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Erschienen in:
28.04.2020 | Less Is More in Intensive Care
Biomarkers in the ICU: less is more? Yes
Erschienen in: Intensive Care Medicine | Ausgabe 1/2021
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In 1900, Dr. Camac wrote in the Journal of the American Medical Association “Rarely in our science is that any one finding is the open sesame to the secrets of the disease” [1]. In 2020, these words remain relevant, as a reminder that the complexities of both pathophysiology and patient care have always rendered any one test only a part of the puzzle. Regarding biomarkers, definitions vary, with most broad and encompassing many test types [2]. We focus on laboratory-based biomarkers, and contend that before widespread adoption of a given biomarker, we should ask four questions—what is the pretest probability for the diagnosis we are considering, are factors present that interfere with interpretation of the result, will I change management based on the result, and what will the outcome benefit be (Table 1)? We further contend that for many biomarkers, robust answers to these questions are lacking and support this position with illustrative examples of novel and commonly used biomarkers in the ICU.
Table 1
Questions to consider before ordering biomarker testing in the ICU
|
Question
|
Example
|
Comments
|
|---|---|---|
|
What is the pretest probability for the diagnosis we are considering?
|
Procalcitonin
|
Low or high pretest probability alone can guide decisions and will heavily affect posttest probability
If used, best used in cases of diagnostic uncertainty, and commitment to act on result
|
|
Are factors present that interfere with interpretation of the biomarker result?
|
Brain natriuretic peptide
|
Limited sensitivity and specificity for heart failure in critically ill patients
Levels affected by common conditions such as obesity, renal dysfunction, and atrial fibrillation
|
|
Will I change management based on the biomarker result?
|
Troponin
|
Established utility for acute coronary syndromes was due to key factors that do not exist in general critical care
Higher levels of troponin are associated with worse outcome, but this fact is not actionable
|
|
Will the outcome be benefited by biomarker guided decisions?
|
suPAR
|
Although higher levels of suPAR are associated with higher rates of death and acute kidney injury, provision of suPAR risk stratification information to clinicians had minimal impact on decisions and no impact on outcome, in a randomized trial
|