Wednesday, November 14, 2012


KRITERIA RAWAT COMMUNITY ACQUIRED PNEUMONIA

Apakah pasien Community Acquired Pneumonia (CAP) harus dirawat inap ? Untuk mengidentifikasi pasien CAP yang memerlukan rawat inap atau rawat jalan dapat digunakan kriteria seperti CURB-65 dan PSI (Strong recommendation;level I evidence.)

1.       CURB-45
Kriteria CURB-65 (Confusion, Uremia, Respiratory rate, low Blood pressure, age > 65 years) merupakan salah satu pedoman untuk identifikasi penderita CAP yang dirancang berdasarkan tingkat keparahan penyakit . Kriteria ini lebih praktis digunakan di unit gawat darurat. Versi sederhananya yaitu CRB-65 (minus Uremia) dapat dipergunakan bila pemeriksaan darah belum dapat dilakukan atau pada praktek dokter sehari-hari.

TABEL 1. SKOR CURB-65

Clinical factors
Points
Confusion
1
Blood urea nitrogen > 19 mg/dL
1
Respiratory rate > 30 x/minute
1
Systolic blood pressure < 90 mmHg
Or
Diastolic blood pressure < 60 mmHg
1
Age > 65 years
1
Total Points

                                              Sumber : Ebell Mh., Family Practice Management, 2006

TABEL 2. INTERPRETASI CURB-65 / CRB-65
CURB-65 score
Deaths/total (%)
Recommendation
0
7/1,223 (0,6)
Low risk; consider home treatment
1
31/1,142 (2,7)
2
69/1,019 (6,8)
Short inpatient hospitalization or closely supervised outpatient treatment
3
79/563 (14,0)
Severe pneumonia; hospitalize and consider admitting to intensive care
4 or 5
44/158 (27,8)

CRB-65 score
Deaths/total (%)
Recommendation
0
2/212 (0,9)
Very low risk of death; usually does not require hospitalization
1
18/344 (5,2)
Increased risk of death; consider hospitalization
2
30/251 (12,0)

3 or 4
39/125 (31,2)
High risk of death; urgent hospitalization
Sumber : Ebell Mh., Family Practice Management, 2006




2.       PSI
Pneumonia Severity Index (PSI) mencakup 20 variabel, sehingga kurang praktis penggunaannya terutama dalam  unit gawat darurat. PSI memilah pasien menjadi 5 kelas risiko kematian.

Tabel 3. SKOR PSI
Risk Factor
Points
Demographics

Men
Age (years) : ____
Women
Age (years) – 10 : ____
Nursing home resident
+ 10
Comorbidities

Neoplasm
+ 30
Liver disease
+ 20
Heart failure
+ 10
Stroke
+ 10
Renal failure
+ 10
Physical examination findings

Altered mental status
+ 20
Respiratory rate > 30 breaths per minute
+ 20
Systolic blood pressure < 90 mmHg
+ 20
Temperature < 95⁰F (35⁰C) or > 104⁰F (40⁰C)
+ 15
Pulse rate > 125 beats per minute
+ 10
Laboratory and radiographic findings

Arterial pH < 7,35
+ 30
Blood urea nitrogen > 30 mg/dL
+ 20
Sodium < 130 mmol/L
+ 20
Glucose > 250 mg/dL
+ 10
Hematocrit 30 percent
+ 10
Partial pressure of arterial oxygen < 60 mmHg
+ 10
Pleural effusion
+ 10
Total points



Sumber : Ebell Mh., Family Practice Management, 2006

TABEL 4. INTERPRETASI PSI


Deaths/total (%)

Point total
Risk class
Adults with CAP
Nursing home patients with CAP
Recommendation
< 51
I
3/1,472 (0,2)
None
Outpatient therapy should be considered, especially for patients in classes I and II
51 to 70
II
7/1,374 (0,5)
None
71 to 90
III
41/1,603 (2,6)
1/21 (4,8)
91 to 130
IV
149/1,605 (9,3)
6/50 (12,0)
Patient should be hospitalized
>130
V
109/438 (24,9)
28/85 (32,9)
Sumber : Ebell Mh., Family Practice Management, 2006

REFERENSI :
Ebell MH. Outpatient vs. Inpatient Treatment of Community Acquired Pneumonia. Family Practice Management. April 2006:41-44; http://www.aafp.org/fpm/20060400/41outp.html.
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. Clinical Infectious Diseases. 2007; 44:S27–72

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