El manual 76

N Ruiz-Vera1_{, MJ Antolino-Martinez}2_{, A Gonzalez-Lisorge}2_, C Garcia-Palenciano2_{, T Sansano-Sanchez}2_{, F Acosta-Villegas}2

1_{University Hospital, Murcia, Spain;} 2_{University Hospital ‘Virgen de la Arrixaca’,} Murcia, Spain

Critical Care 2011, 15(Suppl 1):P275 (doi: 10.1186/cc9695)

Introduction N-terminal pro-BNP (pBNP) could be useful to predict outcome in severe sepsis. We have conducted a study to compare pBNP and procalcitonin (PCT) in the setting of abdominal severe sepsis or septic shock.

Methods We performed a prospective study of 51 consecutive patients with abdominal severe sepsis or septic shock. Age, gender, APACHE II score at admission, in-unit survival, presence of septic shock and serum PCT and pBNP levels during 4 days after admission were determined. Statistics: chi-square test, Student’s t test, Mann–Whitney’s test for samples without normal distribution and Cox’s logistic regression. P <0.05 was considered statistically signifi cant.

Results The mean APACHE II score at admission was 20.52 ± 5.07. This value was found to be signifi cantly higher in nonsurvivors (18.38 ± 4.56 vs. 24.00  ±  4.03, P <0.05). Values of pBNP were signifi cantly higher in nonsurvivors from the fi rst day of the study. PCT levels were higher in nonsurvivors, but only reached statistically signifi cance on day 2 (Table 1). These results were not found to be infl uenced by age, gender or presence of shock in multivariate analysis.

Conclusions Our results shown that pBNP could be more useful than PCT to discriminate the patients with abdominal severe sepsis and worse outcome.

References

1. Phua J, et al.: Shock 2008, 29:328-333.

2. Verdier B, et al.: Ann Fr Anesth Reanim 2008, 27:135-140. 3. Delerme S, et al.: Biomark Insights 2008, 3:203-217.

P276

Prognostic value of proadrenomedullin in severe sepsis and septic shock patients with community-acquired pneumonia

B Suberviola, A Castellanos, L García Astudillo, D Iglesias, F Ortiz Melon University Hospital Marques de Valdecilla, Santander, Spain

Critical Care 2011, 15(Suppl 1):P276 (doi: 10.1186/cc9696)

Introduction Community-acquired pneumonia (CAP) is the leading cause of death from infectious disease in western countries and supposes an important consumption of healthcare resources. Several studies suggest that proADM is possibly as good as validated severity scores in detecting critically ill patients with CAP and probably better than other biomarkers like procalcitonin (PCT).

Methods A single-centre prospective study between January 2009 and September 2009. Eligible patients were all consecutive adult patients, age 17 or older, admitted to the ICU with both a clinical and radiologic diagnosis of pneumonia as per Fine and colleagues, and meeting criteria for severe sepsis or septic shock. Venous blood samples were obtained at admission on the ICU and collected in tubes containing EDTA. After centrifugation, they were kept frozen at –80°C until assayed. MR-proADM, PCT and C-reactive protein (CRP) were measured in these samples.

Results In all cases, proADM values at ICU admission were pathological. ProADM consistently rose as PSI class advanced from II to V (P = 0.02). Diff erences across PSI class were not signifi cant for CRP (P = 0.73) and PCT (P = 0.12). Median proADM levels were higher (P = 0.007) in hospital nonsurvivors (8.1  ±  9.2 nmol/l) versus survivors (3.0  ±  3.2 nmol/l). These diff erences were also signifi cant with respect to ICU mortality (9.9  ±  10.4 vs. 3.2  ±  3.2 nmol/l; P  =  0.001). The receiver-operating characteristic curve for proADM yielded an AUC of 0.72; better than the AUC for PCT and CRP (0.40 and 0.44, respectively) and similar to PSI (0.74).The optimal prognostic cut-off (maximum combined sensitivity and specifi city) related to in-hospital mortality for proADM was 4.86 nmol/l, with a sensitivity of 0.53, specifi city of 0.84, positive likelihood ratio of 3.39, negative likelihood ratio of 0.56, positive predictive value of 64.3 and negative predictive value of 77.1. Those patients with a proADM level higher than 4.86 nmol/l on ICU admission had an in- hospital mortality signifi cantly higher than those with lower value. Conclusions ProADM levels on ICU admission predict the severity and outcome of severe sepsis and septic shock CAP with a similar prognostic accuracy as the PSI and a higher prognostic accuracy compared with commonly measured laboratory parameters.

P277

Infl uence of TIMP-1/MMP-9 ratio on the severity and mortality in sepsis

L Lorente1_{, MM Martín}2_{, J Solé-Violán}3_{, J Blanquer}4_{, L Labarta}5_{, C Díaz}6_, JM Borreguero-León1_{, JA Páramo}7

1_{Hospital Universitario de Canarias, La Laguna, Spain;} 2_{Hospital Universitario} Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain; 3_Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain; 4_{Hospital Clínico} Universitario de Valencia, Spain; 5_{Hospital San Jorge, Huesca, Spain;} 6_Hospital Insular, Las Palmas de Gran Canaria, Spain; 7_{CIMA-Universidad de Navarra,} Pamplona, Spain

Critical Care 2011, 15(Suppl 1):P277 (doi: 10.1186/cc9697)

Introduction The role of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) in sepsis remains unclear. MMPs play a role facilitating the recruitment of leucocytes from the bloodstream (by proteolysis of the basement membrane) and modulating infl ammatory response [1]. Besides, there has been reported a positive association between circulating levels of TIMP-1 and plasminogen activator inhibitor (PAI)-1 in healthy adults [2] and myocardial infarction [3]. In addition there are in vitro studies showing that MMP-9 inhibits platelet aggregation [4,5]. Thus a high TIMP-1/ MMP-9 ratio could contribute to a prothrombotic state, and the development of organ dysfunction and fi nally death in septic patients. The objectives of this study were to investigate the time course of MMP-9, MMP-10 and TIMP-1 levels, and the association with sepsis severity and PAI-1 levels.

Methods This was a multicenter, observational and prospective study carried out in six Spanish ICUs. We included 192 (125 surviving and 67 nonsurviving) patients with severe sepsis. We obtained blood samples at three moments (time of diagnosis, 72 hours and 7 days) for the determination of MMP-9, TIMP-1, TNFα, IL-10 and PAI-1 levels. We assessed survival at 30 days as the endpoint.

Results Nonsurvivor patients showed at the three moments lower MMP-9 levels, higher TIMP-1 levels and higher TIMP-1/MMP-9 ratios than survivors. There were at the three moments an association of the TIMP-1/MMP-9 ratio with lactic acid levels, SOFA score, PAI-1 levels, TNFα and IL-10. Logistic regression analysis showed that TIMP-1 levels, lactic acid levels and SOFA score were associated with death at 30 days. Conclusions To our knowledge, this study includes the largest series reporting data on MMP levels in sepsis. The novel fi ndings of our study are that nonsurviving septic patients showed a persistent higher TIMP- 1/MMP-9 ratio during the fi rst week than survivors. From a therapeutic perspective, the development of modulators of MMP/TIMP activity could be used as a new class of drugs for the treatment of severe sepsis. References

1. Elkington PT, et al.: Clin Exp Immunol 2005, 142:12-20. 2. Aznaouridis K, et al.: Atherosclerosis 2007, 195:212-215. 3. Cavusoglu E, et al.: Am Heart J 2006, 151:1101.e1-1101.e8. 4. Sheu JR, et al.: Br J Pharmacol 2004, 143:193-201. 5. Lee YM, et al.: Eur J Pharmacol 2006, 537:52-58. Table 1 (abstract P275). Values of pBNP and PCT during the study period

Day 1 Day 2 Day 3 Day 4

pBNP (median and Q25 to 75) (pg/ml) Survivors 2,256.50 (1,071 to 2,832)* 1,598.00 (1,412.75 to 3,918.25) 2,102.50 (1,323.50 to 6,166.50) 1,809,00 (939.25 to 5,495.75) Nonsurvivors 4,090.50 (3,064 to 32,147.75) 8,994,00 (4,911 to 27,860.25) 9,528.00 (3,747.75 to 25,793.2) 5,498,00 (1542 to 19,947.25) PCT (mean ± SD) (ng/ml) Survivors 10.13 ± 13.02 11.68 ± 18.29* 12.75 ± 23.16 11.90 ± 24.24 Nonsurvivors 19.81 ± 23.32 25.91 ± 26.87 26.82 ± 26.46 9.89 ± 8.87 *P <0.05.

P278

Impact of pro-domain stability of matrix metalloproteinase-8 on the outcome of sepsis

J McLaughlin1_{, J Rella}2_{, A Bakan}1_{, L Kong}1_{, L Zhu}1_{, D Frederick}3_{, S Yende}1_, R Ferrell1_{, I Bahar}1_{, S Shapiro}1_{, D Angus}1_{, A Kaynar}1

1_{University of Pittsburgh, PA, USA;} 2_{University of Vienna, Austria;} 3_{University of} Tulane, New Orleans, LA, USA

Critical Care 2011, 15(Suppl 1):P278 (doi: 10.1186/cc9698)

Introduction Animal studies suggest matrix metalloproteinase-8 (MMP8) (neutrophil collagenase) impairs neutrophil (PMN) recruitment in infl ammation; in humans, MMP8 has been associated with infl ammation. We hypothesized that septic patients with single nucleotide polymorphisms (SNPs) in the MMP8 promoter region will have a survival advantage, and this advantage is due to diff erences in MMP8 enzymatic activity and not MMP8 levels.

Methods We examined data from patients with CAP-associated sepsis (GenIMS), analyzed three functional SNPs (rs3765620, rs1940475, rs11225395) in 1,567 Caucasians and tested associations with 60-day and 90-day mortality and severe sepsis incidence. We simulated functional MMP8 SNPs using anisotropic network modeling. Modeling suggested pro-domain structural stability aff ecting zymogen activation. Based upon the predictions, we then studied zymogen activation using bioluminescent resonance energy transfer (BRET). We generated recombinant pro-MMP8 with a pro-domain tag of luciferase and carboxy terminus tag of green fl uorescent protein. BRET signal was generated when luciferase-cleaved substrate produced a photon transferring energy to the GFP acceptor. GFP in turn emitted a green light signal when the donor/acceptor pairs were spatially close. Upon MMP activation, pro-domain is cleaved causing a loss in BRET signal. Results The rs1940475 genotype causing an amino acid mutation in the pro-domain was signifi cantly associated with 90-day mortality (AA: 8.5%, AG: 11.1%, GG: 14.7%, P = 0.007). Cumulative incidence showed that the A allele was associated with better 90-day survival. Computer simulation of the mutation suggests a delayed activation. BRET assay confi rmed that pro-domain mutation of MMP8 (K87E) rendered it less amenable to activation.

Conclusions Our results suggest altering the structural stability of the inhibitory MMP8 pro-domain impacts enzyme activation. Therapeutics targeting pro-domain could be used to modulate MMP function and control downstream infl ammatory processes in sepsis.

P279

Pentraxin 3 levels from bronchoalveolar lavage of critically ill