[The prognostic value of the delayed cutaneous immune reaction following multiple trauma in comparison with other...

Infection is a frequent cause of morbidity and mortality after multiple trauma. Although impaired immune function has been assumed to be associated with the development of infection and sepsis in trauma victims, its predictive role is still controversial. In a prospective study, the predictive value of the immunological in vivo response to intradermally applied recall antigens was compared with serial determinations of routine parameters. PATIENTS AND METHODS. Using the commercially available Multitest device, the cutaneous delayed-type hypersensitivity (DTH) response to seven standardized recall antigens was sequentially tested at defined time intervals in 35 mechanically ventilated multiple-trauma patients (4 females, 31 males). Routine clinical and laboratory parameters (FiO2, lactate, creatinine, platelet count, absolute and differential white blood cell (WBC) count) were determined every day. Injury severity scores (ISS), infections, and intensive care unit (ICU) mortality were prospectively documented by the same investigator. RESULTS AND DISCUSSION. The overall ICU mortality was 23%. In survivors, the mean ISS was 29.5, in nonsurvivors 38.9 (P less than 0.05). Mortality significantly increased in association with sepsis. Interestingly, the DTH response and severity of the trauma did not show any interdependence. Immediately after ICU admission, DTH testing failed to correlate with either infection or mortality: most of the multiply traumatized patients were anergic on initial skin testing. In the early posttraumatic stage, the serum levels of creatinine or lactate, lymphocyte and promyelocyte counts, and FiO2 proved to be more reliable predictors. In the later course, however, a good correlation was found between sequential skin test results and the development of infection. Beginning on the 4th day after trauma, DTH scores below 5 mm defined a population with a high incidence of developing a clinically important septic episode. In conclusion, lactate, FiO2, and WBC counts are early indicators of an impending poor outcome, whereas the skin test response is not. In the later course, however, the sequentially determined DTH response may substantially contribute to the identification of multiple-trauma patients at increased risk of infection.