Study further characterizes critical illness in COVID-19

A new study published in The New England Journal of Medicine has offered further characterization of critically ill patients with COVID-19 who received treatment in the Seattle region.

This case series adds to data from a single-center study, which was previously published in JAMA, describing initial characteristics of patients with COVID-19 admitted to the ICU in Kirkland, Washington.

In this case series, the researchers evaluated data from 24 adults with lab-confirmed COVID-19 infection who were admitted to nine Seattle-area ICUs from Feb. 24 to March 9. All patients had at least 14 days of follow-up.

The patients’ mean age was 64 years and 63% were men. Chronic medical conditions were common, with 58% of patients having diabetes, 21% having chronic kidney disease, 14% having asthma and 4% having COPD. Twenty-two percent were also current or former smokers and approximately one-third had more than one coexisting condition. Notably, all three patients with asthma received systemic glucocorticoids as an outpatient for presumed asthma exacerbation before becoming critically ill.

Patients experienced symptoms for an average of 7 days before hospital admission. The most common symptoms were cough and shortness of breath, each of which were present in 88% of patients. Fever, however, was present in only 50% upon presentation to the hospital. Approximately two-thirds were admitted from home and one-quarter were admitted from a skilled nursing facility, according to the researchers.

All patients were admitted to the ICU for hypoxemic respiratory failure, with 75% requiring mechanical ventilation. Seventy-one percent of patients also presented with hypotension requiring vasopressors with no clear evidence of secondary infection. Of these patients, 18% had transient hypotension after intubation and 82% had hypotension that was unrelated to intubation or that persisted for more than 12 hours after intubation. New cardiac dysfunction was not evident in the 38% of patients who had an echocardiogram.

No patients tested positive for influenza A, influenza B or other respiratory viruses.

Results showed that outcomes were poor, with half of patients dying between day 1 and day 18, according to the researchers. Of these, four patients had do-not-resuscitate orders on admission. The researchers noted that more patients aged older vs. younger than 65 years had died (62% vs. 37%).

Five of the 12 surviving patients were discharged home, four were discharged from the ICU but remained in the hospital and three continued to receive mechanical ventilation in the ICU. Among those who survived, the median length of hospital stay was 17 days, the median length of ICU stay was 14 days and the median duration of mechanical ventilation was 10 days. One-third of patients had been extubated by the study’s conclusion on March 23.

“This early experience of the COVID-19 pandemic in the United States resembles the experience in other countries, with high mortality for patients requiring care in the ICU. Patients with coexisting conditions and older age are at risk for severe disease and poor outcomes after ICU admission. Better information is needed to inform care for these challenging patients,” the researchers wrote. “Our findings also highlight the importance of planning for mass critical care as the need for ICU care and ventilatory support to treat patients with COVID-19 grows rapidly in the United States.” – by Melissa Foster

Disclosures: This study was funded by the NIH. Bhatraju reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.