Characteristics and risk factors for mortality in critically ill patients with COVID-19 receiving invasive mechanical ventilation: the experience of a private network in Sao Paulo, Brazil

Eduardo Atsushi Osawa; Alexandre Toledo Maciel

doi:10.2478/jccm-2022-0015

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Characteristics and risk factors for mortality in critically ill patients with COVID-19 receiving invasive mechanical ventilation: the experience of a private network in Sao Paulo, Brazil

The Journal of Critical Care Medicine

Volume 8 (2022): Issue 3 (July 2022)

By: Eduardo Atsushi Osawa and Alexandre Toledo Maciel

Open Access

|Aug 2022

Figures & Tables

Flowchart of the study enrolment. ICU: Intensive Care Unit.

Daily distribution of patients according to study events.
ICU: Intensive Care Unit; IMV: invasive mechanical ventilation.

Table 1

Baseline characteristics of study patients.

Variable	Overall (N = 215)	Discharged from ICU (N = 119)	Died in ICU (N = 96)	P-value
Female gender	69 (32.1)	34 (28.6)	35 (36.5)	0.242
Age, years	62.7 ± 15.4	56.9 ± 13.9	69.9 ± 14.2	< 0.001
Comorbidities
Hypertension	135 (62.8)	68 (57.1)	67 (69.8)	0.066
Diabetes	86 (40.0)	41 (34.5)	45 (46.9)	0.070
COPD	15 (7.0)	3 (2.5)	12 (12.5)	0.006
Smoking	3 (1.4)	0 (0.0)	3 (3.1)	0.087
Obesity	109 (50.7)	75 (63.0)	34 (35.4)	<0.001
Heart failure	15 (7.0)	2 (1.7)	13 (13.5)	< 0.001
Cirrhosis	1 (0.5)	0 (0.0)	1 (1.0)	0.447
Stroke	6 (2.8)	0 (0.0)	6 (6.2)	0.007
Bariatric surgery	2 (0.9)	2 (1.7)	0 (0.0)	0.503
Hyperlipidemia	47 (21.9)	23 (19.3)	24 (25.0)	0.325
Dementia	5 (2.3)	1 (0.8)	4 (4.2)	0.175
Autoimmune disorder	1 (0.5)	1 (0.8)	0 (0.0)	1.000
HIV	4 (1.9)	3 (2.5)	1 (1.0)	0.630
Solid neoplasm	5 (2.3)	3 (2.5)	2 (2.1)	1.000
Hematological neoplasm	3 (1.4)	1 (0.8)	2 (2.1)	0.587
Asthma	12 (5.6)	8 (6.7)	4 (4.2)	0.554
Non-dialysis CKD	14 (6.5)	6 (5.0)	8 (8.3)	0.408
CKD on dialysis	6 (2.8)	2 (1.7)	4 (4.2)	0.411
Coronary artery disease	24 (11.2)	10 (8.4)	14 (14.6)	0.192
Duration from symptom onset to hospital admission, days	7 [5; 9]	7 [5; 9]	6 [5; 8]	0.084
BMI	30.1 [26.6; 34.2]	31.2 [28.3; 35]	28.3 [25.5; 31.6]	<0.001
SpO2 at hospital presentation	91 [86; 95]	92 [88; 96]	90 [82.5; 95]	0.075
SAPS 3 score	49 [44; 55]	47 [42; 51]	54 [48; 59]	< 0.001
Duration from hospital admission to intubation date	3 [1; 5]	4 [1; 6]	3 [1; 5]	0.107

[i] BMI: Body mass index; CKD: Chronic kidney disease; COPD: Chronic obstructive pulmonary disease; HIV: Human immunodeficiency virus; ICU: Intensive Care Unit; SAPS: Simplified Acute Physiology Score; SpO2: Arterial oxygen saturation.

Cummulative percentage of study outcomes within the first 28 days of hospitalization.

Table 2

Laboratory biomarkers measurements obtained at hospital admission.

Variable	Overall (N = 215)	Discharged from ICU (N = 119)	Died in ICU (N = 96)	P-value
CRP	113 [55; 201]	112 [44; 184]	118 [58; 221]	0.165
LDH	380 [281; 510]	364 [269; 460]	416 [294; 536]	0.177
Creatinine	1.0 [0.9; 1.4]	1.0 [0.8; 1.2]	1.1 [0.9; 1.6]	0.002
Lymphocyte count	904 [651; 1266]	932 [718; 1284]	829 [545; 1244]	0.021
Neutrophil count	5050 [3462; 7480]	4812 [3407; 6860]	5346 [3497; 9044]	0.301
Platelet count	180 [138; 232]	186 [142; 231]	172 [136; 240]	0.356
D-dimer	0.6 [0.4; 1.0]	0.5 [0.3; 0.8]	0.7 [0.4; 1.7]	0.003
LCR	8 [4; 18]	9 [4; 25]	6 [3; 14]	0.019
NLR	6 [3; 11]	5 [3; 9]	7 [4; 14]	0.005

[i] CRP: C-reactive protein; LDH: lactate dehydrogenase; LCR: lymphocyte-to-CRP ratio; NLR: neutrophil-to-lymphocyte ratio.

Table 3

Laboratory biomarkers obtained at the date of intubation.

Variable	Overall (N = 215)	Discharged from ICU (N = 119)	Died in ICU (N = 96)	P-value
CRP	221 [143; 293]	199 [139; 270]	235 [155; 329]	0.069
LDH	493 [400; 643]	485 [387; 573]	528 [429; 676]	0.073
Creatinine	1.1 [0.8; 1.5]	1.0 [0.8; 1.3]	1.3 [1.0; 2.0]	< 0.001
Limphocyte count	866 [560; 1238]	884 [586; 1264]	793 [520; 1142]	0.310
Neutrophil count	8039 [5322; 11509]	6850 [5054; 10847]	10014 [6690; 12617]	0.005
Platelet count	228 [179; 300]	240 [196; 302]	206 [161; 284]	0.025
D-dimer	1.1 [0.6; 2.3]	0.9 [0.6; 1.6]	1.2 [0.7; 2.4]	0.301
LCR	4 [3; 8]	4 [3; 8]	4 [2; 7]	0.124
NLR	10 [6; 16]	8 [6; 13]	12 [7; 19]	0.004

[i] CRP: C-reactive protein; LDH: lactate dehydrogenase; LCR: lymphocyte-to-CRP ratio; NLR: neutrophil-to-lymphocyte ratio.

Table 4

Suportive treatment received while in ICU and clinical outcomes.

Variable	Overall (N = 215)	Discharged from ICU (N = 119)	Died in iCU (N = 96)	P-value
Non-invasive strategies prior to IMV
NIV	115 (53.5)	69 (58.0)	46 (47.9)	0.182
HFNC	75 (34.9)	38 (31.9)	37 (38.5)	0.386
Prone positioning	69 (32.1)	36 (30.3)	33 (34.4)	0.619
Neuromuscular blockade	158 (73.5)	88 (73.9)	70 (72.9)	0.988
Nitric oxide	6 (2.8)	2 (1.7)	4 (4.2)	0.016
ECMO	7 (3.3)	2 (1.7)	5 (5.2)	0.010
Worst parameters within 48 hours post-IMV
PEEP	12 [10; 14]	12 [10; 14]	12 [10; 14]	0.852
P/F ratio	126 [93.5; 162]	140 [104; 174]	110 [87; 138]	<0.001
Renal replacement therapy	71 (33)	17 (14.3)	54 (56.2)	<0.001
Vasopressor use	206 (95.8)	113 (95.0)	93 (96.9)	0.722
Pharmacological treatment
Tocilizumab	31 (14.4)	25 (21)	6 (6.3)	0.004
Corticosteroid	109 (50.7)	64 (53.8)	45 (46.9)	0.384
Hydroxycloroquine	71 (33)	46 (38.7)	25 (26)	0.070
Tracheostomy	39 (18.1)	20 (16.8)	19 (19.8)	0.699
Reintubation	22 (10.2)	10 (8.4)	12 (12.5)	0.448
Barotrauma	18 (8.4)	4 (3.4)	14 (14.6)	0.007
Duration of NIV before IMV, days	1 [1.0; 3.0]	2 [1.0; 3.0]	2 [1.0; 3.0]	0.861
Duration of HFNC before IMV, days	1 [1.0; 2.0]	1 [1.0; 3.0]	1 [1.0; 2.0]	0.677
Duration of IMV, days	10 [7; 18]	10 [7; 16]	11 [6; 19]	0.876
ICU length of stay, days	15 [10; 24]	17 [11.5; 25.5]	13 [7; 21.2]	0.002
Hospital length of stay, days	21 [15; 30]	27 [19.5; 39.5]	14.5 [7; 22.2]	<0.001
Days from hospital admission to intubation	3 [1.0; 5.0]	4 [1.0; 5.5]	3 [1.0; 5.0]	0.111
Days from symptom onset to intubation	9 [7 – 12]	10 [8.0 – 12.5]	8.5 [6 – 12]	0.005
Ventilator-free days	9 [3; 16]	15 [11; 23.5]	2 [0; 4.0]	<0.001

[i] ECMO: Extracorporeal membrane oxygenation; HFNC: High-flow nasal cannula; ICU: Intensive Care Unit; IMV: mechanical ventilation; NIV: Non-invasive ventilation; PEEP: Positive end-expiratory pressure; P/F ratio: PaO2/FiO2 ratio.

ROC curves on the multivariable logistic regression model to identify risk factors for mortality (A) Development cohort (B) Validation cohort. AUC: area under curve; ROC: Receiver Operating Characteristic.

Table 5

Risk factors for in-hospital mortality.

Variable	Estimate	Standard Error	Odds ratio (OR)	95% CI	P value
Age, per year	0.065	0.016	1.07	1.47 to 7.33	< 0.001
Creatinine at intubation day	1.188	0.410	3.28	0.84 to 0.99	0.004
BMI	-0.089	0.042	0.91	0.979 to 0.997	0.033
Lowest PF ratio 48 hours post intubation	-0.012	0.005	0.988	1.14 to 23.65	0.011
Barotrauma	1.646	0.774	5.18	0.76 to 0.95	0.034
Duration from symptom onset to intubation	-0.161	0.059	0.85	1.03 to 1.1	0.006

[i] BMI: Body mass index; PF ratio: PaO2/FiO2 ratio.

References

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Articles in this issue

DOI: https://doi.org/10.2478/jccm-2022-0015 | Journal eISSN: 2393-1817 | Journal ISSN: 2393-1809

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Language: English

Page range: 165 - 175

Submitted on: Dec 12, 2021

Accepted on: Jun 12, 2022

Published on: Aug 12, 2022

Published by: University of Medicine, Pharmacy, Science and Technology of Targu Mures

In partnership with: Paradigm Publishing Services

Publication frequency: 4 issues per year

Keywords:

coronavirus,

COVID-19,

mortality,

mechanical ventilation,

Related subjects:

Internal medicine, other,

Surgery,

Surgery, other,

Anaesthesiology,

Emergency medicine and intensive-care medicine

© 2022 Eduardo Atsushi Osawa, Alexandre Toledo Maciel, published by University of Medicine, Pharmacy, Science and Technology of Targu Mures
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 8 (2022): Issue 3 (July 2022)

Characteristics and risk factors for mortality in critically ill patients with COVID-19 receiving invasive mechanical ventilation: the experience of a private network in Sao Paulo, Brazil

Figures & Tables

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Table 1

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Table 2

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Table 4

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Table 5

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