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COVID-19 Mortality 30% in Intubated US Group-Well Below Prior Reports
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Mark Mascolini
Among 217 people critically ill with COVID-19 in 3 Atlanta hospitals, mortality among those needing mechanical ventilation stood at 30%-well below the 50% to 97% reported in previous studies of this coronavirus infection [1]. This retrospective analysis at 3 Emory University hospitals found that 26% of all critically ill people had died at the time of this report. The authors believe their findings support continued use of mechanical ventilation of COVID-19 patients with acute respiratory failure. The report appears as a medRxiv preprint that has not had peer review.
The Emory University researchers who conducted this study note that 15% to 20% of people diagnosed with COVID-19 require hospital admission and 3% to 5% need critical care. Prior reviews of critically ill COVID-19 patients in China and the United States determined that 50% to 97% of those needing mechanical ventilation died [2-7]. Those mortality figures lie significantly above rates ranging from 35% to 46% for people who require mechanical ventilation for H1N1 influenza pneumonia and other causes of acute respiratory distress syndrome. High mortality of intubated patients with COVID-19 led some to ask whether mechanical ventilation should be avoided in this group.
To offer further insight into mortality of critically ill inpatients with COVID-19, Emory University investigators conducted a retrospective cohort study across their academic health system. They included all COVID-19 patients admitted to 6 COVID-designated intensive care units (ICUs) at 3 Emory acute-care hospitals in Atlanta, Georgia. Participants had a positive SARS-CoV-2 PCR assay from March 6 through April 27, 2020.
Over this study period, participating hospitals admitted 217 critically ill adults with COVID-19. Median age stood at 64, 49 people (22.6%) were 75 or older, 153 (70.5%) were black, and 98 (45.2%) were women. High proportions had hypertension (61.7%) or diabetes (45.6), and 21 people (9.7%) had morbid obesity (body mass index 40+ kg/m2).
Among these 217 critically ill people, 165 (76%) needed mechanical ventilation, 143 (65.9%) needed vasopressor support for shock, and 63 (29%) needed renal replacement therapy (either continuous renal replacement or intermittent hemodialysis). About half of these people (114, 52.5%) got at least one dose of hydroxychloroquine, and 49 (22.6%) enrolled in a trial of remdesivir.
At the time of this report, 129 of the 217 critically ill patients (59.4%) recovered well enough to leave the ICU, 52 died in the ICU and 4 more after leaving the ICU for a mortality of 25.8%. Thirty-six people (16.6%) remain in the ICU, and 14 (38.9% of those still in the ICU) remain on mechanical ventilation.
Among 165 people who needed mechanical ventilation, 47 (28.5%) died in the ICU and 49 (29.7%) died in the hospital. Median age of people who died was significantly older than the age of people who survived (70 versus 61, P < 0.001). People who died were less likely to be morbidly obese and more likely to have coronary artery disease. Neither race nor sex affected mortality. Compared with people who survived, those who died in the ICU were more likely to require mechanical ventilation for respiratory failure (90.4% versus 66.7%, P < 0.001) and more likely to have shock requiring vasopressors (92.3% versus 50.4%, P < 0.001) or renal failure requiring renal replacement therapy (53.9% versus 14.7%, P < 0.001). Among 52 people who died in the ICU, median time from admission to death was 8 days.
The Emory investigators believe the lower death rates recorded in their critically ill COVID-19 patients “indicate that a majority of [these patients] can have good clinical outcomes and support the ongoing use of mechanical ventilation for patients with acute respiratory failure.”
The researchers suggested several reasons why their mortality numbers are better than those reported earlier in the United States and China: (1) The peak of the COVID-19 epidemic reached Georgia later than other regions and gave the Emory team “time to establish organizational structures, acquire equipment, prepare personnel, create consensus-driven clinical protocols, and align resources across a large healthcare system.” (2) All critically ill COVID-19 patients in the Emory system could receive care in established ICUs from critical care teams experienced with acute respiratory failure. (3) Patients received care at standard ICU patient-to-provider ratios.
References
1. Auld SC, Caridi-Scheible M, Blum JM, et al. ICU and ventilator mortality among critically ill adults with COVID-19. medRxiv preprint doi: https://doi.org/10.1101/2020.04.23.20076737 (The report appears as a medRxiv preprint that has not had peer review.)
2. Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in critically ill patients in the Seattle region-case series. N Engl J Med. 2020.Mar 30. doi: 10.1056/NEJMoa2004500.
3. Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA. 2020 Mar 19. doi: 10.1001/jama.2020.4326.
4. ICNARC report on COVID-19 in critical care. Intensive Care National Audit and Research Center, 2020. (Accessed April 17, 2020, at https://www.icnarc.org/About/Latest-News/2020/04/04/ReportOn-2249-Patients-Critically-Ill-With-Covid-19.)
5. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area. JAMA 2020 Apr 22. doi: 10.1001/jama.2020.6775.
6. Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med. 2020 Mar 13. doi: 10.1001/jamainternmed.2020.0994.
7. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395:1054-1062.
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