Pnömoni Hastalarında, CRP, Prokalsitonin ve Laktat Ölçümünün Prognostik Değerinin, Sık Kullanılan Skorlama Sistemleri ile Karşılaştırılması
Öz
Giriş:Pnömoni hastalarında hastalığın ciddiyetini ve prognozu belirlemek amacıyla oluşturulmuş, farklı skorlama sistemleri mevcuttur. Ancak hiçbir skorlama sisteminin sensitivite ve spesivitesi %100 değildir. Bu çalışmada amaçlanan, farklı demografik özellikler, etyolojiler ve ko- morbiditelere göre, CRP, laktat ve prokalsitonin değerlerinin, prognozu saptamada sık kullanılan skorlama sistemlerine göre etkinliklerini belirlemek ve hastaların tedavisini düzenlemedeki faydasını saptamaktır.
Metod: Ankara Üniversitesi Tıp Fakültesi Hastanesi Acil Servisi'ne 1 Aralık 2015 ile 31 Mayıs 2016 tarihleri arasında başvuran, pnömoni tanısı alan 144 hastanın vital bulguları, kan tetkikleri ve kan gazı analizinin sonuçları değerlendirmeye alınmıştır. Hastaların tedavileri kılavuzların önerdiği şekilde düzenlenmiştir. Çalışmanın sonlanım noktaları hastane ve yoğun bakım ünitesine yatış ihtiyacı ile 28 günlük mortalite olarak belirlenmiştir. Çalışma kapsamında, hastaların tanı ve tedavisini yönlendirilecek herhangi bir müdahalede bulunulmamıştır.
Bulgular: Çalışmaya dahil edilen, yaş ortalaması 71±20 olarak saptanan ve kadın-erkek dağılımı dengeli olan hastaların her birinin en az bir kronik hastalığı bulunmaktadır ancak bu hastalıkların mortalite ile direk ilişkisi saptanmamıştır. Hastaların başvuru anındaki vital bulguları açısından yaşayan ve ölen hastalar arasında anlamlı fark bulunmazken, konfüzyon mortalite ile ilişkili bulunmuştur. Hastaların CRP, prokalsitonin, laktat ve WBC değerleri arasında mortalite ile istatistiksel olarak anlamlı ilişki saptanmazken, hipoalbuminemi (p=0,092) ve üremi (0,018) değerlerinde korelasyon saptanmıştır. Skorlama sistemlerine bakıldığında; en sık kullanılan CURB-65’in ayaktan takip olacak hastaları ayırt etme gücü yetersiz kalırken (p=0,179); PSI’ın ayaktan takip edilecek hastaları saptamada (p=0,009), SMART-COP’un ise yoğun bakım ihtiyacı olabilecek hastaları saptamada (p=0,007) oldukça başarılı olduğu görülmüştür.
Sonuç: Araştırılan tüm parametreler ve skorlar arasında ayaktan takip edilecek hastaları belirlemede PSI’ın, yoğun bakıma yatışı öngörmede ise SMART-COP’un güvenle kullanılabileceği sonucuna varıldı.
Kaynakça
- 1. Woodhead M. Diagnosis and management of community- and hospital-acquired pneumonia in adults. Natl Clin Guidel Cent. 2014;(December).2. Ruuskanen O, Lahti E, Jennings LC, Murdoch DR. Viral pneumonia. Lancet. 2011;377(9773):1264-1275. doi:10.1016/S0140-6736(10)61459-6.3. Türk Toraks Derneği Erişkinlerde Toplum Kökenli Pnömoni Tanı ve Tedavi Uzlaşı Raporu. http://toraks.dergisi.org/pdf/pdf_Toraksder_639.pdf. Accessed December 11, 2015.4. Halm EA. Understanding Physician Adherence With a Pneumonia Practice Guideline: Effects of Patient, System, and Physician Factors. Arch Intern Med. 2000;160(1):98-104. doi:10.1001/archinte.160.1.98.5. Chalmers JD, Singanayagam A, Hill AT. C-Reactive Protein Is an Independent Predictor of Severity in Community-acquired Pneumonia. Am J Med. 2008;121(3):219-225. doi:10.1016/j.amjmed.2007.10.033.6. Afshari A, Harbarth S. Procalcitonin as diagnostic biomarker of sepsis. Lancet Infect Dis. 2013;13(5):382-384. doi:10.1016/S1473-3099(13)70026-4.7. Musikatavorn K, Thepnimitra S, Komindr A, Puttaphaisan P, Rojanasarntikul D. Venous lactate in predicting the need for intensive care unit and mortality among nonelderly sepsis patients with stable hemodynamic. Am J Emerg Med. 2015. doi:10.1016/j.ajem.2015.04.010.8. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin InfectDis. 2007;44 Suppl 2(1537-6591 (Electronic)):S27-S72. doi:10.1086/511159.9. Weir DL, Majumdar SR, McAlister FA, Marrie TJ, Eurich DT. The impact of multimorbidity on short-term events in patients with community-acquired pneumonia: prospective cohort study. Clin Microbiol Infect. 2015;21(3):264.e7-e264.e13. doi:10.1016/j.cmi.2014.11.002.10. Ljunggren M, Castrén M, Nordberg M, Kurland L. The association between vital signs and mortality in a retrospective cohort study of an unselected emergency department population. Scand J Trauma Resusc Emerg Med. 2016;24(21):1-11. doi:10.1186/s13049-016-0213-8.11. Chester JG, Rudolph JL. Vital Signs in Older Patients: Age-Related Changes. J Am Med Dir Assoc. 2011;12(5):337-343.12. M.F. E, F.P. P, A.I.M. H, V. van der M, J.J. O. Evaluating the evidence for the implementation of c-reactive protein measurement in adult patients with suspected lower respiratory tract infection in primary care: A systematic review. Fam Pract. 2012;29(4):383-393. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed10&NEWS=N&AN=2012476938.13. Krüger S, Ewig S, Papassotiriou J, et al. Inflammatory parameters predict etiologic patterns but do not allow for individual prediction of etiology in patients with CAP: results from the German competence network CAPNETZ. Respir Res. 2009;10:65. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2714042&tool=pmcentrez&rendertype=abstract.14. Trzeciak S, Dellinger RP, Chansky ME, et al. Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med. 2007;33(6):970-977. doi:10.1007/s00134-007-0563-9.15. Bakker J, Nijsten MW, Jansen TC. Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care. 2013;3(1):12. doi:10.1186/2110-5820-3-12.16. Tang Y, Choi J, Kim D, et al. Clinical predictors of adverse outcome in severe sepsis patients with lactate 2-4 mM admitted to the hospital. QJM. 2015;108(4):279-287. doi:10.1093/qjmed/hcu186.17. Gwak MH, Jo S, Jeong T, et al. Initial serum lactate level is associated with inpatient mortality in patients with community-acquired pneumonia. Am J Emerg Med. 2015;33(5):685-690. doi:10.1016/j.ajem.2015.03.002.18. Viasus D, Garcia-Vidal C, Simonetti A, et al. Prognostic value of serum albumin levels in hospitalized adults with community-acquired pneumonia. J Infect. 2013;66(5):415-423. doi:10.1016/j.jinf.2012.12.007.19. Wang B et al. No Title. Correl Lact ratio Lev to organ Fail Mortal Sev sepsis septic Shock J Crit Care , Vol 30 , Issue 2 , 271 - 275.20. Renaud B, Coma E, Labarere J, et al. Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study. Clin Infect Dis. 2007;44(November 2006):41-49. doi:10.1086/509331.21. Serisier DJ, Williams S, Bowler SD. Australasian respiratory and emergency physicians do not use the pneumonia severity index in community-acquired pneumonia. Respirology. 2013;18(2):291-296. doi:10.1111/j.1440-1843.2012.02275.x.22. Aliberti S, Ramirez J, Cosentini R, et al. Low CURB-65 is of limited value in deciding discharge of patients with community-acquired pneumonia. Respir Med. 2011;105(11):1732-1738. doi:10.1016/j.rmed.2011.07.006.23. Sanz F, Restrepo MI, Fernández E, et al. Hypoxemia adds to the CURB-65 pneumonia severity score in hospitalized patients with mild pneumonia. Respir Care. 2011;56(5):612-618. doi:10.4187/respcare.00853.24. Liu J-L, Xu F, Hui Zhou, et al. Expanded CURB-65: a new score system predicts severity of community-acquired pneumonia with superior efficiency. Sci Rep. 2016;6:22911. doi:10.1038/srep22911.25. Parsonage M, Nathwani D, Davey P, Barlow G. Evaluation of the performance of CURB-65 with increasing age. Clin Microbiol Infect. 2009;15(9):858-864. doi:10.1111/j.1469-0691.2009.02908.x.26. Chen J-H, Chang S-S, Liu JJ, et al. Comparison of clinical characteristics and performance of pneumonia severity score and CURB-65 among younger adults, elderly and very old subjects. Thorax. 2010;65:971-977. doi:10.1136/thx.2009.129627.27. Estella A. Usefulness of CURB-65 and pneumonia severity index for influenza A H1N1v pneumonia. Monaldi Arch Chest Dis - Pulm Ser. 2012;77(3-4):118-121.28. Gonzalez T.; Rolston, K.; Merriman, K.; Warneke, C.; Evans, S. C. J. Predicting pneumonia mortality using CURB-65, PSI, and patient characteristics in patients presenting to the emergency department of a comprehensive cancer center. Cancer Med. 2014;3(4):962-970. http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L373704683; http://dx.doi.org/10.1002/cam4.240; http://fq5np7af6j.search.serialssolutions.com?sid=EMBASE&issn=20457634&id=doi:10.1002%2Fcam4.240&atitle=Predicting+pneumonia+mortality.29. Chalmers JD, Singanayagam A, Hill AT. Predicting the Need for Mechanical Ventilation and / or Inotropic Support for Young Adults Admitted to the Hospital with Community-Acquired Pneumonia. Clin Infect Dis. 2008;47:1571-1574. doi:10.1086/593195.30. Robins-Browne KL, Cheng AC, Thomas KAS, Palmer DJ, Currie BJ, Davis JS. The SMART-COP score performs well for pneumonia risk stratification in Australia’s Tropical Northern Territory: A prospective cohort study. Trop Med Int Heal. 2012;17(7):914-919. doi:10.1111/j.1365-3156.2012.03006.x.
The Prognostic Value of CRP, Procalcitonin and Lactate Measurement in Comparison With Frequently Used Scoring Systems in Prenumonia Patients
Öz
Background: Several scoring systems have been used to predict severity and mortality in patients with community acquired pneumonia. However, no scoring system has the 100 % sensitivity and specificity. The aim of this study was to determine the prognosis and the benefits of the managing the treatment according to the different demographic features, etiology and co-morbidities by comparing the CRP, lactate and procalcitonin values with frequently used scoring systems.
Methods: One hundred and fourty four patients ,who admitted to Ankara University Emergency Department between 1 December 2015 and 31 May 2016, and diagnosed as pneumonia were included in this study. Vital signs, blood tests and blood gas analysis results were analyzed. The treatment of patients were arranged according to the international guidelines. The end points of this study were accepted as hospitalization to the wards, intensive care units and also 28-day mortality. In the scope of the study, no intervention was made to guide the diagnosis and treatment of the patients.
Results: The distribution of the male and female patients were equally and the mean age of patients was 71 (±20). All patients had at least one chronic disease, and there wasn’t determined direct relation between mortality and these diseases. No significant difference was found between the admission vital signs of survival and mortal patients; but confusion during the initial admittance was found associated with mortality. CRP, procalcitonin, lactate and WBC values weren’t represent statistically significant relationship between the mortality;however hypoalbuminemia (p = 0.092) and uremia (p=0,018) values had correlation. The comparison of the scoring systems showed that; CURB- 65, most commonly used system to distinguish outpatients was found as insufficient (p = 0.179) however PSI was successfull (p = 0.009). SMART- COP was found successfull to distinguish patients needed intensive care treatment (p = 0.007).
Conclusion: Among all the parameters and scores investigated, PSI was superior in detecting outpatients, whereas SMART-COP could be used safely in detecting patients in need of intensive care.
Kaynakça
- 1. Woodhead M. Diagnosis and management of community- and hospital-acquired pneumonia in adults. Natl Clin Guidel Cent. 2014;(December).2. Ruuskanen O, Lahti E, Jennings LC, Murdoch DR. Viral pneumonia. Lancet. 2011;377(9773):1264-1275. doi:10.1016/S0140-6736(10)61459-6.3. Türk Toraks Derneği Erişkinlerde Toplum Kökenli Pnömoni Tanı ve Tedavi Uzlaşı Raporu. http://toraks.dergisi.org/pdf/pdf_Toraksder_639.pdf. Accessed December 11, 2015.4. Halm EA. Understanding Physician Adherence With a Pneumonia Practice Guideline: Effects of Patient, System, and Physician Factors. Arch Intern Med. 2000;160(1):98-104. doi:10.1001/archinte.160.1.98.5. Chalmers JD, Singanayagam A, Hill AT. C-Reactive Protein Is an Independent Predictor of Severity in Community-acquired Pneumonia. Am J Med. 2008;121(3):219-225. doi:10.1016/j.amjmed.2007.10.033.6. Afshari A, Harbarth S. Procalcitonin as diagnostic biomarker of sepsis. Lancet Infect Dis. 2013;13(5):382-384. doi:10.1016/S1473-3099(13)70026-4.7. Musikatavorn K, Thepnimitra S, Komindr A, Puttaphaisan P, Rojanasarntikul D. Venous lactate in predicting the need for intensive care unit and mortality among nonelderly sepsis patients with stable hemodynamic. Am J Emerg Med. 2015. doi:10.1016/j.ajem.2015.04.010.8. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin InfectDis. 2007;44 Suppl 2(1537-6591 (Electronic)):S27-S72. doi:10.1086/511159.9. Weir DL, Majumdar SR, McAlister FA, Marrie TJ, Eurich DT. The impact of multimorbidity on short-term events in patients with community-acquired pneumonia: prospective cohort study. Clin Microbiol Infect. 2015;21(3):264.e7-e264.e13. doi:10.1016/j.cmi.2014.11.002.10. Ljunggren M, Castrén M, Nordberg M, Kurland L. The association between vital signs and mortality in a retrospective cohort study of an unselected emergency department population. Scand J Trauma Resusc Emerg Med. 2016;24(21):1-11. doi:10.1186/s13049-016-0213-8.11. Chester JG, Rudolph JL. Vital Signs in Older Patients: Age-Related Changes. J Am Med Dir Assoc. 2011;12(5):337-343.12. M.F. E, F.P. P, A.I.M. H, V. van der M, J.J. O. Evaluating the evidence for the implementation of c-reactive protein measurement in adult patients with suspected lower respiratory tract infection in primary care: A systematic review. Fam Pract. 2012;29(4):383-393. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed10&NEWS=N&AN=2012476938.13. Krüger S, Ewig S, Papassotiriou J, et al. Inflammatory parameters predict etiologic patterns but do not allow for individual prediction of etiology in patients with CAP: results from the German competence network CAPNETZ. Respir Res. 2009;10:65. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2714042&tool=pmcentrez&rendertype=abstract.14. Trzeciak S, Dellinger RP, Chansky ME, et al. Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med. 2007;33(6):970-977. doi:10.1007/s00134-007-0563-9.15. Bakker J, Nijsten MW, Jansen TC. Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care. 2013;3(1):12. doi:10.1186/2110-5820-3-12.16. Tang Y, Choi J, Kim D, et al. Clinical predictors of adverse outcome in severe sepsis patients with lactate 2-4 mM admitted to the hospital. QJM. 2015;108(4):279-287. doi:10.1093/qjmed/hcu186.17. Gwak MH, Jo S, Jeong T, et al. Initial serum lactate level is associated with inpatient mortality in patients with community-acquired pneumonia. Am J Emerg Med. 2015;33(5):685-690. doi:10.1016/j.ajem.2015.03.002.18. Viasus D, Garcia-Vidal C, Simonetti A, et al. Prognostic value of serum albumin levels in hospitalized adults with community-acquired pneumonia. J Infect. 2013;66(5):415-423. doi:10.1016/j.jinf.2012.12.007.19. Wang B et al. No Title. Correl Lact ratio Lev to organ Fail Mortal Sev sepsis septic Shock J Crit Care , Vol 30 , Issue 2 , 271 - 275.20. Renaud B, Coma E, Labarere J, et al. Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study. Clin Infect Dis. 2007;44(November 2006):41-49. doi:10.1086/509331.21. Serisier DJ, Williams S, Bowler SD. Australasian respiratory and emergency physicians do not use the pneumonia severity index in community-acquired pneumonia. Respirology. 2013;18(2):291-296. doi:10.1111/j.1440-1843.2012.02275.x.22. Aliberti S, Ramirez J, Cosentini R, et al. Low CURB-65 is of limited value in deciding discharge of patients with community-acquired pneumonia. Respir Med. 2011;105(11):1732-1738. doi:10.1016/j.rmed.2011.07.006.23. Sanz F, Restrepo MI, Fernández E, et al. Hypoxemia adds to the CURB-65 pneumonia severity score in hospitalized patients with mild pneumonia. Respir Care. 2011;56(5):612-618. doi:10.4187/respcare.00853.24. Liu J-L, Xu F, Hui Zhou, et al. Expanded CURB-65: a new score system predicts severity of community-acquired pneumonia with superior efficiency. Sci Rep. 2016;6:22911. doi:10.1038/srep22911.25. Parsonage M, Nathwani D, Davey P, Barlow G. Evaluation of the performance of CURB-65 with increasing age. Clin Microbiol Infect. 2009;15(9):858-864. doi:10.1111/j.1469-0691.2009.02908.x.26. Chen J-H, Chang S-S, Liu JJ, et al. Comparison of clinical characteristics and performance of pneumonia severity score and CURB-65 among younger adults, elderly and very old subjects. Thorax. 2010;65:971-977. doi:10.1136/thx.2009.129627.27. Estella A. Usefulness of CURB-65 and pneumonia severity index for influenza A H1N1v pneumonia. Monaldi Arch Chest Dis - Pulm Ser. 2012;77(3-4):118-121.28. Gonzalez T.; Rolston, K.; Merriman, K.; Warneke, C.; Evans, S. C. J. Predicting pneumonia mortality using CURB-65, PSI, and patient characteristics in patients presenting to the emergency department of a comprehensive cancer center. Cancer Med. 2014;3(4):962-970. http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L373704683; http://dx.doi.org/10.1002/cam4.240; http://fq5np7af6j.search.serialssolutions.com?sid=EMBASE&issn=20457634&id=doi:10.1002%2Fcam4.240&atitle=Predicting+pneumonia+mortality.29. Chalmers JD, Singanayagam A, Hill AT. Predicting the Need for Mechanical Ventilation and / or Inotropic Support for Young Adults Admitted to the Hospital with Community-Acquired Pneumonia. Clin Infect Dis. 2008;47:1571-1574. doi:10.1086/593195.30. Robins-Browne KL, Cheng AC, Thomas KAS, Palmer DJ, Currie BJ, Davis JS. The SMART-COP score performs well for pneumonia risk stratification in Australia’s Tropical Northern Territory: A prospective cohort study. Trop Med Int Heal. 2012;17(7):914-919. doi:10.1111/j.1365-3156.2012.03006.x.
Ayrıntılar
| Birincil Dil | Türkçe |
|---|---|
| Konular | Klinik Tıp Bilimleri |
| Bölüm | Orijinal Çalışma |
| Yazarlar | |
| Yayımlanma Tarihi | 31 Temmuz 2019 |
| Yayımlandığı Sayı | Yıl 2019 Cilt: 2 Sayı: 2 |
