key: cord-1001744-k4c9uhue
authors: Routsi, Christina; Kokkoris, Stelios; Siempos, Ilias; Magira, Eleni; Kotanidou, Anastasia; Zakynthinos, Spyros
title: Fewer Intubations but Higher Mortality Among Intubated Coronavirus Disease 2019 Patients During the Second Than the First Wave
date: 2021-10-05
journal: Crit Care Explor
DOI: 10.1097/cce.0000000000000531
sha: d4e6108073a28ad9952e9d0f023bbf291072d017
doc_id: 1001744
cord_uid: k4c9uhue

Since changes in pharmacological treatments for severely ill patients with coronavirus disease 2019 have been incorporated into clinical practice, both by their use (corticosteroids and remdesivir) and by stopping them (e.g., hydroxychloroquine), we sought to compare the rate of intubation and mortality of intubated patients in our ICUs between the first and second waves of the pandemic. DESIGN: Single-center, observational. SETTING: Four coronavirus disease 2019 designated ICUs at an urban Greek teaching hospital. PATIENTS: All adult patients with coronavirus disease 2019 consecutively admitted to ICU during the first (n = 50) and second (n = 212) waves of the pandemic. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The percentage of intubated ICU patients dropped from 82% during the first wave to 66% during the second wave (p = 0.042). However, the absolute number of intubated ICU patients was lower during the first than the second wave (41 vs 140 patients). ICU or hospital mortality of intubated patients increased from 39% during the first wave to 60% during the second wave (p = 0.028). The binary logistic regression for hospital mortality as the dependent variable in intubated patients and covariates the age, Acute Physiology and Chronic Health Evaluation II score, cardiovascular comorbidity, lactate, positive end-expiratory pressure, Sequential Organ Failure Assessment score, and wave, distinguished only Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.40 with 95% CI, 1.14—1.72; p = 0.001) as the sole independent predictor of hospital mortality. CONCLUSIONS: Pharmacological adaptations and other measures may have led to fewer intubations over time. However, these changes do not seem to be translated into improved outcomes of intubated patients. Perhaps the same change in the use of drugs and protocols that could cause fewer intubations of ICU patients might be a reason of increased mortality in those patients who are eventually intubated. Furthermore, the relative staff inexperience and overall increase in patients’ comorbidities during the second wave could have contributed to increased Acute Physiology and Chronic Health Evaluation II score and mortality of intubated patients.

gained experience and improved algorithms of using oxygen treatment, would have a significant impact on the rate of intubation and mortality of intubated ICU patients. We, therefore, sought to compare the above outcomes in our ICUs between the first and second waves of the pandemic. The study was approved by the hospital institutional review boards (ethical committee of "Evangelismos" Hospital; 116/31 March 2021). Comparison between the first and second waves regarding various patient data on ICU admission, interventions in the ICU, and outcomes is detailed in Tables 1 and 2. The percentage of intubated ICU patients (i.e., patients who were already intubated on ICU admission or intubated after admission) dropped from 82% during the first wave (from March to July 2020) to 66% during the second wave (from September 2020 to January 2021) (p = 0.042). However, the absolute number of intubated ICU patients was more than three times lower during the first compared with the second wave (41 vs 140 patients), compatible with a much stronger second wave in Greece in terms of the number of cases and deaths (4) . ICU or hospital mortality of intubated ICU patients increased from 39% during the first wave to 60% during the second wave (p = 0.028). Intubated patients of the second compared with the first wave had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score and lactate level and lower positive end-expiratory pressure (PEEP) and respiratory system static compliance, were more likely to suffer from cardiovascular comorbidities, and tended to be older. The binary logistic regression model that was built for hospital mortality as the dependent variable in intubated patients who received invasive mechanical ventilation and covariates all variables that were significantly correlated with hospital mortality as demarcated in the univariate logistic regression testing (i.e., age, APACHE II score, cardiovascular comorbidity [yes vs no], lactate, PEEP, Sequential Organ Failure Assessment score, and wave (first vs second)] distinguished only APACHE II score (odds ratio = 1.40 with 95% CI 1.14-1.72, p = 0.001) as significant predictor of hospital mortality. Neither other comorbidities (i.e., hypertension, diabetes, obesity, and chronic lung disease or renal failure), laboratory and respiratory data (i.e., troponin, d-dimer, C-reactive protein, procalcitonin, Pao 2 , Pao 2 /Fio 2 , and respiratory system static compliance), and interventions (i.e., usage of prone position and neuromuscular blockade), nor pharmacological treatments (i.e., usage of glucocorticoids, remdesivir, or their combination) were significantly correlated with hospital mortality in the univariate logistic regression testing.

Although our study is single-center, this could be considered a strength because similar criteria of ICU admission and tracheal intubation were used allowing for comparison between the two waves. In addition, our center did not experience any difficulties in terms of supplies and materials or a shortage of ICU capacity since all critically ill patients with COVID-19 regardless of their age and comorbidities were admitted to our ICUs in time; indeed, lack of ICU beds did not occur in any of the two waves, at least in the area covered by our hospital, due to the opening of a large number of new ICU beds during the second wave (5) . Although the physician or nurseto-patient ratio did not substantially change between the two waves (5), an overwhelming number of patients signify a noticeable stress on the healthcare system. Indeed, the increase in staff required attending a more than three times higher volume of intubated patients during the second wave was not frequently made by experienced critical care physicians and nurses, and this could have played a role in outcome.

The APACHE II score estimates ICU mortality based on a number of laboratory values and patient signs taking both acute and chronic disease into account. The finding that only APACHE II score was the sole independent predictor of ICU or hospital mortality is intriguing. The abovementioned relative lack of experienced ICU personnel during the second wave could have contributed to increased APACHE II score. Furthermore, due to the more severe second wave, it is probable that more frequently patients with chronic health problems developed the serious form of the disease and increased APACHE II score reflected the overall increase in patients' comorbidities during the second wave (Table 1) . Finally, the same change in the use of drugs and algorithms of oxygen treatment that could cause the reduction of the percentage of intubated ICU patients might be a reason of increased mortality in those patients who were eventually intubated by increasing their APACHE II score.

In conclusion, we found that progress in the understanding of the COVID-19 along with pharmacological adaptations and other measures (6) may have led to fewer intubations over time. However, it may be alarming that the same progress does not seem to be translated into improved outcomes of intubated patients with COVID-19 (7, 8) . It is possible that the same change in the use of drugs and algorithms of oxygen treatment that could cause fewer intubations of ICU patients might be a reason of increased mortality in those patients who are eventually intubated. Furthermore, the relative staff inexperience and overall increase in patients' comorbidities during the second wave could have contributed to increased APACHE II score and mortality of intubated patients.

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