C-reactive protein levels correlate with mortality and organ failure in critically ill patients

Modeling effect of the septic condition and trauma on C-reactive protein levels in children with sepsis: a retrospective study

Introduction

Sepsis is the main cause of morbidity and mortality in intensive care units and its early diagnosis is not straightforward. Many studies have evaluated the usefulness of various markers of infection, including C-reactive protein (CRP), which is the most accessible and widely used. CRP is of weak diagnostic value because of its low specificity; a better understanding of patterns of CRP levels associated with a particular form of infection may improve its usefulness as a sepsis marker. In the present article, we apply multilevel modeling techniques and mixed linear models to CRP-related data to assess the time course of CRP blood levels in association with clinical outcome in children with different septic conditions.

Methods

We performed a retrospective analysis of 99 patients with systemic inflammatory response syndrome, sepsis, or septic shock who were admitted to the Pediatric Critical Care Unit at the University Hospital, Brno. CRP blood levels were monitored for 10 days following the onset of the septic condition. The effect of different septic conditions and of the surgical or nonsurgical diagnosis on CRP blood levels was statistically analyzed using mixed linear models with a multilevel modeling approach.

Results

A significant effect of septic condition and diagnosis on the course of CRP levels was identified. In patients who did not progress to septic shock, CRP blood levels decreased rapidly after reaching peak values – in contrast to the values in patients with septic shock in whom CRP protein levels decreased slowly. Moreover, CRP levels in patients with a surgical diagnosis were higher than in patients with a nonsurgical condition. The magnitude of this additional elevation in surgical patients did not depend on the septic condition.

Conclusion

Understanding the pattern of change in levels of CRP associated with a particular condition may improve its diagnostic and prognostic value in children with sepsis.

C-reactive protein is an independent predictor of severity in community-acquired pneumonia

BACKGROUND

C-reactive protein (CRP) is an acute phase protein synthesized by the liver primarily in response to interleukin-6. Initial studies have suggested that inflammatory markers may have a role in predicting severity. We investigated whether admission and day 4 CRP could predict severity in community-acquired pneumonia.

METHODS

A prospective study was carried out over a 2-year period in a large teaching hospital. CRP was measured on admission and on day 4. The outcomes of interest were: 30-day mortality; need for mechanical ventilation and/or inotropic support; development of complicated pneumonia (lung abscess, empyema, or complicated parapneumonic effusion); the value of predictive tests were assessed using multivariate logistic regression.

RESULTS

There were 570 patients included in the study; 30-day mortality was 9.6%. Low CRP levels showed a high negative predictive value for excluding 30-day mortality (CRP <10 mg/L=100%, CRP <50=99.1%, CRP <100=98.9%, CRP <200=94.9%). Low admission CRP levels <100 mg/L were independently associated with reduced 30-day mortality (odds ratio [OR] 0.18; 0.04-0.85), P=.03; need for mechanical ventilation and/or inotropic support (OR 0.21; 0.14-0.4), P=.002; and complicated pneumonia (OR 0.05; 0.01-0.35), P=.003. A CRP that fails to fall by 50% or more within 4 days of admission is independently associated with increased 30 day mortality (OR 24.5; 6.4-93.4), P <.0001; need for mechanical ventilation and/or inotropic support (OR 7.1; 2.8-17.8), P <.0001 and complicated pneumonia (OR 15.4; 6.32-37.6), P <.0001.

CONCLUSIONS

Admission CRP <100 mg/L has reduced risk for 30-day mortality, need for mechanical ventilation and/or inotropic support, and complicated pneumonia. Failure of CRP to fall by 50% or more at day 4 leads to an increased risk for 30-day mortality, need for mechanical ventilation and/or inotropic support, and complicated pneumonia. C-reactive protein is an independent marker of severity in community-acquired pneumonia.

C-reactive protein concentration as a predictor of in-hospital mortality after ICU discharge: a prospective cohort study

OBJECTIVE

The objective was to assess the ability of potential clinical predictors and inflammatory markers within 24 h of intensive care unit (ICU) discharge to predict subsequent in-hospital mortality.

DESIGN AND SETTING

A prospective cohort study of 603 consecutive patients who survived their first ICU admission, between 1 June and 31 December 2005, in a 22-bed multidisciplinary ICU of a university hospital.

MEASUREMENTS AND RESULTS

A total of 26 in-hospital deaths after ICU discharge (4.3%) were identified. C-reactive protein (CRP) concentrations at ICU discharge were associated with subsequent in-hospital mortality in the univariate analysis (mean CRP concentrations of non-survivors=174 vs. survivors=85.6 mg/l, p=0.001). CRP concentrations remained significantly associated with post-ICU mortality (a 10-mg/l increment in CRP concentrations increased the odds ratio [OR] of death: 1.09, 95% confidence interval [CI]: 1.03-1.16); after adjusting for age, the Acute Physiology and Chronic Health Evaluation (APACHE) II predicted mortality, and the Delta Sequential Organ Failure Assessment (Delta SOFA) score. The area under the receiver operating characteristic curve of this multivariate model to discriminate between survivors and non-survivors after ICU discharge was 0.85 (95% CI: 0.73-0.96). The destination and timing of ICU discharge, and the Discharge SOFA score, white cell counts and fibrinogen concentrations at ICU discharge were not significantly associated with in-hospital mortality after ICU discharge.

CONCLUSIONS

A high CRP concentration at ICU discharge was an independent predictor of in-hospital mortality after ICU discharge in our ICU.

Long-term immunosuppression in burned patients assessed by in vitro neutrophil oxidative burst (Phagoburst®)

OBJECTIVE

To assess the duration and magnitude of immunosuppression induced by burns as measured by the neutrophil oxidative burst in vitro.

DESIGN

Prospective exploratory cohort study.

SETTING

Tertiary referral unit, University Hospital, Linkoping, Sweden (National Burn Unit). PATIENTS AND HEALTHY VOLUNTEERS (CONTROLS): Twenty-eight subjects consecutively admitted to the Burn Unit. The mean total burn surface area (TBSA%) was 36 (range 13-87) and mean age 44 years (range 14-89). Patients' data were collected prospectively in the burn unit, which also included sequential organ failure assessment (SOFA) score.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

To assess the changes in the oxidative capacity of neutrophils after the burn, blood samples for the Phagoburst analysis were taken on admission and at least once every second week for the duration of stay in hospital and thereafter monthly up to 12 months after the burn. Neutrophils were stimulated in vitro by Escherichia coli, phorbol 12-phorbol myristate 13-acetate (PMA), and peptide N-formyl-Met-Leu-Phe (fMLP). Oxidative burst was measured by flow cytometry. Oxidative capacity of the neutrophils decreased similarly for all three stimulants: there was a pathological decrease shortly after admission, with the lowest value occurring between days 7 and 10, followed by a gradual recovery during the ensuing months. Full recovery (to the values of the controls) was seen first 3.5 months after the burn. Using multiple regression, we found that only age and time since the burn significantly (p<0.05) affected the oxidative burst. White cell count (WCC) and C-reactive protein (CRP) values returned to reference ranges long before the oxidative burst.

CONCLUSIONS

This study provides evidence that immunosuppression in those injured by burns, as assessed by the in vitro oxidative burst of neutrophils, remains long after the event of the burn (up to 3.5 months after burn). Absence of correlations to TBSA%, FTB%, blood transfusion, opiates provided, and multiple organ failure score and laboratory infection variables together with the finding that decreased oxidative burst was uniform after the injury, suggesting that this immunosuppression is primarily due to the general metabolic response rather than recurring infections.

Markers of inflammation as determinants of mortality in intensive care unit patients

In this study, the investigators explored the relationship between mortality rate and serum levels of C-reactive protein (CRP), erythrocyte sedimentation ratio (ESR), albumin, and hemoglobin, leukocyte, and platelet counts of patients at the time of first admission to the intensive care unit (ICU). A total of 123 patients were admitted to 2 different ICUs. In the emergency departments, serum levels of CRP, ESR, and albumin and hematologic parameters of 81 patients who died and 42 patients who survived were compared. A Student t test and the chi2 test were used for statistical analyses. Mean CRP and ESR levels and leukocyte counts were higher in nonsurvivor than in survivor groups (P<.001 for all). Additionally, serum CRP and ESR elevations and leukocyte counts were determined to be individually related to mortality (P<.001, P<.05, and P<.05, respectively). The investigators concluded that initial serum levels of CRP and ESR and leukocyte counts can be used as determinants of mortality in ICU patients.

Sepsis in 2003: are we still in the middle of nowhere?

PURPOSE OF REVIEW

Although enthusiasm of intensivists has been raised during the last 2-3 years due to several successful clinical trials, severe sepsis and septic shock still have an increasing incidence with more or less unchanged mortality. Within the last 12 months, the progress in sepsis research covering definitions, epidemiology, pathophysiology, diagnosis, standard and adjunctive therapy, as well as experimental approaches is encouraging. In this review, state-of-the-art publications of 2003 are presented to elucidate the possible impact on clinical routine.

RECENT FINDINGS

The rationale for using a new definition based on the PIRO system has been widely acknowledged, although it is not yet applicable in clinical practice. This includes genomic information for stratifying subgroups of patients, and a broader field of laboratory diagnostics due to clinical studies and basic research on the cellular mechanisms of inflammation and organ dysfunction. Early diagnosis is important for a fast implementation of specific therapies, and it has been confirmed that the time until the start of therapy has an impact on patient outcome. Thorough data analysis of successful trials with activated protein C has revealed encouraging details on long-term outcome and subgroup effects. Together with new findings on low-dose hydrocortisone, this stresses the relevance of adjunctive therapy in severe sepsis and septic shock.

SUMMARY

Scientific progress in areas of sepsis has been continuing throughout 2003, although the challenges are still enormous. The identification of more specific markers and new therapeutic approaches will hopefully improve the diagnosis, monitoring of therapy, and outcome in the septic patient.

Statins and sepsis: multiple modifications at multiple levels

Sepsis, an infection-induced inflammatory syndrome, is a leading and increasing cause of mortality worldwide. Animal and human observational studies suggest statins may prevent the morbidity and mortality associated with the sepsis syndrome. In this Review, we describe the demonstrated mechanisms through which statins modulate the inflammatory response associated with sepsis. These mechanisms include effects on cell signalling with consequent changes at the transcriptional level, the induction of haem oxygenase, the direct alteration of leucocyte-endothelial cell interaction, and the reduced expression of MHC II. Since statins do not target individual inflammatory mediators, but possibly reduce the overall magnitude of the systemic response, this effect could prove an important distinguishing feature modulating the host response to septic insults. This work establishes the biological plausibility needed for future trials of statins in critical illness.

Systemic Inflammation and Repair of Abdominal Aortic Aneurysm

BACKGROUND

Inflammation is integral to the pathogenesis of abdominal aortic aneurysm (AAA). This study examines preoperative biomarkers of systemic inflammation in patients undergoing open repair of intact and ruptured AAA.

METHODS

One-hundred twelve patients were entered into a prospective observational study. Preoperative POSSUM physiology score, C-reactive protein (CRP), white blood count (WBC), platelet count, fibrinogen, and albumin were recorded and related to clinical variables using univariate analysis.

RESULTS

Sixty-one patients with a ruptured AAA, 39 with an asymptomatic intact AAA, and 12 with an acutely symptomatic intact AAA underwent attempted repair. There were two inflammatory asymptomatic aneurysms and one inflammatory ruptured aneurysm. No patient had clinical evidence of coexistent inflammatory disease. Patients with a symptomatic intact AAA had a significantly greater level of CRP and fibrinogen, higher WBC, and lower serum albumin, than those with an asymptomatic intact AAA. Patients with a ruptured aneurysm had a significantly greater level of CRP, higher WBC, and lower serum albumin than those with an asymptomatic intact aneurysm. Patients with a symptomatic intact AAA had a significantly higher CRP level, but lower WBC, than those with a ruptured AAA. There was no difference in CRP level, WBC, or serum albumin between survivors and non-survivors of attempted repair of asymptomatic, symptomatic and ruptured AAA.

CONCLUSIONS

Acutely symptomatic and ruptured AAAs are associated with an early elevation in systemic inflammatory biomarkers. This early activation of the inflammatory response might influence perioperative outcome.

Polymorphism of the C-reactive protein gene is associated with mortality in bacteraemia

C-reactive protein (CRP) is an important molecule in the defence against bacterial infections. To discover if variation in the CRP gene is associated with clinical outcome of bacteraemia, we investigated 147 microbiologically verified bacteraemia patients (mean age 59 y, range 19-93 y) and determined whether CRP -717A>G, +1059G>C or +1444C>T single nucleotide polymorphisms (SNPs) were associated with clinical outcome of bacteraemia and/or CRP concentration caused by Staphylococcus aureus, Streptococcus pneumoniae, beta-haemolytic streptococci or Escherichia coli. The patients were genotyped for CRP gene polymorphisms, CRP was measured and clinical outcomes were recorded. The CRP -717A>G, a promoter region polymorphism was strongly associated with mortality from Streptococcus pneumoniae but did not correlate with plasma CRP concentration. These results suggest that mortality from Streptococcus pneumoniae may be associated with polymorphism of the promoter region of the CRP gene.

Inflammatory markers in patients with severe burn injury. What is the best indicator of sepsis?

OBJECTIVE

To estimate the diagnostic value of serum PCT, CRP, leukocyte count and temperature as markers of sepsis in critically ill ICU burn patients.

DESIGN AND SETTING

Prospective, observational study in a four bed Burn Intensive Care Unit.

PATIENTS

Forty-three patients admitted in a Burn ICU were included in our study.

MEASUREMENTS AND RESULTS

Serum PCT, CRP concentrations, WCC (white cell count), neutrophils and temperature were measured within the first 24h after-burn and daily thereafter. Severity of organ failure was estimated by sequential organ failure assessment (SOFA) score. Every day we classified all patients in one of the following three categories: non-systemic inflammatory condition (non-SIRS), SIRS non-infected and SIRS 2 infected or sepsis. Patients with infected SIRS differ significantly from non-infected SIRS in PCT (11.8+/-15.8 versus 0.63+/-0.0.43, respectively, p < 0.001). On the other hand, WCC, temperature and neutrophils did not differ significantly between patients with SIRS non-infected and infected SIRS. CRP was elevated in all three groups but didn't differ significantly between SIRS non-infected and septic patients. Area under receiver operating curves was 0.975 and showed reasonable discriminative power (p = 0.002, 95% CI, 0.91-1.035) in predicting of sepsis only for PCT.

CONCLUSIONS

Serum procalcitonin levels can be used as an early indicator of septic complication in patients with severe burn injury.

Plasma DNA concentration as a predictor of mortality and sepsis in critically ill patients

Introduction

Risk stratification of severely ill patients remains problematic, resulting in increased interest in potential circulating markers, such as cytokines, procalcitonin and brain natriuretic peptide. Recent reports have indicated the usefulness of plasma DNA as a prognostic marker in various disease states such as trauma, myocardial infarction and stroke. The present study assesses the significance of raised levels of plasma DNA on admission to the intensive care unit (ICU) in terms of its ability to predict disease severity or prognosis.

Methods

Fifty-two consecutive patients were studied in a general ICU. Blood samples were taken on admission and were stored for further analysis. Plasma DNA levels were estimated by a PCR method using primers for the human β-haemoglobin gene.

Results

Sixteen of the 52 patients investigated died within 3 months of sampling. Nineteen of the 52 patients developed either severe sepsis or septic shock. Plasma DNA was higher in ICU patients than in healthy controls and was also higher in patients who developed sepsis (192 (65–362) ng/ml versus 74 (46–156) ng/ml, P = 0.03) or who subsequently died either in the ICU (321 (185–430) ng/ml versus 71 (46–113) ng/ml, P < 0.001) or in hospital (260 (151–380) ng/ml versus 68 (47–103) ng/ml, P < 0.001). Plasma DNA concentrations were found to be significantly higher in patients who died in the ICU. Multiple logistic regression analysis determined plasma DNA to be an independent predictor of mortality (odds ratio, 1.002 (95% confidence interval, 1.0–1.004), P = 0.05). Plasma DNA had a sensitivity of 92% and a specificity of 80% when a concentration higher than 127 ng/ml was taken as a predictor for death on the ICU.

Conclusion

Plasma DNA may be a useful prognostic marker of mortality and sepsis in intensive care patients.

Initial and delayed onset of acute respiratory failure: factors associated with development and outcome

In a prospective observational study of 1038 adult admissions to a 31-bed medical/surgical intensive care unit (ICU), acute respiratory failure (ARF, defined as a Pao(2)/Fio(2) ratio <or=200 mm Hg and the need for respiratory support) occurred in 182 (58%) of the 313 admissions with an ICU stay of more than 48 h. Initial ARF (onset within 48 h of ICU admission) occurred in 133 (42%) patients, and delayed onset ARF (onset >48 h after ICU admission) in 49 (16%). On admission, the cardiovascular sequential organ failure assessment (SOFA) score was higher in initial than in delayed onset ARF (1.1 +/- 1.5 vs 0.6 +/- 1.2, P < 0.05). High admission serum C-reactive protein concentrations (OR 1.08, 95% CI 1.04-1.12, P = 0.0001) and SOFA scores (OR 1.20, 95% CI 1.08-1.33, P = 0.0007) were the factors independently associated with initial ARF, and a low Glasgow coma scale (GCS) score (OR 1.13, 95% CI 1.04-1.21, P = 0.0018) was associated with delayed onset ARF. In initial ARF, a high SOFA score (OR 1.24, 95% CI 1.12-1.38, P = 0.0001) and a low GCS score (OR 0.89, 95% CI 0.83-0.96, P = 0.0013) on admission, and in delayed onset ARF, a low GCS score at 48 h (OR 0.67, 95% CI 0.54-0.84, P = 0.0011) were independently associated with death. The mortality rate was similar for initial and delayed onset ARF.

C-reactive protein concentration as a predictor of intensive care unit readmission: a nested case-control study

PURPOSE

The purpose of this study is to assess the ability of potential clinical predictors and inflammatory markers to predict intensive care unit (ICU) readmission during the same hospitalization.

MATERIALS AND METHODS

A nested case-control study utilized prospectively collected de-identified data of a 22-bed multidisciplinary ICU in a university hospital.

RESULTS

There were 1,405 consecutive ICU admissions in 2004, and of these, 18 were regarded as ICU readmissions (1.3%). The destination and timing of ICU discharge, the Sequential Organ Failure Assessment scores, white cell counts, and fibrinogen concentrations at discharge were not associated with ICU readmission. C-reactive protein (CRP) concentration within 24 hours before ICU discharge was associated with ICU readmission (mean CRP concentrations of cases vs controls, 177.8 vs 56.5 mg/L, respectively; P < .0001). The results remained unchanged after adjustment with the propensity scores. The area under the receiver operating characteristic curve for the CRP concentrations to predict ICU readmission was 0.884 (95% confidence interval, 0.765-0.999; P < .0001). Patients readmitted to the ICU had a higher predicted mortality in their second ICU admission (34.9% vs 26.1%; P < .01) and a longer total hospital stay (33.3 vs 20.3 days; P < .003) than patients without ICU readmission.

CONCLUSIONS

A high CRP concentration within 24 hours before ICU discharge is associated with a higher risk of readmission to the ICU.

Persistent Changes in Interleukin-6 and Lower Extremity Function Following Hip Fracture

BACKGROUND

A hip fracture often heralds a period of functional decline in elderly persons. Although an inflammatory reaction would be expected following a hip fracture, whether the degree of this response is associated with adverse functional outcomes is unknown.

METHODS

In a cohort from the Baltimore Hip Studies, women aged 65 years or older with a hip fracture were evaluated at 3 or 10 days (baseline) and 2, 6, and 12 months (follow-up) postfracture. Serum was analyzed for interleukin-6 (IL-6) level. A score of timed performance of 9 tasks, the Lower Extremity Gain Scale (LEGS) was calculated at each evaluation. We divided participants into tertiles based on their cytokine levels at 2, 6, and 12 months, and examined the LEGS score trajectories as a function of IL-6 tertile using generalized estimating equations, adjusting for age, prefracture function, body fat, pain, cognitive function, type of surgical repair, the number of in-hospital complications, and the number of comorbid medical conditions.

RESULTS

At baseline, 2, 6, and 12 months, respectively, 149, 95, 101, and 82 participants provided serum samples; of these participants 65, 78, and 59 also provided a LEGS measure at 2, 6, and 12 months, respectively. At 12 months postfracture the median (interquartile range) of serum IL-6 levels was 7.4 (4.0, 15.9) pg/mL. Participants in the lowest tertile of IL-6 level performed better on the LEGS than did those in the highest tertile (p =.008). At 12 months postfracture, participants in the lowest tertile scored 5.3 points better (95% confidence interval, 2.0-8.6) on the LEGS than did those in the highest tertile (p =.002).

CONCLUSIONS

Higher IL-6 levels are adversely associated with recovery of lower extremity function after hip fracture. Factors that predict cytokine response and the potential mechanisms by which this effect is mediated warrant further study.

Extremely elevated C-reactive protein

BACKGROUND

C-reactive protein (CRP) is a widely used inflammatory marker. Yet, the clinical significance and outcome of extremely elevated CRP levels are poorly characterized.

METHODS

We collected all patients seen at a university hospital in 2004 with at least one CRP level above 500 mg/l and retrospectively analyzed their electronic files, focusing on patient characteristics, clinical diagnosis, microbiology and vital outcome.

RESULTS

CRP was above 500 mg/l in 130 patients with a median age of 62 years. Patient characteristics, settings, etiologies of inflammation, comorbidities and microbiology varied widely. Infections, mainly bacterial, accounted for 88% of episodes. Outcome was fatal in 36% of all patients and in 61% of patients with active malignancies.

CONCLUSION

A wide variety of infections, especially bacterial, that are generally readily identified account for the majority of instances of extreme CRP elevation. Mortality is high, certainly in oncological patients.

Viral load and outcome in SARS infection: the role of personal protective equipment in the emergency department

This study was conducted to evaluate the effectiveness of personal protective equipment (PPE) against severe acute respiratory syndrome (SARS). Sixteen patients in a SARS cluster, including 4 health care workers (HCWs) and 12 non-HCWs were studied. We compared the initial viral load by nasopharyngeal swabs, clinical progression, and outcome of this cluster. The HCWs had a lower viral load. The non-HCWs had a higher mean C-reactive protein, lower oxygen saturation, and a higher incidence of intubation and death. Secondary household transmission developed in three of the non-HCWs’ families. One month after discharge, non-HCWs had more signs of fibrosis on high resolution computed tomography (HRCT) scan and an impaired pulmonary function test. Although most of the PPE do not confer absolute protection against SARS, it seems that they may lower exposure to the virus, leading to a lower risk of secondary transmission, and be associated with relatively mild disease and a better early outcome.

Prognostic value of serum albumin combined with serum C-reactive protein levels in older hospitalized patients: continuing importance of serum albumin

BACKGROUND AND AIMS

Although both serum albumin and C-reactive protein (CRP) levels are separately recognized as predictors of adverse outcomes in many illnesses, the predictive value of their combination for adverse outcomes has not been evaluated. We therefore sought to examine the prognostic value of serum albumin for in-hospital mortality in the presence or absence of severe inflammation, as indicated by high CRP levels.

METHODS

In this cohort study, we measured serum albumin and CRP levels in 1638 older patients (aged 65 years or older) hospitalized for medical problems, and examined their utility, both separately and in combination, for predicting in-hospital mortality.

RESULTS

In separate analyses of CRP and albumin, both high CRP levels (> or =5 mg/dl) and hypoalbuminemia (<3.5 g/dl) were associated with risk of in-hospital death. After dividing participants into four groups based on CRP and albumin levels (<5 mg/dl CRP and <3.5 mg/dl albumin), subjects with severe inflammation (CRP > or =5 mg/dl) and hypoalbuminemia were associated with an adjusted relative risk (ARR) of 3.8 for in-hospital mortality when compared with the reference (high albumin and low CRP). Even in the absence of severe inflammation, the presence of severe hypoalbuminemia was associated with an ARR of 2.6 for in-hospital mortality, when compared with patients without hypoalbuminemia.

CONCLUSIONS

Both serum CRP and albumin levels are predictors of in-hospital mortality. However, high serum albumin levels may have a protective effect in older patients, regardless of degree of inflammation. Serum albumin levels remain a useful predictor for in-hospital mortality in older hospitalized patients.

Clinical laboratory findings associated with in-hospital mortality

The diagnostic approach and the clinical management of critically ill patients is challenging. The recognition of biomarkers related to in-hospital mortality is of importance for identification of patients at increased risk of death. Many prediction models assessing the severity of illness and likelihood of hospital survival were developed using logistic regression analyses. These models include several laboratory parameters, such as white blood cell counts, serum bilirubin, serum albumin, blood glucose, serum electrolytes and markers which reflect acid-base disturbances. Recently, several other biomarkers, including troponin, B-type natriuretic peptide (BNP), N-terminal proBNP, C-reactive protein, procalcitonin, cholesterol and coagulation related markers have emerged as clinically useful tools for risk stratification and mortality prediction of heterogeneous and more specific subgroups of critically ill patients. More investigations are required to verify whether risk stratification based on mortality-related biomarkers may translate into targeted treatment strategies to improve clinical outcome of the critical illness. Biomarkers which are related to in-hospital mortality are highlighted in the current review.

Prognostic factors in patients with minor troponin-I elevation but without acute myocardial infarction

OBJECTIVES

Although cardiac troponin I is widely used as a marker for myocardial infarction, its minor elevations are also observed in other clinical situations, and the prognostic factors in such clinical settings have not been well established. The aim of this study was to identify predictors of mortality in patients with minor troponin elevations without an acute myocardial infarction.

METHODS

We consecutively enrolled 134 patients from the emergency department with a peak troponin I level greater than the lower limit of detectability (0.04 ng/ml) but less than the 10% coefficient of variation cutoff value for diagnosis of myocardial infarction (0.26 ng/ml). These patients had chest pain or nonspecific symptoms of a circulatory abnormality but lacked the traditional features of an acute myocardial infarction. End point was defined as death from all causes. Cox regression analysis was used to test relations between clinical and biochemical variables and the outcome.

RESULTS

During the follow-up of 7.6+/-7.4 months, 12 patients died. Age, log creatine kinase myocardial isoform, and log C-reactive protein were found to be significantly correlated with death. After adjusting for possible confounders in the multivariate model, age (hazard ratio 1.09, confidence interval 1.02-1.16, P=0.012), log creatine kinase myocardial isoform (hazard ratio 13.11, confidence interval 2.01-85.52, P=0.007), and log C-reactive protein (hazard ratio 1.64, confidence interval 1.02-2.56, P=0.041) were identified as independent predictors of mortality.

CONCLUSIONS

Creatine kinase myocardial isoform and C-reactive protein levels and age can be integrated to risk-stratify patients with minor troponin I elevation for reasons other than acute myocardial infarction.

Do we have reliable biochemical markers to predict the outcome of critical illness?

Current outcome prediction in critically ill patients relies on the art of clinical judgement and/or the science of prognostication using illness severity scores. The biochemical processes underlying critical illness have increasingly been unravelled. Several biochemical markers reflecting the process of inflammation, immune dysfunction, impaired tissue oxygenation and endocrine alterations have been evaluated for their predictive power in small subpopulations of critically ill patients. However, none of these parameters has been validated in large populations of unselected ICU patients as has been done for the illness severity and organ failure scores. A simple biochemical predictor of ICU mortality will probably remain elusive because the processes underlying critical illness are very complex and heterogeneous. Future prognostic models will need to be far more sophisticated.

Endocrine markers of severity and prognosis in critical illness

The cellular processes that unfold in critical illness involve a variety of circulating substances, that may provide clinically relevant insight into the severity and outcome. Among hormonal markers, cortisol, several thyroid-related substances, as well as natriuretic peptides are discussed in this review. Glucose and lipids constitute metabolic markers, the identification and treatment of the former has been of particular importance. Among immune markers, both proinflammatory and anti-inflammatory cytokines, such as interleukin-6, contribute essential prognostic information. Finally, the complement and coagulation pathways also provide unique insight into this complex and heterogeneous process.

What does minor elevation of C-reactive protein signify?

Reports of the predictive value of minor elevation of serum C-reactive protein (CRP) levels (between 3 and 10 mg/L) for atherosclerotic events have generated considerable interest, as well as a degree of controversy and confusion. CRP concentrations in this range are found in about one third of the American population. To better understand the mechanisms underlying minor elevation of CRP, we have surveyed its reported associations with a variety of states and conditions. It has become clear that even minimal environmental irritants and inflammatory stimuli elicit a minor CRP response. Minor CRP elevation has been found associated with a number of genetic polymorphisms, with membership in different demographic and socioeconomic groups, with a variety of dietary patterns and with many medical conditions that are not apparently inflammatory. Finally, minor CRP elevation bears negative prognostic implications for many conditions, particularly age-related diseases, and predicts mortality in both diseased and apparently healthy individuals. In sum, minor CRP elevation is associated with a great many diverse conditions, some of which are, or may prove to be, causal. Many of these reported associations imply a mild degree of tissue stress or injury, suggesting the hypothesis that the presence of distressed cells, rather than a resulting inflammatory response, is commonly the stimulus for CRP production.

Retinol-binding protein, transthyretin, and C-reactive protein in extremely low birth weight (ELBW) infants

BACKGROUND

Vitamin A deficiency reduces retinol binding protein (RBP) but not transthyretin (TTR), while inflammation reduces both RBP and TTR and increases C-reactive protein (CRP), an acute phase reactant.

OBJECTIVE

To estimate serum RBP, TTR, and CRP in ELBW infants to test the hypotheses that (a) TTR is a negative acute phase reactant and (b) a higher RBP/TTR ratio or CRP is associated with death/BPD by 36 weeks corrected age.

DESIGN/METHODS

Serum RBP, TTR, and CRP were measured in 79 ELBW infants at 28 days. Area under the curve (AUC) of receiver operating characteristic curve analysis evaluated the predictive value of TTR, the RBP/TTR ratio, and CRP for death/BPD at 36 weeks.

RESULTS

(1) TTR inversely correlated with CRP (r=-0.45, p<0.0001) consistent with TTR being a negative acute phase reactant. (2) The RBP/TTR ratio predicted death/BPD (AUC 0.68 (CI 0.57 to 0.78)). (3) CRP strongly predicted death/BPD (AUC 0.85 (CI 0.76 to 0.92)), even after exclusion of sepsis.

CONCLUSIONS

A higher CRP and RBP/TTR molar ratio on day 28 are associated with death/BPD at 36 weeks in ELBW infants. Lower TTR and maintained RBP/TTR ratios suggest inflammation rather than vitamin A deficiency as the cause for lower serum vitamin A levels in ELBW infants..

Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity

The pathogenic, diagnostic and therapeutic landscape of sepsis is no longer confined to the intensive care unit: many patients from other portals of entry to care, both outside and within the hospital, progress to severe disease. Approaches that have led to improved outcomes with other diseases (e.g., acute myocardial infarction, stroke and trauma) can now be similarly applied to sepsis. Improved understanding of the pathogenesis of severe sepsis and septic shock has led to the development of new therapies that place importance on early identification and aggressive management. This review emphasizes approaches to the early recognition, diagnosis and therapeutic management of sepsis, giving the clinician the most contemporary and practical approaches with which to treat these patients.

MCP-1 is up-regulated in unstressed and stressed HO-1 knockout mice: Pathophysiologic correlates

BACKGROUND

Up-regulation of heme oxygenase-1 (HO-1) occurs in, and often confers protection to, the injured kidney. Up-regulation of monocyte chemoattractant protein-1 (MCP-1) promotes not only acute and chronic nephritides but also acute ischemic and nephrotoxic injury. The present study was stimulated by the hypothesis that expression of MCP-1 is suppressed by HO-1, and analyzed the effect of HO-1 on the expression of MCP-1 in stressed and unstressed conditions.

METHODS

Expression of MCP-1 and pathophysiologic correlates were examined in HO-1 knockout (HO-1-/-) and wild-type (HO-1+/+) mice in the unstressed state in young and aged mice, and following nephrotoxic and ischemic insults.

RESULTS

In unstressed HO-1-/- mice, plasma levels of MCP-1 protein were elevated, and MCP-1 mRNA expression was increased in circulating leukocytes and in the kidney. Such early and heightened up-regulation of MCP-1 was eventually accompanied by phenotypic changes in the aged kidney consistent with MCP-1, namely, proliferative changes in glomeruli, tubulointerstitial disease, and up-regulation of transforming growth factor-beta1 (TGF-beta1) and collagens I, III, and IV. In response to a nephrotoxic insult such as hemoglobin, MCP-1 mRNA was up-regulated in a markedly sustained manner in HO-1-/- mice. In response to a duration of ischemia that exerted little effect in HO-1+/+ mice, HO-1-/- mice exhibited higher expression of MCP-1 mRNA, enhanced activation of nuclear factor-kappaB (NF-kappaB) (the transcription factor that regulates MCP-1), markedly greater functional and structural renal injury, increased caspase-3 expression, and increased mortality.

CONCLUSION

In the absence of HO-1, expression of MCP-1 is significantly and consistently enhanced in unstressed and stressed conditions. We speculate that the protective effects of HO-1 in injured tissue may involve, at least in part, the capacity of HO-1 to restrain up-regulation of MCP-1.

Clinical review: New technologies -- venturing out of the intensive care unit

The delivery of critical care is no longer limited to the intensive care unit. The information gained by utilization of new technologies has proven beneficial in some populations. Research into earlier and more widespread use of these modalities may prove to be of even greater benefit to critically ill patients.

Transgenic sickle mice are markedly sensitive to renal ischemia-reperfusion injury

Ischemic injury is invoked as a mechanism contributing to end-organ damage and other complications of sickle cell disease (SCD). However, the intrinsic sensitivity of tissues in SCD to ischemic insults has never been addressed. We examined the effect of renal ischemia in a transgenic mouse expressing human sickle hemoglobin. Twenty-four hours after bilateral, total renal artery occlusion for 15 minutes, transgenic sickle mice exhibited worse renal function and more marked histological injury. With bilateral renal ischemia of greater duration (22.5 minutes), and after 6 hours, transgenic sickle mice exhibited massive vascular congestion, sickling of red blood cells, more marked histological injury in the kidney, and more prominent congestion in the capillary beds in the lungs and heart. Additionally, serum amyloid P-component, the murine homologue of C-reactive protein, was markedly increased in transgenic sickle mice as compared to wild-type mice. Twenty-four hours after bilateral renal ischemia for 22.5 minutes, transgenic sickle mice exhibited 28% mortality, with no mortality observed in any other group. With bilateral renal ischemia of short or long duration, renal expression of caspase-3 was most prominent in transgenic sickle mice subjected to ischemia. Thus, renal ischemia in this murine model induces more severe renal injury and extrarenal complications. We conclude that tissues in SCD exhibit heightened vascular congestion and sensitivity to ischemia and that clinically apparent or silent episodes of ischemia may contribute to the complications of SCD.

Pilot study evaluating C-reactive protein levels in the assessment of response to treatment of severe bloodstream infection

We evaluated the usefulness of monitoring daily C-reactive protein (CRP) levels after initiation of antimicrobial therapy in 44 patients with bloodstream infection. The ratio of the CRP level during therapy to the level at the start of antimicrobial therapy (CRP ratio) was measured. A CRP ratio of >0.58 at day 4 of therapy was a marker of poor outcome (sensitivity, 0.89; specificity, 0.69). The recognition of a pattern of CRP-ratio response was useful in the prediction of individual clinical course.

Bacteraemia prediction in emergency medical admissions: role of C reactive protein

AIM

To define the contribution made by C reactive protein (CRP) measurement to bacteraemia prediction in adults with medical emergencies in the UK.

METHODS

This two year cohort study involved 6234 patients admitted as emergency cases to the acute medical or infectious diseases services of the Oxford Radcliffe Hospitals, in whom blood cultures were taken on arrival. The main outcome measures were bacteraemia risk associated with admission CRP concentrations, lymphocyte counts, and neutrophil counts.

RESULTS

The quantitative associations between CRP concentration, admission lymphocyte count, and neutrophil count were defined. Risk of bacteraemia rose continuously as the CRP increased: no "cutoff" value was evident. Models examining combinations of CRP, neutrophil count, and lymphocyte count were developed and validated using a split sample technique. CRP contributed to a model including lymphocyte and neutrophil counts, but its effect was small. CRP alone performed no better than either a model combining lymphopenia and neutrophilia, or than lymphopenia alone.

CONCLUSIONS

In patients with acute medical emergencies who are suspected of bacteraemia clinically, CRP concentrations, although associated with bacteraemia, have a limited role in bacteraemia prediction.

C-reactive protein as a marker of infection in critically ill patients

A prospective, observational study was conducted in a medico-surgical intensive care unit to assess the value of C-reactive protein (CRP), temperature and white cell count (WCC) measurements for the diagnosis of infection in critically ill patients. CRP, temperature and WCC were monitored daily in 76 infected and 36 non-infected patients. Multiple receiver-operating characteristics (ROC) curves were used to compare each parameter for infection diagnosis. The area under the curve (AUC) of CRP was significantly higher than that of temperature (0.93 and 0.75, respectively; p < 0.001). A CRP concentration of >8.7 mg/dL and a temperature of >38.2 degrees C were associated with infection, with a sensitivity of 93.4% and 54.8%, and a specificity of 86.1% and 88.9%, respectively. The ROC curve of WCC showed a poor diagnostic performance. The combination of CRP and temperature increased the specificity for infection diagnosis to 100%. In the subgroup of patients with ventilator-associated pneumonia (n = 48), CRP measurements were more reliable than temperature (AUC 0.92 and 0.78, respectively; p 0.006). The CRP levels in infected patients with sepsis, severe sepsis and septic shock were 15.2 +/- 8.2, 20.3 +/- 10.9 and 23.3 +/- 8.7 mg/dL, respectively (p 0.044). It was concluded that CRP was a better marker of infection than temperature. However, the combination of CRP and temperature measurements further increased the specificity for infection diagnosis, even in the subgroup of patients with VAP.

Clinical characteristics, management and prognostic factors in patients with probable severe acute respiratory syndrome (SARS) in a SARS center in Taiwan

BACKGROUND

Severe acute respiratory syndrome (SARS) is an emerging viral infectious disease. We report our experience in treating SARS patients.

METHODS

From April 27 to May 24, 2003, a total of 36 patients with probable SARS were admitted and treated in a hospital rearranged as a special center for the management of SARS patients. Medical records for the patients were retrospectively reviewed. Univariate and multivariate analyses were performed to determine factors associated with respiratory failure and intubation.

RESULTS

Of the 36 patients with probable SARS (median age, 37 years; range, 22-66 years), 9 were male and 27 were female. Thirty-two patients (88.9%) were infected in the hospital setting. All patients presented with fever, and 33 eventually developed lymphopenia during hospitalization. Chest radiography showed no unique pattern, but pleural effusion was not seen. All patients initially received empiric antibacterial therapy against common causative pathogens of atypical pneumonia. Ribavirin was given to all except 1 patient. Twenty-two patients received immunoglobulin therapy, and 32 were given corticosteroids. A total of 20 patients (55.6%) required supplemental oxygen, and 8 (22.2%) were intubated with mechanical ventilatory support. Two of these patients died. A higher body temperature at presentation (median 39.5 vs 38.6 degrees C), and higher peak values of lactate dehydrogenase (410 vs 282 U/L) and C-reactive protein (10.2 vs 2.5 mg/dL), were associated with subsequent respiratory failure. Multivariate analysis showed that peak level of C-reactive protein was the only independent predictor of respiratory failure and intubation (odds ratio for every increment of 1 mg/dL = 1.45; 95% confidence interval = 1.003, 2.097; p = 0.048).

CONCLUSION

All patients with probable SARS who were admitted to hospital presented with fever and lymphopenia. While the efficacy of different treatments could not be evaluated from this retrospective study, a higher value of C-reactive protein was associated with the development of respiratory failure and subsequent intubation.

Management of severe sepsis and septic shock

PURPOSE OF REVIEW

Severe sepsis and septic shock are common and deadly conditions for which the epidemiology, pathogenesis, and management continue to evolve. Recent publications (2003 and early 2004) have been systematically reviewed for important new original research and scholarly reviews, with an emphasis on clinical advances in adults.

RECENT FINDINGS

Important new epidemiologic studies establish the increasing frequency (nearly 9% per year) and falling mortality rates associated with sepsis. Sepsis definitions were reviewed by a group of experts, and the principal features of the 1991 consensus conference definitions were supported, with a new framework for evaluation of sepsis proposed. New research and thoughtful reviews continue to elucidate the pathogenesis of sepsis, with emphasis on innate immunity and time-based changes in immune status, varying from hyperreactive immunity and inflammation to immune depression with enhanced risk for nosocomial infections. A comprehensive evidence-based approach to the management of severe sepsis is presented in an important document developed by representatives from many critical care and infectious disease societies. Management includes early targeted resuscitation, broad empiric antibiotic coverage and source control, effective shock evaluation and treatment, adjuvant therapy with recombinant human activated protein C and moderate-dose hydrocortisone in selected patients, and comprehensive supportive care. Recently published multicenter clinical trials for novel agents have been disappointing, particularly for a nitric oxide synthase inhibitor that effectively supported blood pressure but increased mortality.

SUMMARY

The works reviewed reflect the advances in the care of patients with sepsis.

Relationship between CRP and hypofibrinolysis: Is this a possible mechanism to explain the association between CRP and outcome in critically ill patients?

Background-

Endothelial cell dysfunction may be implicated in the development of multiple organ failure (MOF) by a number of mechanisms. Among these, altered fibrinolysis promotes fibrin deposition, which may create microvascular alterations during inflammation. Elevated concentrations of C-reactive protein (CRP), especially when these persist over time, are correlated with an increased risk of MOF and death. CRP may inhibit fibrinolysis by inducing plasminogen activator inhibitor-1 (PAI-1) release from human aortic endothelial cells. Moreover, the administration of recombinant CRP in volunteers may increase circulating PAI-1 levels.

In this study, we tested the hypothesis that CRP is associated with hypofibrinolysis in intensive care patients with and without sepsis.

Methods-

We studied the association of inflammation and abnormal fibrinolysis in intensive care unit (ICU) patients with (n = 11) and without (n = 21) sepsis. The inflammatory response was assessed by serum concentration of C-reactive protein (CRP), a marker of the acute phase reaction, which increase rapidly in the inflammatory response, and the plasma fibrinolytic capacity was evaluated by the Euglobulin Clot Lysis Time (ECLT), determined by a new semi-automatic method.

Results-

ECLT was significantly higher in septic than non-septic patients (1104 ± 439 vs 665 ± 275 min; p = 0.002) and was significantly correlated with CRP concentration (R² = 0.45; p < 0.001). In a multivariate analysis, CRP was the strongest predictor of ECLT (R² = 0.51, F = 25.6, p < 0.001). In addition, the overall ICU length of stay was significantly correlated with CRP (R² = 0.264, p = 0.003) and ECLT (R² = 0.259, p = 0.003).

Conclusion-

In critically ill patients a significant correlation thus exists between plasma fibrinolytic capacity and serum CRP levels. Our data were obtained in the first 24 hours of ICU admission or of sepsis, thus, the relation between CRP and hypofibrinolysis appeared very quickly. This finding is compatible with a link between inflammation and abnormal fibrinolysis, and may explain the negative prognostic value of CRP in critically ill patients.

C-reactive protein used as an early indicator of infection in patients with systemic inflammatory response syndrome

OBJECTIVE

To assess the diagnostic value of a single determination of serum C-reactive protein as a marker of sepsis in critically ill patients.

DESIGN

Prospective, observational study.

SETTING

Intensive care unit of a university hospital.

PATIENTS AND PARTICIPANTS

One hundred twenty-five adult patients with systemic inflammatory response syndrome (SIRS) (55 patients without evidence of infection and 70 patients with the diagnosis of sepsis confirmed by documented infection). Twenty-five patients with non-complicated acute myocardial infarctions (AMI) and 50 healthy volunteers were used as controls.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Serum C-reactive protein concentration was measured within the first 24 h of SIRS onset. Healthy subjects, AMI and non-infectious SIRS patients showed lower C-reactive protein median values ([(0.21 [95% confidence intervals (95% CI), 0.21-0.4] mg/dl, 2.2 [95% CI, 2.1-4.9] mg/dl and 1.7 [95% CI, 2.4-5.5] mg/dl, respectively) than patients with sepsis (18.9 [95% CI, 17.1-21.8]), p<0.001. The presence of severe sepsis ( r(s)=0.27; p=0.03), SOFA score ( r(s)=0.25; p=0.03) and arterial lactate ( r(s)=0.24; p=0.04) correlated significantly with C-reactive protein concentrations in sepsis cases. The best threshold value for C-reactive protein for predicting sepsis was 8 mg/dl (sensitivity 94.3%, specificity 87.3%). The area under the receiver-operating characteristic curve for C-reactive protein was 0.94 (95% CI, 0.89-0.98).

CONCLUSIONS

Determination of serum C-reactive protein can be used as an early indicator of infection in patients with SIRS.

Optimum treatment of severe sepsis and septic shock: evidence in support of the recommendations

Severe sepsis and septic shock are among the most common causes of death in noncoronary intensive care units. The incidence of sepsis has been increasing over the past two decades, and is predicted to continue to rise over the next 20 years. While our understanding of the complex pathophysiologic alterations that occur in severe sepsis and septic shock has increased greatly asa result of recent clinical and preclinical studies, mortality associated with the disorder remains unacceptably high. Despite these new insights, the cornerstone of therapy continues to be early recognition, prompt initiation of effective antibiotic therapy, and source control, and goal-directed hemodynamic, ventilatory,and metabolic support as necessary. To date, attempts to reduce mortality with innovative, predominantly anti-inflammatory therapeutic strategies have been extremely disappointing. Observations of improved outcomes with physiologic doses of corticosteroid replacement therapy and activated protein C (drotrecogin alfa[activated]) have provided new adjuvant therapies for severe sepsis and septic shock in selected patients. This article reviews the components of sepsis management and discusses the available evidence in support of these recommendations. In addition, there is a discussion of some promising new strategies.

Procalcitonin and C-reactive protein during systemic inflammatory response syndrome, sepsis and organ dysfunction

Introduction

Both C-reactive protein (CRP) and procalcitonin (PCT) are accepted sepsis markers. However, there is still some debate concerning the correlation between their serum concentrations and sepsis severity. We hypothesised that PCT and CRP concentrations are different in patients with infection or with no infection at a similar severity of organ dysfunction or of systemic inflammatory response.

Patients and methods

One hundred and fifty adult intensive care unit patients were observed consecutively over a period of 10 days. PCT, CRP and infection parameters were compared among the following groups: no systemic inflammatory response syndrome (SIRS) (n = 15), SIRS (n = 15), sepsis/SS (n = 71) (including sepsis, severe sepsis and septic shock [n = 34, n = 22 and n = 15]), and trauma patients (n = 49, no infection).

Results

PCT and CRP concentrations were higher in patients in whom infection was diagnosed at comparable levels of organ dysfunction (infected patients, regression of median [ng/ml] PCT = -0.848 + 1.526 sequential organ failure assessment [SOFA] score, median [mg/l] CRP = 105.58 + 0.72 SOFA score; non-infected patients, PCT = 0.27 + 0.02 SOFA score, P < 0.0001; CRP = 84.53 - 0.19 SOFA score, P < 0.005), although correlation with the SOFA score was weak (R = 0.254, P < 0.001 for PCT, and R = 0.292, P < 0.001 for CRP). CRP levels were near their maximum already during lower SOFA scores, whereas maximum PCT concentrations were found at higher score levels (SOFA score > 12).

PCT and CRP concentrations were 1.58 ng/ml and 150 mg/l in patients with sepsis, 0.38 ng/ml and 51 mg/l in the SIRS patients (P < 0.05, Mann–Whitney U-test), and 0.14 ng/ml and 72 mg/l in the patients with no SIRS (P < 0.05). The kinetics of both parameters were also different, and PCT concentrations reacted more quickly than CRP.

Conclusions

PCT and CRP levels are related to the severity of organ dysfunction, but concentrations are still higher during infection. Different sensitivities and kinetics indicate a different clinical use for both parameters.

[C-reactive protein as an indicator of the severity of war injuries]

During the general reaction to trauma, acute phase proteins are synthetized. The aim of the prospective study was to determine CRP concentrations in sera of war casualties during the first 14 posttraumatic days, and to establish the correlation between these changes and severity of trauma. Subjects were 79 war casualties.

CONTROLS

33 blood donors.

METHODS

Injury severity was determined according to ISS and CRP concentrations with immunonephelometric analysis. Blood samples were collected 12 hours after trauma, then on the 1st, 2nd, 5th and 14th posttraumatic day. In war casualties CRP values were significantly increased (56.257.53 mg/dl after 12 hrs, 107.0976.08 on 1st, 144.3570.23 on 2nd, 71.42558.66 on 5th and 37.656.14 on 14th posttraumatic day; p). Significant differences were observed between groups with ISS and ISS12 (p) in first two days and later between group with ISS24 (144.1766.94 mg/dl on 5th and 111.588.5 on 14th posttraumatic day) and others (p).

CONCLUSIONS

During the acute-phase response to trauma, significant changes in concentration of CRP occur in sera of war casualties. These changes are the most prominent during the first 48 hours, with tendency for normalization after the 5th day. Intensity of these changes depend on the severity of trauma. CRP is valid marker of war wound severity.