key: cord-0845271-svn73nko authors: Gul, Noor; Usman, Umer; Ahmed, Umair; Ali, Majid; Shaukat, Aamir; Imran, Mehar Muhammad title: Clinical characteristics and outcomes of patients with COVID‐19 pneumonia admitted to an intensive care unit in Faisalabad, Pakistan date: 2021-03-25 journal: Int J Clin Pract DOI: 10.1111/ijcp.14152 sha: 56aeb380ac080351afbec3f356b82a0c731372e1 doc_id: 845271 cord_uid: svn73nko AIM: To describe the clinical characteristics and outcomes of adult patients with severe COVID‐19, with the exploration of risk factors for mortality in the hospital. METHODS: This study included 20 adult patients diagnosed with COVID‐19 admitted to the ICU of DHQ Hospital, Faisalabad (Pakistan). Patients were categorised into the survival group and the death group according to the outcome. We retrieved demographics, clinical manifestations and signs, laboratory indicators, treatment measures and clinical outcomes from the medical record, and summarised the clinical characteristics and outcomes of these patients. RESULTS: The average age of patients was 70 ± 12 years, of which 40% were male. They were admitted to the ICU 11 days after the onset of symptoms. The most common symptoms on admission were cough (19 cases, 95%), fatigue or myalgia (18 cases, 90%), fever (17 cases, 85%) and dyspnoea (16 cases, 80%). Eleven (55%) patients had underlying diseases, of which hypertension was the most common (11 cases, 55%), followed by cardiovascular disease (4 cases, 20%) and diabetes (3 cases, 15%). Six patients (30%) received invasive mechanical ventilation and continuous renal replacement therapy and eventually died. Acute heart injury was the most common complication (19 cases, 95%). Ten (50%) patients died between 2 and 19 days after admission to the ICU. Compared with dead patients, the average body weight of surviving patients was lower (61.70 ± 2.36 vs 68.60 ± 7.15, P = .01), Glasgow Coma Scale score was higher (14.69 ± 0.70 vs 12.70 ± 2.45, P = .03), with fewer concurrent shocks (2 vs 10, P = .001) and acute respiratory distress syndrome (2 vs 10, P = .001). CONCLUSION: The mortality rate is high in critically ill patients with COVID‐19. Lower Glasgow Coma Scale, higher body weight and decreased lymphocyte count appear to be potential risk factors for the death of patients with COVID‐19 in the ICU. March 2020, because of the alarmingly increasing number of global cases of coronavirus disease 2019 (COVID- 19) , the World Health Organization declared the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a pandemic. 1 As of 18 August 2020, the number of globally confirmed COVID-19 cases exceeded 21 million, the number of existing active cases was more than 6 million of which patients with severe COVID-19 accounted for 1% and the mortality rate in 216 countries and regions, based on the cases which had an outcome, was 5%. 2, 3 With the spread of COVID-19 around the world, the intensive care unit (ICU) is one of the major rescue departments for severe pneumonia ensuing from COVID-19. 4 Numerous studies have described preliminary findings of the epidemiology of patients with COVID-19, 5 clinical features, outcomes and risk factors for death. [6] [7] [8] [9] However, there are relatively few studies that have reported clinical characteristics and survival outcomes of critically ill patients with COVID-19. A retrospective study from Italy has published baseline characteristics of patients with COVID-19 admitted to ICU. 10 Similarly, two retrospective studies from Wuhan also described the severe clinical course and outcome of critically ill patients with COVID-19. 11, 12 Another study from Wuhan has reported the poor outcomes in cancer patients infected with COVID- 19. 13 Current research shows that the mortality rate of patients with SARS-CoV-2 pneumonia in the ICU is extremely high, which exerts significant pressure on hospital intensive care resources. 11, 13 More evidence is required to better observe and summarise the characteristics and outcomes of patients with COVID-19 admitted to ICU, which would be essential to guide the treatment of ICU patients and the rational allocation of intensive care resources. This study aimed to describe the demographics, survival status, clinical outcomes and the risk factors of patients diagnosed with COVID-19 who were admitted to the ICU of District Headquarter (DHQ) Hospital, Faisalabad (Pakistan) from 10 May to 10 July 2020. According to the diagnostic and classification criteria of the National Institute of Health [NIH] Pakistan, 14 the following criteria were used to enrol the patients admitted to the ICU of DHQ Hospital, Faisalabad, because of COVID-19-associated pneumonia: 1. Age ≥18 years. 2. Patients who met the diagnostic criteria of NIH Pakistan for COVID-19 infection, which are as follows: 1. Clinical manifestations including fever and pulmonary symptoms (cough, shortness of breath, chest pain and tightness). 2. Radiological findings of consolidation, ground-glass opacities (GGOs) either on chest X-ray or high-resolution computed tomography (HRCT). The laboratory confirmation of SARS-CoV-2 infection was carried out by the local health department. Following patients were excluded from the study: 1. Patients with negative detection for novel coronavirus nucleic acid. 2. Heart failure with pulmonary oedema (non-COVID heart disease). 3. Allergic pneumonia (acute or chronic eosinophilic pneumonia). 4. Patient refusal to be enrolled in the study. Twenty eligible confirmed cases of patients with COVID-19 were available to be enrolled in the study in the above time period. This was a retrospective, cross-sectional, descriptive study conducted in the ICU of DHQ Hospital, Faisalabad (Pakistan), during the above time period. The facility was designated as a referral centre by the provincial health department to cater to ~13 million population from the surrounding districts. The patients from these districts were referred to this facility for the management of patients with COVID-19. • Mortality rate is higher in critically ill patients with COVID-19 and hypertension is the most commonly associated comorbidity in South Asian population also. • Lower GCS score, higher body weight and lymphocytopenia appear to be potential risk factors for the death of patients with COVID-19 in the ICU. According to the provisional guidelines of the NIH Pakistan, 14 the following definitions were employed in the study. with any one of the following features: 1. Respiratory rate ≥30/min at rest. 2. Oxygen saturation (SpO 2 ) ≤93% on room air. 3. Arterial oxygen partial pressure (PaO 2 )/oxygen uptake concentration (FiO 2 ) ≤300. Severe disease: Patients with moderate disease criteria plus any one of the following: 1. Oxygen requirement of more than 10 litres for 90% saturation. 2. 50% of lung involvement on either chest X-ray or HRCT. 3. CRP >10 mg/L, D-dimer >1000 mg/mL, serum ferritin >1000 ng/ mL. Continuous variables were expressed as means with standard deviation and 95% confidence interval. Categorical variables were expressed as frequencies (percentages) with 95% confidence interval. Where appropriate, the t-test and chi-squared test (Fisher's exact test where required) were used to compare the differences between the survival and death groups. Single-factor logistic analysis was used to explore the risk factors associated with hospital deaths. If the number of events was too small to calculate the odds ratio or there was collinearity between the variables, the variable was excluded from the univariate logistic analysis. A value of P < .05 was considered statistically significant unless otherwise stated. Twenty eligible patients diagnosed with severe COVID-19 pneumonia admitted to the ICU of DHQ Hospital, Faisalabad from 10 May to 10 July 2020 were included in the study. The mean age of the patients was 70 ± 12 years (35-85 years), 40% of them were male. The mean duration of symptoms before admission to the ICU of DHQ Hospital was 11 ± 9 days. The most common symptom on admission was cough. Other common symptoms include fatigue or myalgia (n = 18, 90%), fever (n = 17, 85%) and dyspnoea (n = 16, 80%). Six (30%) patients had more than one underlying disease. More than 50% (n = 11, 55%) of patients had underlying diseases, of which hypertension was the most common (n = 11, 55%), followed by cardiovascular diseases (n = 4, 20%) and diabetes (n = 3, 15%). Ten patients died during the ICU hospitalisation (hereinafter referred to as "death group") and 10 patients recovered and were discharged (hereinafter referred to as "survival group"). Table 1 represents the demographics, clinical characteristics and laboratory indicators of the patients in each group. Laboratory parameters showed that 11 patients (55%) developed lymphopenia (lymphocyte count < 0.8 × 10 9 /L), of which 8 patients eventually died (P = .07). The baseline lymphocyte count of the survival group was significantly higher than that of the death group. Among the survivors, the lymphocyte count was the lowest on days 1-3 after hospitalisation; however, it improved during hospitalisation while persistent lymphopenia was observed in the death group. The white blood cell count in the death group showed a increasing trend, and its mean value began to be higher than that in the survival group from 4 to 6 days after admission to the ICU of DHQ Hospital, The serum creatinine and blood urea nitrogen in the death group were significantly higher than those in the survival group, and the urine volume continued to decrease after 4-6 days of admission to the ICU. The D-dimer increased at admission to 6.91 ± 11.17 mg/ mL in all patients and 15 (75%) patients had D-dimer > 1 mg/mL. The duration of stay in ICU was 15 ± 11 days. Most patients (n = 19, 95%) required oxygen inhalation in the ICU. Fourteen patients (70%) required NIV support. All 10 patients in the death group received NIV treatment, of which 6 (30%) received further IMV treatment. Six patients receiving IMV also received CRRT because of multi-organ dysfunction. Acute heart injury was the most common complication (n = 19, 95%), followed by shock (n = 12, 60%), ARDS (n = 12, 60%) and pneumothorax (n = 2, 10%). The death group patients were all considered complicated with shock and ARDS, and the probability of complicating shock and ARDS in the death group was significantly higher than that in the survival group (100% vs 20%, P = .001; 100% vs 20%, P = .001). Table 2 represents the treatment measures, complications and clinical outcomes of the patients. Half of the patients (10 patients) died between 2 and 19 days after admission to the ICU. Figure Table 3 represents the association of various factors with death in the regression model. Our critically ill patients with COVID-19 were older which is in line with other studies. 8, 18 In previous studies involving patients with severe COVID-19, most common symptoms were fever, cough, fatigue and dyspnoea. [6] [7] [8] [9] 11, 18 Similarly, the incidence of cough, fatigue or myalgia, fever and dyspnoea on admission in our study were 95% (n = 19), 90% (n = 18), 85% (n = 17) and 80% (n = 16), respectively. In these patients, mean duration of symptoms was 11 ± 9 days from onset to ICU admission, and the previous studies More than half of the patients (n = 11, 55%) in our centre had underlying diseases, similar to the data reported by the study from Wuhan (n = 64, 46%). 8 However, a much higher percentage of patients has been reported in other studies. 7, 18 Similar to the previous studies, 8, 18 hypertension was the most common comorbidity, fol- Most critically ill patients in our centre had an increased LDH (n = 17, 85%) when they were admitted, slightly higher than the 76% 6 and 67% 5 observed in patients from the other studies. All patients in our study had elevated D-dimers on admission and 15 (75%) patients had D-dimers > 1 mg/L. However, in the study of patients with moderate COVID-19, only 36% had an increase in D-dimer. 6 Another early study from Wuhan also showed that ICU patients had a higher level of D-dimer (median D-dimer level of 2.4 mg/L) than non-ICU patients (median D-dimer level of 0.5 mg/L). Studies have also found that D-dimer >1 mg/L has been associated with increased mortality of patients. 5 Our study did not observe differences between the survival and death groups in terms of D-dimer, which may be related to small sample size. The CRP of all patients in our study was increased to 101.46 ± 65.60 mg/L, which was much higher than the average CRP in patients with moderate COVID-19, 51.4 ± 41.8 mg/L. 6 The probability of CRP increase (100%) was also higher in our study than that of patients with moderate COVID-19, 60.7% 18 and 86%. 6 Similarly, the probability of elevated ProCT (85%, n = 17) was much higher in our study than the 6% to 30% probability found in patient with moderate COVID-19 studies. 5, 6, 18 It is, therefore, suggested that secondary bacterial infection may be a complication in severe patients and cannot be disregarded. Mechanical ventilation is the main supportive treatment for critically ill patients with COVID-19. In our study, only six patients (30%) received further IMV treatment, which is much lower than reported in other ICU patients: 88% (Lombardy, Italy), 10 47% (Wuhan), 8 42% (Wuhan) 11 and 30% (Wuhan). 7 Non-invasive ventilation was used [5, 6 9-11] . [7] [8] [9] [10] [11] In our study, acute heart injury was the most common (19 cases, 95%), followed by ARDS (12 cases, 60%), shock (12 cases, 60%) and pneumothorax (2 cases, 10%). A study of patients with mild COVID-19 in Wuhan reported that 53% of patients in their cohort died of respiratory failure, 7% died of shock (probably caused by fulminant myocarditis) and 33% of patients died of both conditions. 21 In our study, the 10 patients in the death group were all complicated with shock and ARDS. The probability of death and ARDS in the death group was much higher than that in the survival group. Because of the limited sample size, this study failed to show the association of concurrent ARDS or shock with the death of patients. In summary, critically ill patients with COVID-19 tend to be relatively older. Hypertension is the most common underlying condition in critically ill patients with COVID-19. The mortality rate is high in critically ill patients with COVID-19. Lower GCS score, higher body weight and decreased lymphocyte count appear to be potential risk factors for the death of patients with COVID-19 in the ICU. The authors declare no conflict of interest. NG designed the study. All authors were involved in data collection, Abbreviations: ALT, alanine transaminase; APTT, activated partial thromboplastin time; BMI, body mass index; BNP, B-type natriuretic peptide; BUN, blood urea nitrogen; CI, confidence interval; CK, creatine kinase; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; GCS, Glasgow Coma Scale; LDH, Lactate dehydrogenase; OR, odds ratio; ProCT, procalcitonin; PT, prothrombin time. 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