New Study Provides Additional Insight About Critical Patients Amid the COVID-19 Pandemic

^{By: Yvette C. Terrie, RPh, consultant pharmacist}

A new study published in The New England Journal of Medicine has presented further characterization of critically ill patients with COVID-19 who obtained treatment. Lead author, Bhatraju et al identified patients from nine Seattle-area hospitals who were admitted to the intensive care unit (ICU) with confirmed infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Clinical data was obtained through review of medical records. The publication indicates that the data reported was from data available through March 23, 2020. Each patient had at least 14 days of follow-up. In this case series, researchers identified 24 patients with confirmed COVID-19. The following was revealed:

• The mean (±SD) age of the patients was 64±18 years, 63% were men.  
• No patient tested positive for influenza A, influenza B, or other respiratory viruses.
• Chronic medical conditions were frequent: 14 patients (58%) had diabetes mellitus and 5 (21%) had chronic kidney disease; 3 patients (14%) had asthma, and all 3 had recently received, as an outpatient, systemic glucocorticoids for a presumed asthma exacerbation before becoming critically ill.
• Five patients (23%) were also current or former smokers and 1 patient (4%) had chronic obstructive pulmonary disease; 8 patients (33%) had more than one coexisting condition and almost one-third had more than one coexisting condition.
• Symptoms began on average 7 days before admission.
• The most common symptoms were cough and shortness of breath each of which were present in 88% of patients; 50% of patients had fever on admission.
• All the patients were admitted for hypoxemic respiratory failure; 75% (18 patients) needed mechanical ventilation.
• The results revealed that 71% of patients (17 patients) also presented with hypotension needing 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 apparent in the 38% of patients who had an echocardiogram.
• Almost two-thirds were admitted from home and one-quarter were admitted from a skilled nursing facility.
• All patients had at least 14 days of hospital follow-up. As of March 23, of the 24 patients, 12 (50%) had died, 4 (17%) had been discharged from the ICU but remained in the hospital, 3 (13%) were receiving mechanical ventilation and were still in the ICU, and 5 (21%) had been discharged from the hospital
• The researchers noted that more patients aged older vs. younger than 65 years had died (62% vs. 37%).

The researchers concluded that during the first 3 weeks of the COVID-19 outbreak in the Seattle area, the most widespread reasons for admission to the ICU were hypoxemic respiratory failure leading to mechanical ventilation, hypotension requiring vasopressor treatment, or both. Mortality among these critically ill patients was elevated.

The authors noted that, “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. 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.”

Yvette C. Terrie, RPh, is a consultant pharmacist, medical writer, and the creator of A Pharmacist’s Perspective (https://apharmacistsperspective.blogspot.com ).

References

1. Bhatraju PK, Doremalen Nvan, Fauci AS, Holshue ML, Computed Tomographic Imaging of Patient, Computed Tomographic Imaging of Patient. Covid-19 in Critically Ill Patients in the Seattle Region - Case Series [publishes online March 30, 2020]. N Eng J Med. doi: 10.1056/NEJMoa2004500
2. Study further characterizes critical illness in COVID-19. Healio website. https://www.healio.com/pulmonology/critical-care/news/online/%7Bb2cd684e-f910-46b9-9697-9f9112c13967%7D/study-further-characterizes-critical-illness-in-covid-19  Published April 1, 2020. Accessed April 2, 2020.