BACKGROUND
Community transmission of coronavirus 2019 (Covid-19) was detected in the state of Washington in February 2020.
METHODS
We 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 were obtained through review of medical records. The data reported here are those available through March 23, 2020. Each patient had at least 14 days of follow-up.
RESULTS
We identified 24 patients with confirmed Covid-19. The mean (±SD) age of the patients was 64±18 years, 63% were men, and symptoms began 7±4 days before admission. The most common symptoms were cough and shortness of breath; 50% of patients had fever on admission, and 58% had diabetes mellitus. All the patients were admitted for hypoxemic respiratory failure; 75% (18 patients) needed mechanical ventilation. Most of the patients (17) also had hypotension and needed vasopressors. No patient tested positive for influenza A, influenza B, or other respiratory viruses. Half the patients (12) died between ICU day 1 and day 18, including 4 patients who had a do-not-resuscitate order on admission. Of the 12 surviving patients, 5 were discharged home, 4 were discharged from the ICU but remained in the hospital, and 3 continued to receive mechanical ventilation in the ICU.
CONCLUSIONS
During the first 3 weeks of the Covid-19 outbreak in the Seattle area, the most common 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 high
This multicenter case series describes 24 critically ill patients who presented with acute hypoxemic respiratory failure and laboratory-confirmed Covid-19 infection. We included all patients with Covid-19 who were admitted to an ICU at nine Seattle-area hospitals between February 24 and March 9, 2020. All the patients had acquired Covid-19 without known exposure to a returning traveler. Coexisting lower respiratory bacterial infections were not identified in sputum and blood cultures obtained early in the clinical course. Overall outcomes were poor in patients who received ICU care.
The patients in our series presented with respiratory symptoms similar to those of patients described in reports from China, which indicates a common host response to SARS-CoV-2. Cough was the most common presenting symptom, as it was in reports from China, and the mean duration of symptoms before ICU admission was 1 week.Only half the patients had fever at the time of hospital admission, which suggests that fever may not be a useful criterion to determine the severity of illness and that diagnostic algorithms that require fever for Covid-19 testing may delay diagnosis. The majority of patients had chronic illnesses before their admission to the ICU, most commonly diabetes mellitus and chronic kidney disease. Lymphocytopenia was common on hospital admission, as it was in reports from China. The case fatality rate of 50% in this series (to date) is similar to that reported among critically ill patients in Chinese hospitals but lower than that in a single-center experience reported from our area.Although the case fatality rate was higher in persons 65 years of age or older, it was still substantial (37%) in persons younger than 65 years of age. Our case fatality rate may be an underestimate, given that 3 patients remained intubated at the time data were censored.
Patients who received mechanical ventilation had high oxygen requirements soon after initiation of mechanical ventilation, with plateau pressures (mean, 25 cm of water) and driving pressures (mean, 12 to 13 cm of water) similar to those in populations of patients with ARDS enrolled in clinical trials.For example, the mean plateau pressure in the Reevaluation of Systemic Early Neuromuscular Blockade (ROSE) trial was 25 to 26 cm of water. Of the 18 patients who received invasive mechanical ventilation in this series, 6 had been successfully extubated. The earliest extubation occurred 8 days after initiation of invasive mechanical ventilation, which suggests that acute respiratory failure due to Covid-19 may require prolonged mechanical ventilation lasting days to weeks and that readiness for extubation is unlikely to occur early in patients receiving mechanical ventilation. Of patients who were extubated, the age range was 23 to 88 years, which suggests that age may not be the sole indicator for successful extubation.
A large proportion of patients in this series presented with shock that required vasopressor support. In patients who had an echocardiogram, myocardial dysfunction was uncommon. The lack of bacterial or viral coinfection suggests that the observed shock was directly related to Covid-19. In these preliminary data, Covid-19 infection appears to differ from seasonal influenza, which is commonly associated with bacterial coinfection due to pathogens that colonize the nasopharynx, such as staphylococcus and streptococcus. Regarding antiviral interventions, 7 patients received compassionate-use remdesivir, but we have insufficient information to report associated outcomes. Bronchoscopy was performed in a minority of patients and did not appear to change clinical management.
Three patients with mild asthma had received systemic glucocorticoids within 1 week before ICU admission, as outpatients, for presumed asthma exacerbation while they had symptoms of Covid-19. These 3 patients then presented to the hospital again, with severe respiratory failure requiring invasive mechanical ventilation. Previous studies have shown that glucocorticoid treatment for phylogenetically similar viruses, SARS-CoV (2003) and Middle East respiratory syndrome coronavirus (MERS-CoV), was associated with a higher subsequent plasma viral load, longer duration of viremia, and worse clinical outcomes.These findings are in contrast to those of a recent nonrandomized observational study that suggested that glucocorticoids may be associated with improved clinical outcomes in patients with Covid-19 and ARDS.Further research is necessary to determine the role of systemic glucocorticoids in patients with Covid-19 infection.
Our study has several notable limitations. First, some cases had incomplete documentation of clinical symptoms, missing laboratory testing, or both. However, given the need to provide objective data and the urgent timeline, we did not approach patients to obtain additional history or biologic samples for laboratory measurement. Second, 7 patients (29%) remained in hospitals at the time of data censoring on March 23, 2020; as a result, outcomes for those patients were not known. Third, because of our focus on the critical care needs of patients with the greatest severity of illness, our sample size is small. Finally, it is possible that critically ill patients with established goals of care that were not consistent with admission to an ICU were not included in this report. Specifically, this includes patients who received care on the general medical ward that focused on comfort measures only.
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.
Reference & source information: https://www.nejm.org/
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