| BackgroundHospital acquired pneumonia is the most common hospital acquired infection at home and abroad,the diagnosis and treatment are difficult and the fatality rate is high.The disease is one of the main causes of death for inpatients in China,especially for elderly patients[1-2].During course of diagnosis and treatment of pneumonia,the evaluation of the severity of pneumonia patients plays an important role,accurate evaluation can predict the clinical outcome of the patients,determine the treatment site and treatment strategy.However,at present,the domestic and foreign guidelines haven’t provide a clear mean of prediction[1].Score scales and biomarkers may be used for prognostic evaluation of HAP patients.A score scale is composed of multiple physiological and biochemical indexes,which requires patients to have multiple examination and test data in a period of time,including age and basic medical history,etc.It is a comprehensive quantitative evaluation result,but the complexity of operation is not convenient for dynamic monitoring.Biomarkers are clinical biochemical indicators,which have been widely used in disease diagnosis,clinical stage and prognosis evaluation.the data results are objective and convenient for dynamic monitoring,but the amount of information of biomarkers is limited.the correlation between biomarkers and score scale with high value remains to be studied.Some current clinical studies have recommended PSI,APACHEII,SOFA and other rating scales as possible means of evaluation[3-5],but the lack of a control study of the same group of clinical data makes it difficult to judge the merits and demerits.Some clinical test results,such as hyperlactemia,may have a worse prognosis,and patients with high lactate clearance or clearance rate may have a better prognosis.However,in the absence of the same group of clinical data,the comparison of lactate and lactate clearance or clearance rate to prognosis evaluation is unknown,the relationship and duration of prognosis are not clear neither.Furthermore,HAP patients have not only non-perioperative patients in internal medicine,but also perioperative patients who have undergone surgery.Some clinical studies excluded perioperative HAP patients,and lack of prognostic evaluation research data for this part of the patients.In the clinic,perioperative HAP is not only related to the effect of surgery,but also to the survival of patients,perioperative HAP patients prognosis evaluation should be concerned.Therefore,this subject is included in the medical department of the non-perioperative HAP patient data and surgical perioperative HAP patient data.In the first part of the study,the same set of data is used to compare the advantages and disadvantages of the three rating scales of PSI,APACHEII,SOFA scale.In the second part of the study,we have explored the value of biomarkers arterial blood lactate value,lactate clearance,lactate clearance rate for HAP prognosis evaluation,and further analyzed the correlation of biomarker and score scale with high value.To provide a basis for the selection of prognostic assessment scale tools and the application of arterial lactate in patients with hospital-acquired pneumonia.Objective1.To investigate the prognostic value of PSI,APACHEII and SOFA scores in patients with hospital acquired pneumonia.2.To explore the value of arterial lactate monitoring in predicting the prognosis of hospital acquired pneumonia.Materials and Methods1.A total sample of 80 adult patients with hospital acquired pneumonia admitted in our hospital from January 2016 to December 2017 were retrospectively analyzed.According to the diagnosis time sequence,the data of 40 patients with non-perioperative hospital acquired pneumonia and 40 patients with perioperative hospital acquired pneumonia were collected continuously.The following data were collected:（1）patient sex,age,basic medical history,history of surgery,length of stay,whether or not to stay in nursing home;（2）vital signs,laboratory and imaging findings,history of drug use（See annex for specific indicators）;（3）patient survival 30 d after HAP diagnosis.Each group was evaluated by PSI,APACHEII and SOFA scores with the physiological parameters within 24 hours after diagnosis of hospital acquired pneumonia.Using survival after 30 days as a prognostic index,the receiver operating characteristic curve（ROC）was drawn to compare the difference of the three scores.On the basis of reference to APACHEII age score,SOFA score was re-graded to compare the effect of SOFA score before and after weighted age.2.Retrospectively analyzed the data of 71 consecutive patients diagnosed as hospital acquired pneumonia admitted in our hospital from January 2016 to December 2017,the patients were divided into two groups（survival group and death group）after 30 days to evaluate the prognostic value of arterial blood lactate test results within 5 days after diagnosis of hospital acquired pneumonia.The change trend of arterial lactate,lactate clearance and lactate clearance rate with time was observed by repeated metric analysis;the prognostic of30 days of lactate was compared by ROC curve;the difference in the mortality rate was compared by the size of the peak within 5 days,divided into<2.0 mmol/l,≥2.0 mmol/l and≥4.0 mmol/l;the correlation analysis was used to calculate the correlation between the lactate peak and the PSI score.Results1.The ROC curve in the study of the prognostic value of three scores for patients with HAP showed that:40 cases of non-perioperative HAP,the area under the curve（AUC）of ROC in PSI,APACHEII and SOFA were 0.75,0.69,0.66.40 cases of perioperative HAP,the AUC in PSI,APACHEII and SOFA were 0.87,0.64,0.70.80 cases of HAP,the the AUC in PSI,APACHEII and SOFA were 0.80,0.73,0.66.Whether or not the patient had received a surgery,the PSI score was better than the other two in evaluating the prognosis of HAP patients.The age weighting advantage of PSI score was obvious.After age weighting of SOFA score which was lack of age factor,the AUC of 40 non-perioperative HAP was 0.75,the AUC of 40 perioperative HAP was 0.75,the AUC of 80 HAP was 0.72.Whether or not the patient had received a surgery,SOFA score with age factor was more effective in evaluating the prognosis of HAP patients.2.The study of the value of arterial blood lactate monitoring in the prognosis of HAP showed that:among 71 cases,32 cases survived and 39 cases died after 30 days of diagnosis of HAP.In the survival group,the lactate decreased with time,lactate clearance and lactate clearance rate increased with time;in the death group,the lactate increased with time,lactate clearance and lactate clearance rate decreased with time.The ROC curve showed that the lactate within 5 days of diagnosis of hospital acquired pneumonia could be used to judge the prognosis,while the other values couldn’t.The area under the lactate ROC curve of D1,D2,D3,D4,D5,within 5 days were 0.67,0.71,0.77,0.71,0.70,0.74.The mortality rate of the peak value of lactate within 5 days,divided into less than 2.0 mmol/l,greater than or equal to2.0 mmol/l and greater than or equal to 4.0 mmol/l was 20.00%,64.29%and 78.95%.Comparison of mortality rate among three groups?2=13.27,p=0.00.There was a significant correlation between the lactate within 5 days and PSI score,r=0.41,p=0.00.Conclusions1.PSI score is good to evaluate the prognosis of HAP patients.Age factor is important for prognosis,the older the patient,the worse the prognosis.2.In the survival group,the lactate is decreased with time,while in the death group,the lactate is increased with time.Compare with the lactate clearance and lactate clearance rate,the arterial lactate can be better to evaluate the prognosis of HAP patients.The higher the lactate peak,the greater the risk of death.The lactate peak is statistically associated with the PSI score. |
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