ELEVATED CARBOHYDRATE-DEFICIENT TRANSFERRIN PREDICTS PROLONGED INTENSIVE CARE UNIT STAY IN TRAUMATIZED MEN

0 Trauma and Reconstructive Surgery 1 Departments of Anaesthesiology and Operative Intensive Care Medicine, 'Neurology 2 General Surgery, Benjamin Franklin Medical Centre, Free University of Berlin , Hindenburgdamm 30, D-12200 Berlin and institute of Forensic Medicine. Charite, Humboldt-University of Berlin , Germany Carbohydrate-deficient transferrin (CDT) is reported to have a higher specificity in alcoholism than conventional markers. As the morbidity and mortality rates amongst chronic alcoholics are raised following trauma, the objective was to investigate if CDT could be used to predict prolonged intensive care unit (ICU) stay and an increased morbidity in patients with multiple injuries admitted to the ICU. In this prospective double-blind study, 66 traumatized male patients were transferred to the ICU following admission via the emergency room and operative management. Blood samples for CDT determination were taken upon admission to the emergency room, the ICU and on days 2 and 4 following admission. The patients were allocated a priori to two groups: high CDT group (CDT >20U/l on admission to the emergency room) and low CDT group (CDT <20 U/l). CDT values were determined by microanion-exchange chromatography and radioimmunoassay. Thirty-six patients had an elevated CDT value on admission to the emergency room. The high CDT group had a significantly prolonged ICU stay (median high CDT group: 13 days; median low CDT group: 5 days). Major intercurrent complications, such as alcohol-withdrawal syndrome, tracheobronchitis. pneumonia, pancreatitis, sepsis, and congestive heart failure, were significantly increased in the high CDT group The increased risk of pneumonia in the high CDT group may be related to the significantly increased period of mechanical ventilation. As high CDT values were associated with an increased risk of intercurrent complications and a prolonged ICU stay, it seems reasonable to use CDT as a marker in intensifying research work into preventing alcoholism-associated complications. - INTRODUCTION Almost half of all trauma beds are occupied by patients who have been injured while under the influence of alcohol (Gentilello et al., 1995). The prevalence of chronic alcoholics among traumatized patients admitted to the intensive care unit (ICU) is reported to range from 23 to 68% (Herve et al., 1986; Spies et al., 1996a). A subsequent intensive care stay may be complicated by the development of alcoholism-related complications. In ICU wards, the rate of morbidity and mortality is reported to be two to four times greater in chronic alcoholics (Jensen et al., 1988; Spies et al., 1996a). The incidence of infections, cardiopulmonary insufficiency, and alcohol-withdrawal syndrome has been noted to be increased in traumatized men admitted to the ICU (Spies et al., Author to whom correspondence should be addressed. 1996a). Chronic alcoholics have been reported to have an altered immune status (Jerrells, 1993; Wang et al., 1994), which may play a role in the development of infections during ICU stay. The occurrence of post-traumatic alcoholismrelated complications illustrates the importance of the precise diagnosis of alcoholism. An alcoholrelated history and completed questionnaires on alcoholism (Selzer et al., 1975; Ewing, 1984; American Psychiatric Association, 1987) are frequently unobtainable in cases of traumatized patients, owing to their injuries and subsequent intubation. Therefore, laboratory tests with sufficient sensitivity and specificity, such as carbohydrate-deficient transferrin (CDT), may assist in the diagnosis and the possible prevention of these complications. A regular intake of alcohol results in increased levels of transferrin isoforms (Stibler, 1991). These are deficient of carbohydrate and have an elevated isoelectric point. A chronic daily intake of more than 50 to 80 g of alcohol for longer than a week is reported to increase CDT levels. The half-life of CDT has been reported to be approximately 2 weeks (Stibler, 1991), but in intensive care patients it has been reported to be much shorter (Spies et al., 1995). The objective of this study was to investigate whether an elevated CDT value on admission to the ICU can predict a prolonged ICU stay (primary outcome measure) and whether CDT is a predictor of intercurrent complications (secondary outcome measure). SUBJECTS AND METHODS Patients This prospective double-blind controlled clinical trial comprised the study of 66 male traumatized patients following their admission to the emergency room and transfer to the ICU for further medical care. The inclusion criteria for admission to the ICU consisted of the necessity for mechanical ventilation or observation/therapy due to the risk of organ failure or rupture. Patients were included in the study according to the concept of deferred consent (Biros et al., 1995; Levine, 1995) i.e. patients or their relatives provided their written informed consent to participate in this institutionally approved study (Review Board: Ethical Committee of the Benjamin Franklin Medical School, Free University of Berlin). The study was conducted over a period of 18 months. Basic patient characteristics were documented (Table 1); these included age, height, weight, Trauma Score and Injury Severity Score (TRISS) (Parr and Grande, 1993), and Acute Physiology and Chronic Health Evaluation score (APACHE II) (Knaus et al., 1985). Women and patients under 18 years of age were excluded from the study. Women were excluded because the prevalence of alcoholism in traumatized women is reported to be lower, whereas CDT values are reportedly higher (Stibler, 1991). The following were also excluded: patients who had received a blood transfusion or more than 2 1 fluid replacement prior to inclusion and patients with liver cirrhosis (Child B or C, liver biopsy) or severe head injury requiring barbiturate coma or hypothermia. The patient's history was obtained from the patient or the relatives along with the results of alcoholism-related questionnaires, the CAGE Questionnaire and the short Michigan Alcoholism Screen Test (sMast) (Selzer et al., 1975; Ewing, 1984). A chronic alcoholic was defined according to the DSM-III-R criteria (American Psychiatric Association, 1987). Patients with a CAGE = 0, a sMAST <1 and a daily alcohol intake <20g were considered as non-alcoholics, all others who failed to meet the above-mentioned criteria were characterized as social drinkers. A total of 156 consecutive patients were seen in the emergency room. Thirty-eight patients or their relatives refused to give their consent to participate in this study. A further 19 patients received a fluid replacement of more than 2 1 or a blood transfusion prior to CDT sampling in the emergency room, and were therefore excluded owing to the fact that CDT sensitivity and specificity may have been influenced (Spies et al., 1995). A further 27 patients were also excluded, because they were not admit (...truncated)