► Severe pneumonia is an important cause of death in elderly patients. In current clinical practice, mortality remains high and ranks 5th-6th in total human mortality based on timely anti-infective and symptomatic treatment. We collected 93 patients eligible for severe pneumonia in our hospital over a five-year period, and the diagnostic criteria were in accordance with the consensus guidelines for the management of adult CAP published by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) in 2007; we explored that completing cluster therapy for patients with severe pneumonia could significantly reduce the morbidity and mortality. By clustering treatment, we mean a treatment measure based on the pneumonia treatment guidelines, which is a multidisciplinary treatment team established in our department early immediately after the diagnosis of severe pneumonia and completed rapidly in a short period of time (6-24h) [1]. The purpose of cluster treatment is to explore individualized treatment measures on the basis of standardized clinical behavior of severe pneumonia treatment, and finally to achieve the purpose of reducing the morbidity and mortality rate. The analysis is as follows: Department of Internal Medicine, Wuxi Ninth People’s Hospital, Mao F
1 Information and methods
1.1 General information
The 93 cases in this group were all patients with severe pneumonia admitted to the Ninth People’s Hospital of Wuxi City from July 2005 to July 2010, of whom 53 were men and 40 were women, aged 50 to 85 years, with an average of (74.54±18.35) years. Diagnostic criteria were in accordance with the consensus guidelines for the management of adult CAP published by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) in 2007: primary criteria: 1. need for invasive mechanical ventilation. 2 infectious shock requiring vasoconstrictor therapy secondary criteria: 1 respiratory rate >= 30 breaths/min. 2 oxygenation index <= 250. 3 multiple lobe infiltrates. 4 impaired consciousness/disorientation. 5 Azotemia. 6 Leukopenia. 7 Thrombocytopenia. 8 Hypothermia. 9 Hypotension.
1.2 Grouping
According to the treatment strategy, they were divided into the group without completed centralized treatment (group A) for archived cases from July 2005 to August 2008, and the group with completed centralized treatment from September 2008 to July 2010 (group B). 46 cases in group A, 27 males and 19 females, mean (73.21±19.31) years old; 47 cases in group B, 26 males and 21 females, mean (74.62± 18.56) years old. There was no statistically significant difference between the age and APACHE II score and the risk rate of death in the two groups (P>0.05).
1.3 Treatment methods
Patients in both groups were given the following treatments: ① Active infection control: early infection control using step-down strategy. ②Organ support: those with acute brain dysfunction were given nutritional brain cells and dehydration to lower cranial pressure; those with acute myocardial damage were given nutritional myocardium and improved cardiac function; those with acute liver dysfunction were given hepatoprotective therapy; those with bleeding peptic stress ulcers were given hemostasis, acid suppression and mucosa protection. Patients with bleeding peptic ulcer were given hemostasis, acid suppression and mucosal protection.
In addition to the above treatment, the following treatments were given: 1) respiratory support; 2) blood purification treatment; 3) regular nutritional support; 4) intensive insulin treatment to control blood glucose ≤7.5 mmol/L and avoid hypoglycemia; 5) early target hemodynamic support treatment to achieve resuscitation target within 6 h: central venous pressure of 8-12 mmHg; mean arterial pressure >65 mmHg. Urine volume >0.5 ml/(kg・h). [2].
1.4 Observation index
The in-hospital morbidity and mortality rate and length of stay of patients with severe pneumonia were used as the main observation indexes to explore the relationship between the prognosis of patients with severe pneumonia and the completion of the intensive care strategy.
1.5 Statistical methods
All data were statistically analyzed using the SPSS 15.0 software package. Count data were compared by r test; measurement data were expressed as mean ± standard deviation, and comparison between two groups was performed by two independent samples t test; regression analysis was performed by binomial classification logistic regression analysis, and the difference was considered statistically significant at P<0.05.
2 Results
The in-hospital morbidity and mortality rate and length of stay in the two groups (Table 1) were significantly lower in Group B than in Group A (P<0.05), and the difference between the length of stay in Group B and Group A was not statistically significant (P>0.05).
Table 1 Comparison of morbidity and mortality rate and length of hospitalization between the two groups
Group Number of cases Morbidity and mortality rate (%) Length of hospitalization (days)
Group A 46 34.35 17.85±3.25
Group B 47 16.17 18.37±2.89
P value <0.05 >0.05
3 Discussion
3.1 Measures of intensive care.
3.1.1 Respiratory support: Group B patients with arterial partial pressure of oxygen below 80% were given non-invasive assisted ventilation, in addition, severe acidosis was rapidly corrected by rapid dripping of sodium bicarbonate to raise the blood pH to 7.0 in a short time; mechanical ventilation was considered to increase the patient’s arterial partial pressure of oxygen, increase tissue oxygen supply, improve respiratory failure, and reduce the production of lactic acid, accelerate the metabolism of lactic acid, improve the efficacy and promote recovery. However, it has been mentioned in the literature that rapid supplementation of sodium bicarbonate may cause increased production of C02 in the body and, at the same time, inhibit too rapid respiration, thus increasing PaC02 and aggravating neurological damage [3]; mechanical ventilation can promote the excretion of excessive C02 produced by rapid input of large amounts of sodium bicarbonate, maintain acid-base balance and improve the prognosis of patients.
3.1.2 Monitoring and removal of lactate: tissue hypoperfusion and hypoxia in patients with severe pneumonia existed prior to changes in hemodynamic monitoring indicators, and lactate levels were already elevated. Studies have shown that persistent elevation of blood lactate is closely related to APACHE II score, and patients with infectious shock with blood lactate > 4 mmol/L have a morbidity and mortality rate of 80 , so lactate can be used as one of the indicators to evaluate the severity of disease and prognosis, which is beneficial for early treatment of severe infection and infectious shock. In this study, it was found that 31% of patients with severe pneumonia in the elderly in group B had hyperlactatemia, and timely intervention of hyperlactatemia is very important for disease control. In the archived cases, none of the elderly patients with severe pneumonia had their blood lactate checked, and it is possible that among the elderly patients with severe pneumonia who died, hyperlactatemia also played a fatal factor.
3.1.3 Hemopurification treatment: In the archived cases, none of them underwent early hemodialysis intervention, but in the early cluster treatment group, 23 cases were given timely hemodialysis, while treatments such as CRRT or conventional hemodialysis were chosen according to the patient’s hemodynamics and degree of illness at that time, according to current domestic and international reports, hemodialysis technology has been widely used in multidisciplinary and multisystem resuscitation treatment of patients with acute and critical illnesses, obtaining satisfactory results [4,5]. We considered that 18 cases of 23 cases of severe pneumonia with different degrees of hyperlactatemia were corrected acidosis in a short time through blood purification, because lactic acid is a small molecule substance with relative molecular weight <90, which can easily pass through the hemofilter, and blood purification therapy, especially continuous blood purification therapy, can mimic the glomerular principle and use blood pump for extracorporeal circulation [6], which can both slowly correct acidosis and well correct electrolyte disorders, remove inflammatory transmitters and bivalirudin, and control blood glucose level at the same time. The amount of rehydration can also be well grasped, so as not to cause heart failure due to rehydration, thus more conducive to recovery.
3.1.4 Nutritional therapy: the metabolic changes after stress make the energy consumption and nutrition loss of critically ill patients increase significantly, if not treated early, negative nitrogen balance will soon appear and progressively aggravate, which is difficult to correct at a later stage, not only prolonging the hospitalization time and increasing medical costs, but also malnutrition itself has become a risk factor predicting poor prognosis of critically ill patients and affecting the incidence of complications and mortality of critically ill patients; B All patients in the group were given early enteral and parenteral nutrition, Bepril, fish oil fat milk, etc.; consider (Omega)-3 fatty acids, which are polyunsaturated fatty acids in the diet and are inhibitors of prostaglandin synthesis, to attenuate the effect of platelet coagulant A2 (TXA2). This attenuates the role of prostaglandin-like substances in the pathophysiological process of endotoxin pathogenesis and modulates the immune inflammatory response in critically ill patients. In practice we feel that for elderly patients with severe pneumonia, the timely administration of nutritional therapy plays an important role in the recovery of the disease and the reduction of mortality.
3.1.5 Intensive insulin therapy: All patients in group B had their blood glucose controlled at 6-7.5 mmol/L according to their condition, and elevated blood glucose has become an independent factor directly affecting the prognosis of such patients. Several prospective and retrospective clinical studies have shown that strict glycemic control improves the prognosis of these patients [7,8,9] and reduces the incidence of in-hospital acquired renal damage and shortens the duration of mechanical ventilation and the number of days of hospitalization. Therefore, aggressive glycemic control is clinically important for such patients. Strict glycemic control as a simple and easy to promote the application of clinical measures, strict glycemic control is still recommended in patients with severe pneumonia.
3.2 Adherence to cluster therapy
In our opinion, the morbidity and mortality rate of patients who completed cluster therapy was significantly lower than that of patients who did not complete cluster therapy, suggesting that improving adherence to cluster therapy can achieve the goal of reducing the morbidity and mortality rate of infectious shock by 25% in 5 years as proposed in the Barcelona Declaration [10]. Analysis of the reasons for low adherence may be related to the fact that some traditional treatment concepts still influence health care providers, and on the other hand, to age factors such as old age and advanced age of patients or financial costs for families to abandon active treatment.
Clustered treatment has reduced the morbidity and mortality rate of patients with severe pneumonia and is actually a change in treatment management and modality. While specialty care now tends to bias specialty clinicians toward a particular specialty, cluster care integrates respiratory, cardiology, gastroenterology, neurology, endocrinology, and nephrology resources. After a critical patient is admitted to the hospital, all examinations are completed in the shortest possible time, a diagnosis is made in the shortest possible time, and all resuscitation measures are given in the shortest possible time, relying on group operations. This is a process of medical method implementation, as well as medical quality management.