Risikostratifizierung - Was sollte man tun?

Risikostratifizierung - Was sollte man tun? Prof. Torsten T. Bauer Klinik für Pneumologie Lungenklinik Heckeshorn HELIOS Klinikum Emil von Behring, Berlin

60 years, very ill afebrile respiratory rate 40 bpm pulse rate 150 bpm blood pressure 102/72 mm Hg oxygen saturation 88% WBC count of 2200 cells/ml hemoglobin 12.7 g/dl serum creatinine 216 mmol/l liver-associated enzyme normal HIV status unknown Keren Tzukert, Colin Block, Sigal Sviri, and Shmuel Benenson. A 60-Year-Old Man with Fever and a Lung Mass. Clinical Infectious Diseases 45 (7):899-900, 2007.

Risk factors: Complicated course age > 65 years OR 2.7 comorbidity OR 3.2 body temperature > 38.3 o C OR 4.1 immunosuppression OR 12.0 high-risk etiology OR 23.3 Increasing the risk with increase of the number of risk factors Fine MJ, Smith DN, Singer DE. Am J Med 1990; 89:713-721.

Risk factors: Mortality pleuritic chest pain RR 0.4 mental status changes RR 2.6 severe vital sign abnormality RR 2.1 neoplastic disease RR 5.0 high-risk etiology RR 2.8 Fine MJ, Orloff JJ, Arisumi D, et al. Am J Med 1990; 88:1N-8N

Comparative perfomance of the scores Make everything as simple as possible,...

2006: Sterblichkeit Bauer,T.T. et al. (2006) J Int Med 260, 93-101

Make everything as simple as possible Bauer,T.T. et al. (2006) J Int Med 260, 93-101

Bringt die Krankenhausaufnahme die Menschen um? out-patients hospital Percent 80 70 60 50 40 30 20 10 0 0 1 2 3 4 Positive Criteria

Bringt die Krankenhausaufnahme Menschen um? CURB OR 3.0, 95%CI 2.3 4.0 Treatment setting n.s.

Risikostratifizierung bei CAP

Pneumonia Severity Index (PSI) Age Men: Age; Women: Age-10 Nursing Home 10 Coexisting illness Neoplastic disease 30 Liver disease 20 CHF, cerebrovascular disease, renal disease 10 Physical-examination findings Altered mental status, RR > 30/min, syst. RR < 90 mmhg 20 Temp. < 35 C or > 40 C 15 Pulse > 125/min 10 Laboratory and Radiography ph < 7.35 30 BUN >30 mg/dl, Sodium <130 mmol/l 20 Glucose > 250 mg/dl, Hkt < 30%, PaO 2 < 60 mmhg 10 Pleural effusion 10 Fine et al. New Engl J Med 1997; 336(4):243-250

PSI: Mortality in Risk Classes 30 25 Outpatients Hospitalised Percent 20 15 10 5 0 I II (<71) III (71-90) IV (91-130) V (>130) Score Fine et al. New Engl J Med 1997; 336(4):243-250

PSI in the Emergency Department Renaud,B. et al. (2007) Clinical Infectious Diseases 44, 41-49

Pneumonia Severity Index (PSI) Age Men: Age; Women: Age-10 Nursing Home 10 Coexisting illness Neoplastic disease 30 Liver disease 20 CHF, cerebrovascular disease, renal disease 10 Physical-examination findings Altered mental status, RR > 30/min, syst. RR < 90 mmhg 20 Temp. < 35 C or > 40 C 15 Pulse > 125/min 10 Laboratory and Radiography ph < 7.35 30 BUN >30 mg/dl, Sodium <130 mmol/l 20 Glucose > 250 mg/dl, Hkt < 30%, PaO 2 < 60 mmhg 10 Pleural effusion 10 Fine et al. New Engl J Med 1997; 336(4):243-250

From PSI to CURB Retrospective Design Missing data RR 81% Complete data sets 77% No outpatients W. S. Lim, S. Lewis, and J. T. Macfarlane. Severity prediction rules in community acquired pneumonia: a validation study. Thorax 55 (3):219-223, 2000. http://www.capnetz.de

Mortality according to CURB criteria Confusion Urea nitrogen (> 7mmol/L) Respiratory rate ( 30/min) Blood pressure (DP < 60, SP < 90 mmhg) Percent 50 40 30 20 10 0 34 8 1 0 1 or 2 3 or 4 S. Ewig, A. de Roux, T. Bauer, E. Garcia, J. Mensa, M. Niederman, and A. Torres. Validation of predictive rules and indices of severity for community acquired pneumonia. Thorax 59 (5):421-427, 2004.

From PSI to CURB S. Ewig, A. de Roux, T. Bauer, E. Garcia, J. Mensa, M. Niederman, and A. Torres. Validation of predictive rules and indices of severity for community acquired pneumonia. Thorax 59 (5):421-427, 2004.

Geht es auch einfacher? Confusion Blood Urea Nitrogen > 7mmol/l Respiratory Rate > 30/min Blood pressure (sys. <90 mmhg, dias. <60 mmhg) Age > 65 years W. S. Lim, S. Lewis, and J. T. Macfarlane. Severity prediction rules in community acquired pneumonia: a validation study. Thorax 55 (3):219-223, 2000.

Make everything as simple as possible outpatients inpatients Bauer,T.T. et al. (2006) J Int Med 260, 93-101

Datenvollständigkeit im wirklichen Leben Percent 100 90 80 70 60 50 40 30 20 10 0 out-patients p < 0.001 CURB hospital ns CRB-65

Comparative perfomance of the scores Make everything as simple as possible..

CURB -Kriterien zur Prognose- Abschätzung bei CAP Verwirrtheit * Blood Urea Nitrogen > 7mmol/l Atemfrequenz >30/min Blutdruck (sys. <90 mmhg, dias. <60 mmhg) Alter >65 Jahren * definiert als Mental Test Score < 8, oder neuaufgetretene Desorientierung zur Person, Zeit und Ort

CRB-65 -Kriterien zur Prognose- Abschätzung bei CAP 35 Mortality (%) 30 25 20 15 10 CURB CRB CRB-65 5 0 0 1-2 3-4 Number of positive criteria

Prognose der Krankenhausaufnahme 0.0 0.25 0.5 0.75 1.0 Sensitivity 1 - Specificity 0.0 0.25 0.5 0.75 1.0 CURB AUC = 0.685 SEM = 0.019 95% CI= 0.648-0.721 CRB-65 AUC = 0.698 SEM = 0.019 95% CI= 0.661-0.735

Besser als andere einfache Systeme Receiver operating curve for each prognostic tool. SEWS, standardised early warning score; SIRS, systemic inflammatory response syndrome. Barlow,G. et al. (2007) Thorax 62, 253-259

Comparative perfomance of the scores Make everything as simple as possible, but not simpler.

Schweregradbestimmung Spielen Biomarker eine Rolle? Prospektive Studie hospitalisierter Patienten mit CAP n = 1671 (61±18 Jahre, 55 % männlich) Serum PCT mittels Immunofluoreszenz-Assay (B.R.A.H.M.S PCT sensitive KRYPTOR, B.R.A.H.M.S AG, Henningsdorf, Germany) Sensitivität von 0.06 ng/ml untere Detektionsgrenze 0.02 g/ml. S. Kruger, S. Ewig, R. Marre, J. Papassotiriou, K. Richter, H. von Baum, N. Suttorp, T. Welte, and on behalf of the CAPNETZ Study Group. Procalcitonin predicts patients at low risk of death from community-acquired pneumonia across all CRB-65 classes. European Respiratory Journal 31 (2):349-355, 2008.

CRB-65 and PCT ROC der 30 Tage-Letalität 1000 1000 100 100 PCT PCT (logarithmical) (logarithmical) 10 10 1 1 0,1 0,1 0,01 0,01 0 1 2 3 4 0 1 2 3 4 CRB65-Class CRB65-Class Krüger S, Ewig S et al., Eur Respir J 2008

CRB-65 and WBC / CRP / PCT ROC der 30 Tage-Letalität 1,0 0,8 0,6 0,4 0,2 pct+crb65, A = 0,83 pct, A = 0,80 crp, A = 0,62 leuco, A = 0,61 crb, A = 0,79 0,0 0,0 0,2 0,4 0,6 0,8 1,0 Krüger S, Ewig S et al., Eur Respir J 2008

60 years, very ill afebrile respiratory rate 40 bpm pulse rate 150 bpm blood pressure 102/72 mm Hg oxygen saturation 88% WBC count of 2200 cells/ml hemoglobin 12.7 g/dl serum creatinine 216 mmol/l liver-associated enzyme normal HIV status unknown Keren Tzukert, Colin Block, Sigal Sviri, and Shmuel Benenson. A 60-Year-Old Man with Fever and a Lung Mass. Clinical Infectious Diseases 45 (7):899-900, 2007.

60 years, very ill afebrile respiratory rate 40 bpm pulse rate 150 bpm blood pressure 102/72 mm Hg oxygen saturation 88% WBC count of 2200 cells/ml hemoglobin 12.7 g/dl serum creatinine 216 mmol/l liver-associated enzyme normal HIV status unknown Keren Tzukert, Colin Block, Sigal Sviri, and Shmuel Benenson. A 60-Year-Old Man with Fever and a Lung Mass. Clinical Infectious Diseases 45 (7):899-900, 2007.

Erste Blutgasanalyse / Pulsoxymetrie QI 1: Krankenhäuser mit 20 Fällen 2005 2006 20072008 2009 Anteil Fälle mit erster Blutgasanalyse oder Pulsoxymetrie 8 h Stunden nach Aufnahme 67,3% 74,8% 84,1% 89,8% 93,3% Spannweite 0 100% 3 100% 0 100% 0 100% 2,5 100% 2010 AQUA-Institut GmbH

Erste Blutgasanalyse / Pulsoxymetrie Auf Grund der hohen Variabilität t besteht weiterhin Handlungsbedarf 2010 AQUA-Institut GmbH

Pneumonie Ergänzungen 11.21/11.22 Zuverlegungen, Tumor

HELIOS Todesfallstatistik (2008 in %) n = 253/3174 Bund

Zusammenfassung Die Mortalität der CAP ist nicht null. Die Abschätzung einer Kohortenmortalität gelingt am einfachsten mit dem CRB-65 und sollte in allen Häusern bei Vergleichen herangezogen werden. Die Vorhersage der Mortalität gelingt noch etwas besser, wenn das PCT mit eingeschlossen wird. Welche therapeutische Konsequenzen dies hat bleibt abzuwarten.