| Community acquired pneumonia(CAP) is a kind of infectious pulmonary parenchyma inflammation, which is infected outside the hospital. It includes pneumonia that has pathogen infection which has a clear latency while the onset of pneumonia is inside of latency after admissions. CAP is one of the most common infectious diseases, seriously threatens the human health, the mortality rate of CAP ranks first in infectious diseases.When a variety of pathogenic microorganisms invade local lung, partial lung and systemic inflammatory reaction produce during the pneumonia. A large amount of inflammatory mediators and cytokines(such as IL-1, IL-6, TNF-α, etc.) are released through inflammation, which promote tissue factor(TF) released by monocytes and endothelial cells. The composite which consists of TF, FVⅡ and Ca2 + ions rapidly active the extrinsic coagulation pathway. The damage of vascular endothelial cell makes negatively charged collagen exposed then factor Ⅻ is activated,so the intrinsic coagulation pathway is started. The exposed collagen by the binding of von Willebrand factor(v WF) and platelet promotes platelet activation and participates in coagulation reaction. The thrombin is ultimately produced by a series of orderly activation of coagulation factors which results in the activation of coagulation, then anticoagulant is reduced, fibrinolysis fuction is inhibited, so the body suffers from hypercoagulation state.There is close relationship between inflammation and coagulation. Inflammation can lead to coagulation function disorders while the activation of the coagulation system can amplify the inflammatory reaction. Therefore, it is necessary to monitor coagulation and fibrinolysis indicators in patients with pneumonia in clinical practice. It is essential that early anticoagulation intervention is employed in patients with coagulation changes. Hypercoagulation state and fibrinolysis are early detected that provides not only new mean of blocking another major pathological changes of pneumonia except for antibiotic treatment for pneumonia but also a new way which improves outcome of the patient. This study consists of two parts:Part I: Comparison of coagulation and fibrinolysis related indicators in patients with CAPPart II: Research of anticoagulant therapy using low molecular weight heparin in patients with CAP Part I: Comparison of coagulation and fibrinolysis related indicators in patients with CAPObjective:To observe of coagulation and fibrinolysis related indicators in patients with CAP and investigate the incidence of coagulation dysfunction in patients with pneumonia.Methods:A total of 107 CAP hospitalized patients at Department of Respiratory Medicine, Affiliated Hospital, Cheng De Medical College from July 2013 to June 2014 were enrolled as pneumonia group while another 52 healthy outpatients served as control group. The levels of routine blood test, coagulation function, procalcitonin(PCT) and C-reactive protein(CRP) were measured and compared among different groups. All hospitalized CAP patients were divided into low and high-risk groups according to pneumonia severity index(PSI). And all indicators were measured to examine the differences among different groups.Results:1. Comparison between pneumonia group and control group:1.1 Comparisons of patients general information, routine blood test, coagulation indicators between pneumonia group and control group.There were no statistically difference among gender, age, drug used and pre-exist diseases of patients between the two groups(p>0.05). The white blood leukocyte count in pneumonia group was significantly higher than that in control group(p<0.01). The red blood cell count, hemoglobin and platelet count in pneumonia group were significantly lower than those in control group( p<0.01). The D-dimer, fibrinogen degradation products(FDPs), fibrinogen(FIB), activated partial thromboplastin time(APTT) and prothrombin time(PT) in pneumonia group were significantly higher than those in control group( p<0.05) while thromboplastin time(TT) was lower than that in control group(p<0.01).2. Comparison between the low-risk group and high-risk group:2.1 Comparisons of patients general information between low-risk group and high-risk group :There were no statistically difference among gender, drug used and pre-exist diseases of patients between the two groups(p>0.05). Age in the high-risk group is higher than that in the low-risk group(p<0.05).2.2 Comparisons of patients routine blood test between low-risk group and high-risk group:The platelet count in the high-risk group was lower than that in low-risk group(p<0.01). There were no statistically difference among the white blood leukocyte count, the red blood cell count and hemoglobin of patients between the two groups(p>0.05).2.3 Comparisons of patients coagulation and inflammatory indicators between low-risk group and high-risk group:The levels of D- dimer, FDPs, APTT, PT, PCT and CRP in high-risk group were significantly higher than those in low-risk group(p<0.05) while TT was lower than that in low-risk group(p<0.01); There was no significant difference about FIB between the two groups(p>0.05).2.4 Comparisons of the abnormal rates about all the indicators between low-risk group and high-risk group:The abnormal rates of PCT, D-dimer and FDPs in high-risk group were significantly higher than those in low-risk group( p<0.05) while the CRP, FIB, APTT, PT, TT in the two groups were not statistically significant(p>0.05).2.5 Correlation Analysis:The plasma levels of D-dimer, FDPs, procalcitonin and CRP were well-correlated with pneumonia severity index(PSI)(r=0.636, 0.608, 0.629, 0.250, p<0.05). And the plasma level of platelet was negatively correlated with PSI(r=-0.320, p<0.01).2.6 The predictive evaluation for severe pneumonia by D-dimer, FDPs, PCT, CRP, PSI and PLT:Monitoring D-dimer, FDPs, PCT, CRP, PSI and PLT, then analyse their independent predictive power on the severity of pneumonia patients by ROC, the area under the receiver operator characteristic curve(ROC) of D-dimer, FDPs, PCT, CRP, PSI and PLT were 0.828(95%CI 0.741~0.916), 0.863(95%CI 0.785~0.942), 0.887(95%CI 0.823~0.952), 0.771(95%CI 0.675~0.861), 0.894(95%CI 0.834~0.954) and 0.660(95%CI 0.544~0.777). The ability of D-dimer, FDPs, PCT, CRP, PSI’ in predicting severe pneumonia is better than that of PLT.Conclusion:1. The red blood cell, hemoglobin and platelets are lower in patients with pneumonia than those in normal subjects while D- dimer, FDPs, FIB, APTT, PT were higher. There were coagulation and fibrinolysis disorders in patients with pneumonia.2. As the condition of CAP patients worsens, coagulation indicators were more abnormal. The plasma levels of D-dimer, FDPs, PCT, CRP and platelets are well-correlated with severity of CAP. It is important to monitor the levels of coagulation indicators in evaluating the severity of CAP patients. Part II: Research of anticoagulant therapy using low molecular weight heparin in patients with CAPObjective:To investigate the clinical efficacy and adverse reactions of assistant therapy using low molecular weight heparin in patients with CAPMethods:In the prospective randomized control study, 89 cases of CAP patients in Department of Respiratory Medicine, Affiliated Hospital, Chengde Medical College from July 2013 to June 2014 were enrolled, 85 cases were effectively selected into the study group. All above patients were divided into anti-coagulation and control group according to the random number table. 43 cases of the control group received routine therapy; 42 cases of the anticoagulation group received not noly routine therapy but also low molecular weight heparin(Su Bilin Glaxo Wellcome Production(France) H20080480) 4100iu/d subcutaneously, once daily, for 8 days of treatment. The indicators of D- dimer, FDPs, routine blood test and coagulation were recorder before and after the treatment in the two groups. Incidence of adverse reactions, the duration of hospital stay and hospital cost were observed between the two groups.Results:1. Comparison of patient’s general information between the anticoagulation group and control group:There were no statistically difference among gender, age, drug used and pre-exist diseases of patients between the two groups(p>0.05).2. Comparison of coagulation indicators between the anticoagulation group and control group:The D-dimer, FIB and FDPs of anticoagulation group were significantly lower on the 8th day than before treatment, the difference were statistically significant( p<0.05). The FIB of the control group were significantly lower on the 8th day than before treatment(p<0.05). D-dimer and FDPs in the anticoagulant group were significantly lower on the 8th day than that in the control group(p<0.05).3. Comparisons of routine blood test and arterial blood gas analysis between the anticoagulation group and control group:The WBC of the two groups were significantly lower on the 8th day than before treatment(p<0.05). Pa O2 and oxygenation index in the anticoagulant group were significantly higher on the 8th day than before treatment and on the 3th day(p<0.05). The Pa O2 of the control group on the 8th day was significantly higher than before treatment(p<0.05). The Pa O2 of the anticoagulant group on the 8th day was significantly higher than that of the control group(p<0.05).4. Comparisons of adverse reactions, the duration of hospital stay and hospital cost between the anticoagulation group and control group:Adverse reactions between the two groups showed no statistically significant(p=0.241).The duration of hospital stay and hospital cost in the anticoagulant group were lower than in the control group(p<0.05).Conclusion:Treatment with low molecular weight heparin in patients with CAP can significantly improve the hypercoagulation and hypoxia state. The duration of hospital stay and hospital cost in the CAP patients using the anticoagulant treatment were lower than routine therapy. There were no serious adverse events in the CAP patients of treatment with low molecular weight heparin. |
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