself, as well as to other factors influencing this value, like duration or intesity of surgery. Therefore, obtained pct cut-off values of the before mentioned studies lack external validity. One has to keep in mind that in trauma patients not only septic insults, but also other events (like re-surgery, or newly developed circulatory shock of other than inflammatory causes, just to name two of them) can cause pct elevations, or alter the expected decline of pct. Every single pct value has to be carefully evaluated in the clinical context of every single patient.
I fully agree with you Matthias.
Other causes in addition to sepsis (like re-surgery, or newly developed circulatory shock) can derminare the increase of PCT in trauma, however, these causes are known (re-surgery) or obvious (shock), while the onset of sepsis is initially silent. So every single pct value has to be carefully evaluated in the clinical context of every single patient: don't forget the septic complication in trauma!
thus THe consensus: do not use a single PCT value, but KINETIC is useful and should be recommended