Outcomes of Critically Ill Adults With COVID-19 in New York City
Quick Takes
- Critical illness is common in hospitalized patients with COVID-19.
- Predominant features of COVID-19 critical illness are the need for mechanical ventilation and renal replacement therapy.
- Obesity, older age, and cardiac and pulmonary disease are the main risk factors for in-hospital mortality.
Study Questions:
What are the clinical characteristics, clinical course, and outcomes of critically ill patients with coronavirus disease 2019 (COVID-19)?
Methods:
In this observational study of hospitalized patients at two New York-Presbyterian Hospitals in Manhattan, the authors identified 257 (22%) critically ill patients among 1,150 adults hospitalized with COVID-19 between March 2 and April 1, 2020. Critical illness was defined as requiring admission to the intensive care or high-dependency unit. Clinical characteristics, laboratory results, imaging findings, biomarker data, and outcomes were collected. The primary outcome was in-hospital death. Secondary outcomes included mechanical ventilation, renal replacement therapy, and time to in-hospital clinical deterioration defined as an increase of ≥1 point from baseline on a 7-point ordinal scale recommended by the World Health Organization for clinical research in COVID-19.
Results:
Among critically ill patients, the median age of patients was 62 years and the majority (67%) were men. Two thirds (62%) were Hispanic or Latino, and 13 (5%) were health care workers. Most patients (82%) had ≥1 chronic illness, and nearly one half were obese (46%). Most patients had proteinuria on urinalysis (87%). Inflammatory biomarkers (interleukin-6, high-sensitivity C-reactive protein, ferritin, D-dimer, and procalcitonin) were elevated in most patients. The vast majority of patients (79%) required prolonged mechanical ventilation, lasting a median of 27 days for survivors. Two thirds (66%) of patients received vasopressors and 31% received renal replacement therapy during hospitalization. Overall mortality was 39%, with a median hospitalization of 9 days. Over one third (37%) of patients were still hospitalized at the time of analysis. Independent predictors of mortality included age, pre-existing cardiac or pulmonary disease, D-dimer, and interleukin-6 levels.
Conclusions:
Critical illness occurs in over 20% of patients hospitalized with COVID-19 and is associated with a high frequency of invasive mechanical ventilation, extrapulmonary organ dysfunction, and substantial in-hospital mortality.
Perspective:
This study provides interesting epidemiologic and outcomes data on critical illness in COVID-19, confirming prior observations such as the association between age, obesity, and mortality; the high frequency of mechanical ventilation and renal replacement therapy; and proteinuria. Interestingly, while most of the patients were men, there were no differences in in-hospital mortality between men and women, suggesting that while women may be at lower risk for critical illness, those who do experience severe forms of COVID-19 have similar outcomes as men. While cardiovascular disease was a risk factor for poor outcomes, no data on cardiovascular events aside from the troponin levels are provided in this study. Last, findings may not be generalizable, as the study had a relatively small sample size, and was limited to two New York centers with an ethnic makeup that may not be reflective of many other health care systems burdened by COVID-19.
Clinical Topics: COVID-19 Hub, Dyslipidemia, Noninvasive Imaging, Prevention, Lipid Metabolism
Keywords: Coronavirus, COVID-19, C-Reactive Protein, Critical Illness, Diagnostic Imaging, Ferritins, Hospital Mortality, Interleukin-6, Obesity, Outcome Assessment, Health Care, Primary Prevention, Proteinuria, Renal Insufficiency, Respiration, Artificial, Risk Factors, Troponin
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