A single-centre, prospective cohort study of COVID-19 patients admitted to ICU for mechanical ventilatory support

Sociodemographic Profile and Risk Factors for the Evolution of Patients with COVID-19 in ICUs in Brazil: A Cross-Sectional Study

This is a cross-sectional study, with secondary data from Brazilian hospitals in the state of Paraíba, between January 2021 and January 2022. The evolution of clinical cases configured the dependent variable (cure or death), while the predictive variables were sociodemographic data, risk factors, use of ventilatory support, and vaccination against COVID-19. With the help of R software, the following tests were used: chi-square, Pearson's chi-square, and Fisher's exact adherence. Simple logistic regression models were constructed, and odds ratios (95% CI) were estimated using the LR test and Wald test. 7373 cases were reported, with a mean age of 58.1. Of the reported cases, 63.8% died. The most frequent sociodemographic profile included male people, of mixed race, with less than eight years of schooling. Chronic cardiovascular disease (OR 1.28; 95% CI: 1.13-1.45), diabetes (OR 1.41; 95% CI: 1.24-1.61), lung disease (OR 1.52; 95% CI: 1.11-2.09), and the use of invasive ventilatory support (OR 14.1; 95% CI: 10.56-18.59) were all associated with increased mortality. Nonvaccination was associated with a decreased risk of death (OR 0.74; 95% CI: 0.65-0.84). Male patients, nonwhite, and those with low education were more likely to have a worse clinical outcome. The risk factors studied were related to deaths, and those who did not require ventilatory support were related to cure.

Exploring heterogeneity in reported venous thromboembolism risk in COVID-19 and comparison to other viral pneumonias: a systematic review and meta-regression

Background

Sources of heterogeneity in venous thromboembolism (VTE) risk in COVID-19 are unclear and comparisons to other viruses are lacking.

Objectives

To describe VTE risk in patients with COVID-19, explore sources of heterogeneity, and make comparisons with other viral pneumonia.

Methods

PubMed and Embase data were searched on March 14, 2021, for studies on VTE in adults hospitalized with viral pneumonia. VTE risk estimates were pooled in a random effects meta-analysis stratified by virus type. Heterogeneity in COVID-19 was explored in multivariable meta-regression.

Results

Seventy studies in COVID-19 (intensive care [ICU] [47] vs ward [23]), 4 studies in seasonal influenza (ICU [3] vs ward [1]), 2 ICU studies in H1N1 and 1 ICU study in SARS-CoV-1 were included. For COVID-19 ICU, pooled VTE risk was 19.6% (95% confidence interval [CI], 16.2%-23.5; I2 = 92.8%) for nonscreening studies and 30.0% (95% CI, 17.9%-45.7%; I2 = 81.9%) for screening studies. For COVID-19 ward, pooled VTE risk was 3.4% (95% CI, 2.4%-4.7%; I2 = 91.3%) and 22.5% (95% CI, 10.2%-42.7%; I2 = 91.6%) for nonscreening and screening studies, respectively. Higher sample size was associated with lower VTE risk. Pooled VTE risk in seasonal influenza and H1N1 at ICU were 9.0% (95% CI, 5.6%-14.2%; I2 = 39.7%) and 29.2% (95% CI, 8.7%-64.2%; I2 = 77.9%), respectively. At ward, VTE risk of seasonal influenza was 2.4% (95% CI, 2.1%-2.7%). In SARS-CoV-1, VTE risk was 47.8% (95% CI, 34.0-62.0).

Conclusion

Pooled risk estimates in COVID-19 should be interpreted cautiously as a high degree of heterogeneity is present, which hinders comparison to other viral pneumonia. The association of VTE risk in COVID-19 to sample size suggests publication bias.

Risk Factors for Mortality of Hospitalized Adult Patients with COVID-19 Pneumonia: A Two-Year Cohort Study in a Private Tertiary Care Center in Mexico

During the COVID-19 pandemic, the high prevalence of comorbidities and the disparities between the public and private health subsystems in Mexico substantially contributed to the severe impact of the disease. The objective of this study was to evaluate and compare the risk factors at admission for in-hospital mortality of patients with COVID-19. A 2-year retrospective cohort study of hospitalized adult patients with COVID-19 pneumonia was conducted at a private tertiary care center. The study population consisted of 1258 patients with a median age of 56 ± 16.5 years, of whom 1093 recovered (86.8%) and 165 died (13.1%). In the univariate analysis, older age (p < 0.001), comorbidities such as hypertension (p < 0.001) and diabetes (p < 0.001), signs and symptoms of respiratory distress, and markers of acute inflammatory response were significantly more frequent in non-survivors. The multivariate analysis showed that older age (p < 0.001), the presence of cyanosis (p = 0.005), and previous myocardial infarction (p = 0.032) were independent predictors of mortality. In the studied cohort, the risk factors present at admission associated with increased mortality were older age, cyanosis, and a previous myocardial infarction, which can be used as valuable predictors for patients' outcomes. To our knowledge, this is the first study analyzing predictors of mortality in COVID-19 patients attended in a private tertiary hospital in Mexico.

Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome Patients Requiring Invasive Mechanical Ventilation in a Lower Middle-Income Country

Background

COVID-19 related acute respiratory distress syndrome (ARDS) requires intensive care, which is highly expensive in lower-income countries. Outcomes of COVID-19 patients requiring invasive mechanical ventilation in Pakistan have not been widely reported. Identifying factors forecasting outcomes will help decide optimal care levels and prioritise resources.

Methods

A single-centre, retrospective study on COVID-19 patients requiring invasive mechanical ventilation was conducted from 1st March to 31st May 2020. Demographic variables, physical signs, laboratory values, ventilator parameters, complications, length of stay, and mortality were recorded. Data were analysed in SPSS ver.23.

Results

Among 71 study patients, 87.3% (62) were males, and 12.7% (9) were females with a mean (SD) age of 55.5(13.4) years. Diabetes mellitus and hypertension were the most common comorbidities in 54.9% (39) patients. Median(IQR) SOFA score on ICU admission and at 48 hours was 7(5-9) and 6(4-10), and median (IQR) APACHE-II score was 15 (11-24) and 13(9-23), respectively. Overall, in-hospital mortality was 57.7%; 25% (1/4), 55.6% (20/36) and 64.5% (20/31) in mild, moderate, and severe ARDS, respectively. On univariate analysis; PEEP at admission, APACHE II and SOFA score at admission and 48 hours; Acute kidney injury; D-Dimer>1.5 mg/L and higher LDH levels at 48 hours were significantly associated with mortality. Only APACHE II scores at admission and D-Dimer levels> 1.5 mg/L were independent predictors of mortality on multivariable regression (p-value 0.012 & 0.037 respectively). Admission APACHE II scores, Area under the ROC curve for mortality was 0.80 (95%CI 0.69-0.90); sensitivity was 77.5% and specificity 70% (cut-off ≥13.5).

Conclusion

There was a high mortality rate in severe ARDS. The APACHE II score can be utilised in mortality prediction in COVID-19 ARDS patients. However, larger-scale studies in Pakistan are required to assess predictors of mortality.

Coronavirus Disease 2019 as Cause of Viral Sepsis: A Systematic Review and Meta-Analysis

OBJECTIVE

Coronavirus disease 2019 is a heterogeneous disease most frequently causing respiratory tract infection, which can induce respiratory failure and multiple organ dysfunction syndrome in its severe forms. The prevalence of coronavirus disease 2019-related sepsis is still unclear; we aimed to describe this in a systematic review.

DATA SOURCES

MEDLINE (PubMed), Cochrane, and Google Scholar databases were searched based on a prespecified protocol (International Prospective Register for Systematic Reviews: CRD42020202018).

STUDY SELECTION

Studies reporting on patients with confirmed coronavirus disease 2019 diagnosed with sepsis according to sepsis-3 or according to the presence of infection-related organ dysfunctions necessitating organ support/replacement were included in the analysis. The primary end point was prevalence of coronavirus disease 2019-related sepsis among adults hospitalized in the ICU and the general ward. Among secondary end points were the need for ICU admission among patients initially hospitalized in the general ward and the prevalence of new onset of organ dysfunction in the ICU. Outcomes were expressed as proportions with respective 95% CI.

DATA EXTRACTION

Two reviewers independently screened and reviewed existing literature and assessed study quality with the Newcastle-Ottawa Scale and the Methodological index for nonrandomized studies.

DATA SYNTHESIS

Of 3,825 articles, 151 were analyzed, only five of which directly reported sepsis prevalence. Noting the high heterogeneity observed, coronavirus disease 2019-related sepsis prevalence was 77.9% (95% CI, 75.9-79.8; I2 = 91%; 57 studies) in the ICU, and 33.3% (95% CI, 30.3-36.4; I2 = 99%; 86 studies) in the general ward. ICU admission was required for 17.7% (95% CI, 12.9-23.6; I2 = 100%) of ward patients. Acute respiratory distress syndrome was the most common organ dysfunction in the ICU (87.5%; 95% CI, 83.3-90.7; I2 = 98%).

CONCLUSIONS

The majority of coronavirus disease 2019 patients hospitalized in the ICU meet Sepsis-3 criteria and present infection-associated organ dysfunction. The medical and scientific community should be aware and systematically report viral sepsis for prognostic and treatment implications.

Longer Prehospitalization and Preintubation Periods in Intubated Non-survivors and ECMO Patients With COVID-19: A Systematic Review and Meta-Analysis

Purpose: There is no clear consensus on the clinical course of critical COVID-19 patients. We examined the clinical course among intubated survivors, non-survivors, and extracorporeal membrane oxygenation (ECMO) patients to reveal the standard clinical course and the difference among critical COVID-19 patients.

Methods: In this systematic review and meta-analysis, we searched PubMed, Web of Science, and Scopus for original studies published until December 11, 2020, including case accumulation and clinical course reporting. Pregnant patients and children were excluded. We followed PRISMA guidelines and registered them with PROSPERO (CRD42021235534).

Results: Of the 11,716 studies identified, 94 met the selection criteria, and 2,549 cases were included in this meta-analysis. The times from intubation to extubation and death were 12.07 days (95% confidence interval 9.80–14.33 days) and 10.14 days (8.18–12.10 days), respectively, and the ECMO duration was 14.72 days (10.57–18.87 days). The time from symptom onset to hospitalization (prehospitalization period) of intubated survivors, non-survivors, and ECMO patients was 6.15 (4.61–7.69 days), 6.45 (4.55–8.34 days), and 7.15 days (6.48–7.81 days), and that from symptom onset to intubation (preintubation period) was 8.58 (7.36–9.80 days), 9.14 (7.26–11.01 days), and 10.54 days (9.18–11.90 days), respectively. Sensitivity analysis showed that the time from intubation to extubation and death was longer in the US and Europe than in East Asia.

Conclusion: For COVID-19, we hypothesize that prehospitalization and preintubation periods are longer in intubated non-survivors and ECMO patients than in intubated survivors. These periods may serve as a predictor of disease severity or death and support therapeutic strategy determination.

Low mortality rates among critically ill adults with COVID-19 at three non-academic intensive care units in south Sweden

Background

The COVID‐19 pandemic has put an exceptional strain on intensive care units worldwide. During the first year, the survival of patients with acute hypoxaemic respiratory failure appears to have improved. We aimed to describe the mortality rates, management characteristics and two pandemic waves during the first year at three non‐academic rural intensive care units in Sweden.

Methods

We retrospectively analysed all cases of COVID‐19 admitted to intensive care units in Region Jönköping County during 1 year. The primary endpoint was 30‐day mortality.

Results

Between 14th March 2020 and 13th March 2021, 264 patients were admitted to undergo intensive care with confirmed SARS‐CoV‐2 infection. The 30‐day mortality rate after the initial intensive care admission was 12.9%, and this rate remained unchanged during both pandemic waves. However, we found several distinct differences between the two pandemic waves, including an increase in the use of high‐flow nasal oxygen but a decrease in invasive mechanical ventilation use, biochemical markers of inflammation, continuous renal replacement therapy and length of stay in the intensive care unit.

Conclusion

Our study showed that critically ill patients with COVID‐19 in Sweden have a low 30‐day mortality rate which compares well with results published from academic centres and national cohorts throughout Scandinavia. During the second pandemic wave, the proportion of patients receiving invasive mechanical ventilation and continuous renal replacement therapy was lower than that in the first wave. This could be the result of increased knowledge and improved therapeutic options.

Prognostic Factors in Hospitalized COVID-19 Patients at the Start of the Pandemic in Colombia: A Retrospective Cohort Study

Introduction Different factors are critical when assessing COVID-19 mortality, and can explain why severity differs so widely among populations. However, there is little information regarding prognostic factors and mortality in COVID-19 from Latin American countries. Objectives To determine prognostic factors in hospitalized COVID-19 patients and to evaluate the impact of tocilizumab use in patients with hyperinflammatory syndrome and severe disease defined by the National Early Warning Score 2 (NEWS2) with a value greater than or equal to seven points. Materials and methods This retrospective cohort study included hospitalized COVID-19 patients from May to July 2020. A multivariate logistic regression analysis was performed to determine independent factors associated with mortality. Results A total of 136 patients required hospital admission. In-hospital mortality was 39.7%. Mortality was observed to be potentiated by older age, LDH serum levels and the presence of type 2 diabetes mellitus. Lymphopenia and lower PaO2/FiO2 ratio were more common in these patients. Similarly, patients who died were classified more frequently with severe disease. The independent factors associated with in-hospital mortality were age greater than 65 years, type 2 diabetes mellitus, NEWS2 greater than or equal to seven points and LDH greater than 400U/L. The use of Tocilizumab alone was not related with decreased in-hospital mortality. Subgroup analysis performed in patients with hyperinflammation and severe disease showed similar results. Conclusions COVID-19 mortality in hospitalized patients was high and mainly related with older age, comorbidities, LDH and the severity of disease at hospital admission.

A single-centre, prospective cohort study of COVID-19 patients admitted to ICU for mechanical ventilatory support

BACKGROUND

Mortality rates in COVID-19 patients in need of mechanical ventilation are high, with wide variations between countries. Most studies were retrospective, and results may not be generalizable due to differences in demographics, healthcare organization and surge capacity. We present a cohort of mechanically ventilated COVID-19 patients from a resource-rich, publicly financed healthcare system.

METHODS

Prospective study from a tertiary hospital. Consecutive SARS-CoV-2 positive adult patients admitted to the ICU for mechanical ventilation from 10 March 2020 to 04 May 2020 were included. Triage and treatment were protocolized. High-dose dalteparin was adjusted by D-dimer. Demographics, treatments and high-resolution physiological variables were collected. Outcomes were 30-day and hospital mortality. Data are medians (quartiles).

RESULTS

Of the 1484 persons in the hospital catchment area testing positive for SARS-CoV-2, 201 (13.5%) were hospitalized. Thirty-eight (19%) patients were mechanically ventilated, of whom five (13%) died. Of the 163 patients treated with supplemental oxygen, eight (5%) died. In ventilated patients (75% males, age 61 (53-70) years), severe, moderate and mild ARDS was present in 25%, 70% and 5%. Tidal volume ≤8 mL/kg ideal bodyweight was achieved in 34 (94%) patients. Proning and neuromuscular blockers were used in 19 (54%) and 20 (61%) patients. Duration of ventilation was 12 days (8-23). D-dimer peaked at 3.8 mg/L (2.1-5.3), and maximum dalteparin dose was 15 000 IU/24 h (10 000-15 000). Despite organizational changes, a high degree of adherence to treatment protocols was achieved.

CONCLUSION

In a prospective cohort study of mechanically ventilated COVID-19 patients treated in a resource-rich, publicly financed healthcare system, mortality was considerably lower than previously reported in retrospective studies.

Pre-hospital critical care management of severe hypoxemia in victims of Covid-19: a case series

Objective

Despite critical hypoxemia, Covid-19 patients may present without proportional signs of respiratory distress. We report three patients with critical respiratory failure due to Covid-19, in which all presented with severe hypoxemia refractory to supplemental oxygen therapy. We discuss possible strategies for ventilatory support in the emergency pre-hospital setting, and point out some pitfalls regarding the management of these patients. Guidelines for pre-hospital care of critically ill Covid-19 patients cannot be established based on the current evidence base, and we have to apply our understanding of respiratory physiology and mechanics in order to optimize respiratory support.

Methods

Three cases with similar clinical presentation were identified within the Norwegian national helicopter emergency medical service (HEMS) system. The HEMS units are manned by a consultant anaesthesiologist.

Patient’s next of kin and the Regional committee for medical and health research ethics approved the publication of this report.

Conclusion

Patients with Covid-19 and severe hypoxemia may pose a considerable challenge for the pre-hospital emergency medical services. Intubation may be associated with a high risk of complications in these patients and should be carried out with diligence when considered necessary. The following interventions are worth considering in Covid-19 patients with refractory hypoxemia before proceeding to intubation. First, administering oxygen via a tight fitting BVM with an oxygen flow rate that exceeds the patient’s ventilatory minute volume. Second, applying continuous positive airway pressure, while simultaneously maintaining a high FiO₂. Finally, assuming the patient is cooperative, repositioning to prone position.

Clinical characteristics and outcomes of critically ill patients with COVID-19 admitted to an intensive care unit in London: A prospective observational cohort study

BACKGROUND

Cohorts of severely ill patients with COVID-19 have been described in several countries around the globe, but to date there have been few published reports from the United Kingdom (UK). Understanding the characteristics of the affected population admitted to intensive care units (ICUs) in the UK is crucial to inform clinical decision making, research and planning for future waves of infection.

METHODS

We conducted a prospective observational cohort study of all patients with COVID-19 admitted to a large UK ICU from March to May 2020 with follow-up to June 2020. Data were collected from health records using a standardised template. We used multivariable logistic regression to analyse the factors associated with ICU survival.

RESULTS

Of the 156 patients included, 112 (72%) were male, 89 (57%) were overweight or obese, 68 (44%) were from ethnic minorities, and 89 (57%) were aged over 60 years of age. 136 (87%) received mechanical ventilation, 77 (57% of those intubated) were placed in the prone position and 95 (70% of those intubated) received neuromuscular blockade. 154 (99%) patients required cardiovascular support and 44 (28%) required renal replacement therapy. Of the 130 patients with completed ICU episodes, 38 (29%) died and 92 (71%) were discharged alive from ICU. In multivariable models, age (OR 1.13 [95% CI 1.07-1.21]), obesity (OR 3.06 [95% CI 1.16-8.74]), lowest P/F ratio on the first day of admission (OR 0.82 [95% CI 0.67-0.98]) and PaCO2 (OR 1.52 [95% CI 1.01-2.39]) were independently associated with ICU death.

CONCLUSIONS

Age, obesity and severity of respiratory failure were key determinants of survival in this cohort. Multiorgan failure was prevalent. These findings are important for guiding future research and should be taken into consideration during future healthcare planning in the UK.