Comparação da acurácia de preditores de mortalidade na pneumonia associada à ventilação mecânica

Abstract

Objective: Levels of procalcitonin, midregional pro-atrial natriuretic peptide (MR-proANP), C-terminal provasopressin (copeptin), and C-reactive protein (CRP), as well as Sequential Organ Failure Assessment (SOFA) scores, are associated with severity and described as predictors of outcome in ventilator-associated pneumonia (VAP). This study sought to compare the predictive value of these biomarkers for mortality in VAP. Methods: An observational study of 71 patients with VAP. Levels of procalcitonin, MR-proANP, copeptin, and CRP, together with SOFA scores, were determined at VAP onset, designated day 0 (D0), and on day 4 of treatment (D4). Patients received empirical antimicrobial therapy, with modifications based on culture results. Patients who died before D28 were classified as nonsurvivors. Results: Of the 71 patients evaluated, 45 were classified as survivors. Of the 45 survivors, 35 (77.8%) received appropriate antimicrobial therapy, compared with 18 (69.2%) of the 26 nonsurvivors (p = 0.57). On D0 and D4, the levels of all biomarkers (except CRP), as well as SOFA scores, were lower in eventual survivors than in eventual nonsurvivors. For D0 and D4, the area under the ROC curve was largest for procalcitonin. On D0, MR-proANP had the highest positive likelihood ratio (2.71) and positive predictive value (0.60), but procalcitonin had the highest negative predictive value (0.87). On D4, procalcitonin had the highest positive likelihood ratio (3.46), the highest positive predictive value (0.66), and the highest negative predictive value (0.93). Conclusions: The biomarkers procalcitonin, MR-proANP, and copeptin can predict mortality in VAP, as can the SOFA score. Procalcitonin alone has the greatest predictive power for such mortality.Keywords: Pneumonia, ventilator-associated/mortality; Biological markers/analysis; Health Status Indicators. ResumoObjetivo: Níveis de procalcitonina, midregional pro-atrial natriuretic peptide (MR-proANP, pró-peptídeo natriurético atrial midregional),, C-terminal provasopressin (copeptina), proteína C reativa (CRP) e escore do Sequential Organ Failure Assessment (SOFA) são associados a gravidade e descritos como preditores de desfechos na pneumonia associada a ventilação mecânica (PAVM). Este estudo procurou comparar o valor preditivo de mortalidade desses biomarcadores na PAVM. Métodos: Estudo observacional com 71 pacientes com PAVM. Níveis de procalcitonina, MR-proANP, copeptina e PCR, bem como escore de SOFA foram obtidos no dia do diagnóstico de PAVM, designado dia zero (D0), e no quarto dia de tratamento (D4) Os pacientes receberam tratamento antimicrobiano empírico, com modificações baseadas nos resultados de cultura. Os pacientes que morreram antes de D28 foram classificados como não sobreviventes. Resultados: Dos 71 pacientes, 45 sobreviveram. Dos 45 sobreviventes, 35 (77,8%) receberam tratamento antimicrobiano adequado, comparados com 18 (69,2%) dos 26 não sobreviventes (p = 0,57). Os sobreviventes apresentaram valores significativamente mais baixos em todos os b...

The Importance of Serum Procalcitonin in Diagnosis and Treatment of Serious Bacterial Infections and Sepsis

“…3). The authors concluded that the increase of serum procalcitonin is an important diagnostic marker in identifying and predicting the outcome of VAP, and its usefulness is confirmed by the result of many other studies (23, 24, 25). …”

Copeptin and its potential role in diagnosis and prognosis of various diseases

“…The V1a receptor is widely expressed and mediates AVPs prothrombotic and vasoconstrictor effects. Thus, AVP agonists are used in treating bleeding and hypotensive disorders (15–17). Through V1a receptor AVP also mediates liver glycogenolysis (16,17).…”

“…Through V1a receptor AVP also mediates liver glycogenolysis (16,17). The V1b receptor is expressed in the pituitary gland and pancreas (15,16). Through this receptor AVP stimulates the release of adrenocorticotropic hormone.…”

“…Insulin and glucagon secretion are mediated via V1b receptor as well (16,17). The V2 receptor is expressed in the renal collecting ducts and through those receptors the antidiuretic effect of AVP is mediated (15,16). Pharmacological blockade of V2 receptor has been used to treat hyponatremia and heart failure (16,17).…”

Publicações do Jornal Brasileiro de Pneumologia

“…Another important sub-area in our field in which there has been an increase in interest and in scientific production is intensive care, ( 32 - 34 ) including mechanical ventilation and the essential participation of respiratory therapy, an area in which the volume of research has also increased. ( 35 , 36 ) The use of ventilatory support and extracorporeal membrane oxygenation was the subject of a study conducted in the city of São Paulo ( 37 ) and of an editorial authored by Professor Alan Morris of Salt Lake City, Utah.…”