key: cord-0835852-c96qks7n
authors: Shi, Ming; Chen, Lianhua; Yang, Yadong; Zhang, Jingpeng; Xu, Ji; Xu, Gang; Li, Bin; Yin, Yiping
title: Analysis of clinical features and outcomes of 161 patients with severe and critical COVID‐19: A multicenter descriptive study
date: 2020-06-02
journal: J Clin Lab Anal
DOI: 10.1002/jcla.23415
sha: c1b8ea19bf8bcd84e72b15512ec66fa5889bd8a7
doc_id: 835852
cord_uid: c96qks7n

BACKGROUND: This study aimed to investigate clinical characteristics, laboratory indexes, treatment regimens, and short‐term outcomes of severe and critical coronavirus disease 2019 (COVID‐19) patients. METHODS: One hundred and sixty one consecutive severe and critical COVID‐19 patients admitted in intensive care unit (ICU) were retrospectively reviewed in this multicenter study. Demographic features, medical histories, clinical symptoms, lung computerized tomography (CT) findings, and laboratory indexes on admission were collected. Post‐admission complications, treatment regimens, and clinical outcomes were also documented. RESULTS: The mean age was 59.38 ± 16.54 years, with 104 (64.60%) males and 57 (35.40%) females. Hypertension (44 [27.33%]) and diabetes were the most common medical histories. Fever (127 [78.88%]) and dry cough (111 [68.94%]) were the most common symptoms. Blood routine indexes, hepatic and renal function indexes, and inflammation indexes were commonly abnormal. Acute respiratory distress syndrome (ARDS) was the most common post‐admission complication (69 [42.86%]), followed by electrolyte disorders (48 [29.81%]), multiple organ dysfunction (MODS) (37 [22.98%]), and hypoproteinemia (36 [22.36%]). The most commonly used antiviral drug was lopinavir/ritonavir tablet. 50 (31.06%) patients died, while 78 (48.45%) patients healed and discharged, and the last 33 (20.50%) patients remained in hospital. Besides, the mean hospital stay of deaths was 21.66 ± 11.18 days, while the mean hospital stay of discharged patients was 18.42 ± 12.77 days. Furthermore, ARDS (P < .001) and MODS (P = .008) correlated with increased mortality rate. CONCLUSION: Severe and critical COVID‐19 presents with high mortality rate, and occurrence of ARDS or MODS greatly increases its mortality risk.

Severe and critical disease was defined according to 7th version of the guidelines on the Diagnosis and Treatment of COVID-19 issued by the National Health Commission of China as follows: (a) Severe disease, met anyone of the following criteria: shortness of breath, respiratory rate (RR) ≥30 times/min; finger pulse oxygen saturation ≤93% in resting state; arterial partial oxygen pressure (PaO 2 )/oxygen absorption concentration (FiO 2 ) ≤300 mm Hg (1 mm Hg = 0.133 kpa); pulmonary imaging showed that the lesions progressed more than 50% within 24-48 hours. (b) Critical disease, met anyone of the following conditions: respiratory failure and need mechanical ventilation; shock; and other organ failure requiring ICU monitoring and treatment.

Clinical data of severe and critical COVID-19 patients were re- and (d) the nucleic acid test of respiratory samples such as sputum and nasopharynx swab was negative twice in a row (the sampling time interval was at least 24 hours).

The continuous variable of normal distribution was represented as mean ± standard deviation (SD), while the continuous variable of non-normal distribution was represented by median (interquartile range [IQR]). The categorical variable was displayed as count (percentage). The chi-square test was used to compare the mortality rate between or among groups. SPSS 25.0 statistical software (IBM) was used for the statistical analysis. P < .05 was considers as significant. Table 2 . Table 3 . Table 4 .

A total of 50 (31.06%) patients died, while 78 (48.45%) patients healed and discharged, and the last 33 (20.50%) patients remained in hospital (Table 5) 

The mortality rate was 24.13%, 34.69%, 36.00%, and 24.24% in patients aged ≤44 years, patients aged 45-59 years, patients aged 60-74 years, and patients aged ≥75 years, respectively; further comparison analysis revealed that no difference was found among these four group patients (P = .525) (Figure 1) . Notably, ARDS (P < .001) and MODS (P = .008) correlated with increased mortality rate, while electrolyte disorders (P = .249) and hypoproteinemia (P = .248) did not associated with mortality risk (Figure 2 ).

In Meanwhile, an earlier study focusing Chinese COVID-19 patients observes their median age is around 41 years. 4 Our study disclosed that the mean age of severe and critical COVID-19 patients was 59.38 years, indicating the severe and critical disease is more popular in aged population, which might result from that the elders had poor immunity and increased basic diseases. In terms of gender, we found that the proportion of men was about twice as that of women in severe and critical COVID-19 patients, which might be due to the men were more commonly outside and in public place instead of women in severe and critical COVID-19 patients, and the complications such as lung diseases were also more common in men. So as to medical history, we observed that hypertension and diabetes were most common in severe and critical COVID-19 patients, which was in line with the conditions of MERS. 5 With regard to the clinical symptoms of severe and critical COVID-19 patients on admission, we observed that fever and dry F I G U R E 1 Mortality rate among different age-subgroups F I G U R E 2 Correlation of common complications post-admission with mortality rate. ARDS, acute respiratory distress syndrome; MODS, multiple organ dysfunction cough were the most common symptoms, which were in accordance with findings in previous studies of COVID-19, 6 and were similar to patients with MERS-CoV and SARS coronavirus infection. 7, 8 In terms of laboratory indexes, we discovered that blood routine indexes, hepatic and renal function indexes, and inflammation indexes were commonly abnormal in severe and critical COVID-19 patients, these might be account of that (a) COVID-19 mainly acted on lymphocytes, especially T lymphocytes, which was similar to SARS-CoV 9 and MERS-CoV, 10 patients, and therefore, it was essential to timely monitor and prevent ARDS and MODS potency. However, electrolyte disorders and hypoproteinemia were not associated with prognosis, but the latter was previously reported to be independent risk factor for severe MERS-CoV infection 14 and serum albumin could reflect nutritional status therefore related to severe and critical COVID-19.

In aspect of treatment regimen, all the treatment procedures were set according to the guidelines and accumulating clinical experience, based on antiviral drugs and other supported treatments.

And among the antiviral drugs, the most commonly used was lopinavir and ritonavir tablets.

The clinical outcome of COVID-19 patients is an essential issue to be explored. According to a previous meta-analysis, the mortality rate of COVID-19 patients ranges from 2.0% to 4.4%. 15 Meanwhile, the severe COVID-19 patients present with a higher mortality rate of 8.1%, but at the time of this study disclosed, 89.0% patients were still in hospitalization, and therefore, the mortality rate might be greatly underestimated. 16 As to outcome of critical-ill COVID-19 patients, seldom report is disclosed. In this study, we found that the mortality rate was as high as 31.06% in severe and critical COVID-19 patients, which was higher than previous studies. These might be to be: (a) the longer follow-up duration of our study and (b) critical-ill patients were also included in our study. Furthermore, the previous study reveals that the mortality rate of severe MERS is around 43.75%, 5 which is higher compared to severe and critical COVID-19 patients in our study. As to healed and discharged rate, 48.45% severe and critical COVID-19 patients realized it, which was acceptable. Notably, we observed that a small proportion of patients who were discharged in accordance with the current discharge standard were tested positive for the new type of coronavirus nucleic acid again within 14 days of isolation and returned to hospital for treatment. Therefore, we suggested at least three consecutive negative tests were a necessity for discharge.

Some limitations existed in this study: Firstly, since this was a retrospective study, potential bias and residual confounding might exist; secondly, all the patients were retrieved from ICU database, and therefore, these patients might not represent all general severe and critical COVID-19 patients; thirdly, there were still a proportion of patients in hospitalization, and therefore, the mortality rate and discharged rate might be influenced.

In summary, severe and critical COVID-19 presents with high mortality rate, and occurrence of ARDS or MODS greatly increases its mortality risk. Therefore, it is essential for early intervention to prevent mild/moderate COVID-19 from progressing to severe and critical COVID-19, and early prevention of ARDS and MODS is also important, as so to improve the prognosis of COVID-19.

Yiping Yin https://orcid.org/0000-0002-2288-4260

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