key: cord-0914543-gmr76967
authors: Abdallah, Khaled; Hamed, Fadi; Rahman, Nadeem; Salam, Shameen; Mallat, Jihad
title: Characteristics of critically ill patients infected with COVID-19 in Abu Dhabi, United Arab Emirates
date: 2020-07-01
journal: Anaesth Crit Care Pain Med
DOI: 10.1016/j.accpm.2020.06.014
sha: f8bab08bf5a428b44cfb59c779ef7d7e12e4643f
doc_id: 914543
cord_uid: gmr76967

nan

Since December 2019, a novel coronavirus SARS-CoV-2 emerged in Wuhan City and extended around the globe. As of June 26, 2020, approximately 46,563 confirmed cases have been documented in the United Arab Emirates (UAE), with 308 deaths [1] .

There are no reports describing patients admitted to the intensive care unit (ICU) with in the UAE. This study's primary objective was to describe the clinical characteristics of patients with laboratory-confirmed COVID-19 admitted to the ICU at Cleveland Clinic Abu Dhabi.

A retrospective study was conducted for this purpose. A waiver of informed consent was obtained from the Ethics Committee at Cleveland Clinic Abu Dhabi (number: A-2020-035). All consecutive adult patients admitted to our ICU between March 31 and May 10, 2020, with confirmed SARS-CoV-2 infection (virus detected by a real-time reverse-transcriptase-polymerase chain reaction assay of a nasopharyngeal sample) were included. De-identified data from the electronic medical record were collected: comorbidities, laboratory data at ICU admission, arterial blood gas and respiratory mechanics data on admission and during the first 3 days.

Continuous variables are expressed as mean ± SD or as median [interquartile range], and proportions were used for categorical variables.

From March 31 to May 10, 2020, 508 adult patients with COVID-19 infection were admitted to the hospital. Among them, 55 patients (11%, 51 males) required ICU admission and were included in this study ( Figure 1 ). The main characteristics of the cohort are summarised in Table 1 . Twentyeight patients (51%) had at least one comorbidity. Diabetes and hypertension were the most 2 common comorbid conditions (38% and 36%, respectively). At ICU admission, all patients had bilateral infiltrates on chest X-ray, and 24 patients (44%) experienced fever.

On admission to ICU, lymphocytopenia was common (73%). Ferritin, C-reactive protein, and interleukin-6 were all elevated ( Table 1 ). The median initial PaO2/FiO2 ratio was 82 mmHg and improved on day 3.

Forty patients (73%) required mechanical ventilation (MV) (Figure 1 ). The median initial tidal volume was 6.5 [5.8-7.0] ml/kg predicted body weight and the median initial positive endexpiratory pressure (PEEP) was 12 [12] [13] [14] cmH2O. Neither value changed during the first 3 days.

Thirty-three patients (82%) had a plateau pressure < 30 cmH2O on day 1, and 38 (95%) on day 3

( Table 1 ). The median driving pressure on day 1 of MV was 16 [13-18] cmH2O, and 14 cmH2O on day 3, with 24 patients (60%) having a driving pressure ≤ 15 cmH2O. The mean static pulmonary compliance (Crs) was 28.0 ± 9.3 mL/ cmH2O on day 1 and did not improve during the first 3 days of MV (Table 1) . A Crs > 40 mL/cmH2O was observed in 4 patients (10%) on day 1, 3 patients (7%) on day 2, and 5 patients (12%) on day 3.

The median PaO2/FiO2 in the 15 patients treated with high-flow nasal cannula (HFNC)/noninvasive ventilation (NIV) and did not require MV was 89 [54-156] mmHg at ICU admission. Also, in these patients, the mean respiratory rate was 37 ± 7 breath/min at ICU admission. As of June 20, 2020, 43 patients were alive (mortality rate: 22%); among them, 34 (79%) were discharged from the hospital (Figure 1 ).

Unlike patients in the previous reports from the different parts of the world, our patients were younger and mostly men (91%) [2] . However, diabetes and hypertension were the most common J o u r n a l P r e -p r o o f 3 comorbidities [2, 3] . Forty-four percent had a fever at ICU admission, in line with what was observed previously [2] , but much lower than in other studies [4] . Lymphocytopenia was common at ICU admission, as was observed in previous findings [2] .

All patients had bilateral infiltrates on the chest X-ray, and most of them were severely hypoxemic. Also, all inflammatory markers were elevated at ICU admission (Table 1 ). These findings are suggestive of severe COVID-19 infection-induced cytokine release syndrome.

Gattinoni et al. [5] proposed the presence of two "phenotypes" of COVID-19 pneumonia. Type-L [atypical acute respiratory syndrome (ARDS)], characterised by low elastance, low ventilation to perfusion (VA/Q) ratio, low lung weight, and low recruitability; Type-H (typical ARDS), characterised by high elastance, high right-to-left shunt, high lung weight, and high lung recruitability. In our cohort, 15 patients (27%) were treated with HFNC/NIV ventilation and did not require MV (Figure 1 ). These patients presented with severe hypoxemia, had bilateral chest X-ray infiltrates and were tachypnoeic, suggesting severe COVID-19 pneumonia; still, they did not appear overtly dyspnoeic and were breathing comfortably. These patients had probably a type-L COVID-19 pneumonia. In these patients, hypoxemia is mainly due to VA/Q mismatch resulted from the loss of hypoxic pulmonary vasoconstriction and impaired regulation of pulmonary blood flow [5] . The good outcomes observed ( Figure 1 ) might suggest that some of the severely hypoxemic COVID-19 patients without increased work of breathing can be managed without the use of intubation and MV. However, further studies are needed to assess whether the benefits from such an approach outweigh the known costs of prolonged sedation, paralysis, and MV required to achieve reduced mechanical power in these patients. In any case, these patients should be closely monitored, and clinical signs of marked air hunger and vigorous ventilatory Page 4 of 9 J o u r n a l P r e -p r o o f 4 efforts should be carefully scrutinised. If increased work of breathing is present, intubation and protective lung mechanical ventilation should be strongly considered to avoid the development of patient self-inflicted lung injury resulted from the generation of high transpulmonary pressure.

The majority of our mechanically ventilated patients had low compliance (< 40 ml/cmH2O) during the first three days of MV ( Table 1 ), suggesting that these patients had a type H COVID-19 induced ARDS, as proposed by Gattinoni et al. [5] . These patients were managed with low tidal volume, moderate/high PEEP, and plateau pressure < 30 cmH2O (Table 1 ) similar to those in populations of patients with typical ARDS. Our results are in line with previous findings [2] that reported low Crs in COVID-19 induced ARDS.

In conclusion, the majority of patients were younger males, a large proportion had typical acute respiratory distress syndrome and received MV. 

World Health Organization

Covid-19 in Critically Ill Patients in the Seattle Region -Case Series

Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to Heart rate, beats/min 105±19 Heart rate > 100 beats/min, n (%) 31 (56) Respiratory rate, mean ± SD (range)

Lymphocytes ≤ 1000/mm 3 , n (%) 40 (73) Neutrophils, per mm

 (2) ICU, intensive care unit; PaO2; partial pressure of arterial oxygen; FiO2; fraction of inspired oxygen; NT-proBNP; N-terminal prohormone brain natriuretic peptide Data are presented as median [interquartile range], mean ± standard deviation, or count (percentage).