key: cord-0977202-sm44g2xh
authors: Chen, Tao; Wu, Di; Chen, Huilong; Yan, Weiming; Yang, Danlei; Chen, Guang; Ma, Ke; Xu, Dong; Yu, Haijing; Wang, Hongwu; Wang, Tao; Guo, Wei; Chen, Jia; Ding, Chen; Zhang, Xiaoping; Huang, Jiaquan; Han, Meifang; Li, Shusheng; Luo, Xiaoping; Zhao, Jianping; Ning, Qin
title: Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study
date: 2020-03-26
journal: BMJ
DOI: 10.1136/bmj.m1091
sha: 6f3f4bb01d3c561aebd65c4a1e8d4a1b879ed3e9
doc_id: 977202
cord_uid: sm44g2xh

OBJECTIVE: To delineate the clinical characteristics of patients with coronavirus disease 2019 (covid-19) who died. DESIGN: Retrospective case series. SETTING: Tongji Hospital in Wuhan, China. PARTICIPANTS: Among a cohort of 799 patients, 113 who died and 161 who recovered with a diagnosis of covid-19 were analysed. Data were collected until 28 February 2020. MAIN OUTCOME MEASURES: Clinical characteristics and laboratory findings were obtained from electronic medical records with data collection forms. RESULTS: The median age of deceased patients (68 years) was significantly older than recovered patients (51 years). Male sex was more predominant in deceased patients (83; 73%) than in recovered patients (88; 55%). Chronic hypertension and other cardiovascular comorbidities were more frequent among deceased patients (54 (48%) and 16 (14%)) than recovered patients (39 (24%) and 7 (4%)). Dyspnoea, chest tightness, and disorder of consciousness were more common in deceased patients (70 (62%), 55 (49%), and 25 (22%)) than in recovered patients (50 (31%), 48 (30%), and 1 (1%)). The median time from disease onset to death in deceased patients was 16 (interquartile range 12.0-20.0) days. Leukocytosis was present in 56 (50%) patients who died and 6 (4%) who recovered, and lymphopenia was present in 103 (91%) and 76 (47%) respectively. Concentrations of alanine aminotransferase, aspartate aminotransferase, creatinine, creatine kinase, lactate dehydrogenase, cardiac troponin I, N-terminal pro-brain natriuretic peptide, and D-dimer were markedly higher in deceased patients than in recovered patients. Common complications observed more frequently in deceased patients included acute respiratory distress syndrome (113; 100%), type I respiratory failure (18/35; 51%), sepsis (113; 100%), acute cardiac injury (72/94; 77%), heart failure (41/83; 49%), alkalosis (14/35; 40%), hyperkalaemia (42; 37%), acute kidney injury (28; 25%), and hypoxic encephalopathy (23; 20%). Patients with cardiovascular comorbidity were more likely to develop cardiac complications. Regardless of history of cardiovascular disease, acute cardiac injury and heart failure were more common in deceased patients. CONCLUSION: Severe acute respiratory syndrome coronavirus 2 infection can cause both pulmonary and systemic inflammation, leading to multi-organ dysfunction in patients at high risk. Acute respiratory distress syndrome and respiratory failure, sepsis, acute cardiac injury, and heart failure were the most common critical complications during exacerbation of covid-19.

Meeting any of the following: Respiratory failure occurs and mechanical ventilation is required; Shock occurs; Complicated with other organ failure that requires monitoring and treatment in ICU Acute respiratory distress syndrome (ARDS) 11

Onset: new or worsening respiratory symptoms within one week of known clinical insult. Chest imaging: bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules. Origin of oedema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment to exclude hydrostatic cause of oedema if no risk factor present. Oxygenation (adults): • Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cmH2O, or non-ventilated) • Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cmH2O, or non-ventilated) • Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cmH2O, or non-ventilated) • When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients) Acute kidney injury 12

Identified on the basis of the highest serum creatinine level according to the kidney disease improving global outcomes classification Sepsis 11

Adults: life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection, with organ dysfunction. Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia. Septic shock 11

Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain mean artery pressure (MAP) ≥65 mmHg and serum lactate level >2 mmol/L. Acute liver injury Jaundice with a total bilirubin level of ≥ 3 mg/dl and an acute increase in alanine aminotransferase of at least five times the upper limit of the normal range and/or an increase in alkaline phosphatase of at least twice the upper limit of the normal range. Acute heart failure 13 Using age-related amino-terminal pro-brain natriuretic peptide cut-points of 450, 900, and 1800 pg/mL for ages <50, 50-75, and >75, which yielded 90% sensitivity and 84% specificity for acute heart failure. Cardiac injury 8 Serum levels of cardiac biomarkers (e.g. cardiac troponin I) were >

99th percentile upper reference limit, or new abnormalities were shown in electrocardiography and echocardiography. Abbreviations: CAPA, continuous positive airway pressure

COVID-19, coronavirus disease

FIO2, fraction of inspired oxygen

partial pressure of oxygen; PEEP, positive end expiratory pressure; RT-PCR, reverse transcription-polymerase chain reaction

SARS-CoV-2, severe acute respiratory syndrome coronavirus 2