Risk Factors of Death in Mechanically Ventilated COVID-19 Patients: A Multi-Center Study From Iran
-
Mohammadreza Salehi
,
Mohamad-Taghi Beig Mohammadi
,
Seyed Hamidreza Abtahi
,
Sarmand-Fattah Ghazi
,
Abolfazl Sobati
,
Rama Bozorgmehr
,
Seyed Ali Dehghan Manshadi
,
Saeed Reza Jamali Siahkali
,
Mostafa Mohammadi
,
Banafsheh Moradmand Badie
,
Tahereh Sajadifard
,
Ensiyeh Rahimi
Abstract
Despite the improvement in COVID-19 therapeutic management the mortality of mechanically ventilated COVID-19 patients remains high. In this study, we determined the risk factors of death in these cases. This cross-sectional study evaluated clinical and paraclinical features of mechanically ventilated COVID-19 patients at the time of hospital admission until death or discharge from hospital between April and September in 2021 in three COVID-19 referral hospitals. The patients were divided into survivors and non-survivors and then the characteristics were compared. One hundred twenty-five patients (60% male, mean age 62±15.18, range 17 to 97 years old) were recruited to the study. 51(40%) survived and 74 (60%) didn’t survive. At the time of hospital admission, the vital signs were not significantly different between the survivors and non-survivors, although diarrhea was not reported in non-survivors, but reported in 9.5% of survivors (P=0.02). The mean age of non-survivors was higher (65.1±14.17 vs 56.9±15.41, P=0.003). The intubation time since the patients were admitted was not significantly different between the two groups (3.38±2.88 days vs 4.16±3.42 days, P=0.34). The mean of serum LDH and D-dimer at the time of ICU admission were significantly higher in the non-survivors (863±449 vs 613±326, P=0.01; 4081±3342 vs 542±634, P=0.009; respectively). However, the mean CRP was not significantly different between the two groups (76±66.4, 54±84.3; P=0.1). Mean APACHE-II score was higher in the non-survivors than the survivors (15 vs 13; P=0.01). Use of remdesivir, interferon beta-1a, and low dose corticosteroids were significantly higher in the survivors group (P=0.009, P=0.001, P=0.000). Success of weaning and ICU discharge among mechanically ventilated COVID-19 patients are probably higher in younger patients with lower D-dimmer and LDH that received remdesivir, interferon beta-1a and low dose corticosteroids, while the intubation time did not seem to play a role on patients' outcome.
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2. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA 2020;323:1239-42.
3. Wynants L, Van Calster B, Collins GS, Riley RD, Heinze G, Schuit E, et al. Prediction models for diagnosis and prognosis of covid-19 infection: Systematic review and critical appraisal. BMJ 2020;369:m1328
4. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395:1054-62.
5. Xie J, Tong Z, Guan X, Du B, Qiu H, Slutsky AS. Critical care crisis and some recommendations during the COVID-19 epidemic in China. Intensive Care Med 2020;46:837-40.
6. Myers LC, Parodi SM, Escobar GJ, Liu VX. Characteristics of Hospitalized Adults With COVID-19 in an Integrated Health Care System in California. JAMA. 2020;323:2195-2198.
7. Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, et al. Covid-19 in Critically Ill Patients in the Seattle Region—Case Series. N Engl J Med 2020;382:2012-22.
8. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA 2020;323:1612-14.
9. Farzan N, Vahabi S, Foroghi ghomi SY, Shirvani R, Madani Ss, Shakeri M, et al. Evaluation of invasive ventilation (intubation) prognosis in patients with Covid-19 Symptoms. Int J Surg Open 2020;27:149-53.
10. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395:507-13.
11. Flynn D, Moloney E, Bhattarai N, Scott J, Breckons M, Avery L, et al. COVID-19 pandemic in the United Kingdom. Health Policy Technol 2020;9:673-91.
12. Scully EP, Haverfield J, Ursin RL, Tannenbaum C, Klein SL. Considering how biological sex impacts immune responses and COVID-19 outcomes. Nat Rev Immunol 2020;20:442-7.
13. Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region. Italy. JAMA 2020;232:1574-81.
14. Henry BM, Aggarwal G, Wong J, Benoit S, Vikse J, Plebani M, et al. Lactate dehydrogenase levels predict coronavirus disease 2019 (COVID-19) severity and mortality: a pooled analysis. Am J Emerg Med 2020;38:1722-6.
15. De Vita N, Scottia L, Cammarotab G, Raccac F, Pissaiad C, Maestronee C. Predictors of intubation in COVID-19 patients treated with out-of-ICU continuous positive airway pressure. Pulmonology 2022;28:173-80.
16. Sharifpour M, Rangaraju S, Liu M, Alabyad D, Nahab FB, Creel-Bulos CM, et al. C-Reactive protein as a prognostic indicator in hospitalized patients with COVID-19. PLoS ONE 2020;15:e0242400.
17. Bavishi AA, Mylvaganam R, Agrawal R, Avery R, Cuttica MJ. Early vs Late Intubation in COVID-19 Acute Respiratory Distress Syndrome: A Retrospective Study of Ventilator Mechanics, Computed Tomography Findings, and Outcomes. Am J Respir Crit Care Med 2021;203:A2546.
18. Zuo M, Huang Y, Ma W, Xue Z, Zhang J, Gong Y, et al. Expert recommendations for tracheal intubation in critically iii patients with noval coronavirus disease 2019. Chin Med Sci J 2020;35:105-9.
19. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020;75:785-99.
20. Brown CA, Mosier JM, Carlson JN, Gibbs MA. Pragmatic recommendations for intubating critically ill patients with suspected COVID-19. J Am Coll Emerg Phys Open 2020;1:80-4.
21. Brewster DJ, Chrimes N, Do TB, Fraser K, Groombridge CJ, Higgs A, et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Med J Aust 2020; 212:472-81.
22. Bauer PR, Gajic O, Nanchal R, Kashyap R, Martin-Loeches I, Sakr Y, et al. Association between timing of intubation and outcome in critically ill patients: a secondary analysis of the ICON audit. J Crit Care 2017;42:1-5.
23. Kang BJ, Koh Y, Lim CM, Huh JW, Baek S, Han M, et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med 2015;41:623-32.
24. Kangelaris KN, Ware LB, Wang CY, Janz DR, Zhuo H, Matthay MA, et al. Timing of intubation and clinical outcomes in adults with acute respiratory distress syndrome. Crit Care Med 2016; 44:120-9.
25. Pandya A, Kaur NA, Sacher D, O'Corragain O, Salerno D, Desai P, et al. Ventilatory Mechanics in Early vs Late Intubation in a Cohort of Coronavirus Disease 2019 Patients With ARDS :A Single Center's Experience. Chest 2021;159:653-6.
26. Papoutsi E, Giannakoulis VG, Xourgia E, Routsi C, Kotanidou A, Siempos II. Effect of timing of intubation on clinical outcomes of critically ill patients with COVID‑19: a systematic review and meta‑analysis of non‑randomized cohort studies. Crit Care 2021;25:121.
27. Tehrania S, Killandera A, Åstranda P, Jakobssonb J, Gille-Johnsona P. Risk factors for death in adult COVID-19 patients: Frailty predicts fatal outcome in older patients. Int J Infect Dis 2021:102:415-21.
28. Liu W, Tao ZW, Wang L, Yuan ML, Liu K, Zhou L, et al. Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease. Chin Med J (Engl) 2020;133:1032-8.
29. Ticinesi A, Nouvenne A, Folesani G, Prati B, Morelli I, Guida L, et al. An investigation of multimorbidity measures as risk factors for pneumonia in elderly frail patients admitted to hospital. Eur J Intern Med 2016;28:102-6.
30. Cilloniz C, Polverino E, Ewig S, Aliberti S, Gabarrus A, Menendez R, et al. Impact of age and comorbidity on cause and outcome in community-acquired pneumonia. Chest 2013;144:999-1007.
31. Ladha KS, Zhao K, Quraishi SA, Kurth T, Eikermann M, Kaafarani HM, et al. The Deyo-Charlson and Elixhauser-van Walraven comorbidity indices as predictors of mortality in critically ill patients. BMJ Open 2015;5:e008990.
32. Rahimzadeh P, Faiz HR, Farahmandrad R, Hassanlouei B, Habibi A, Hedayati Emami S, et al. Clinical Features and Prognosis of Invasive Ventilation in Hospitalized Patients with COVID-19: A Retrospective Study. Anesth Pain Med 2020;10:e108773.
33. Fu L, Wang B, Yuan T, Chen X, Ao Y, Fitzpatrick T, et al. Clinical characteristics of coronavirus disease 2019 (COVID-19) in China: A systematic review and meta-analysis. J Infect 2020;80:656-65.
34. Sardu C, Gambardella J, Morelli MB, Wang X, Marfella R, Santulli G. Hypertension, thrombosis, kidney failure, and diabetes: Is COVID-19 an endothelial disease? A comprehensive evaluation of clinical and basic evidence. J Clin Med 2020;9:1417.
35. Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: a nationwide analysis. Eur Respir J 2020;55:2000547.
36. Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int 2020;97:829-38.
37. Chou CY, Wang SM, Liang CC, Chang CT, Liu JH, Wang IK, et al. Risk of pneumonia among patients with chronic kidney disease in outpatient and inpatient settings. Medicine (Baltimore) 2014;93:e174.
38. Henry BM, Lippi G. Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID-19) infection. Int Urol Nephrol 2020;52:1193-4.
39. Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, et al. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect Dis 2013;13:752-61.
40. Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt GM, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348:1986-94.
41. Wang ZH, Shu C, Ran X, Xie CH, Zhang L. Critically Ill Patients with Coronavirus Disease 2019 in a Designated ICU: Clinical Features and Predictors for Mortality. Risk Manag Healthc Policy 2020;13:833-45.
42. Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al. Risk Factors Associated with Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med 2020;180:934-43.
43. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
44. Wang L. C-reactive protein levels in the early stage of COVID-19. Med Mal Infect 2020;50:332-4.
45. Bhargava A, Fukushima EA, Levine M, Zhao W, Tanveer F, Szpunar SM, et al. Predictors for Severe COVID-19 Infection. Clin Infect Dis 2020;71:1962-8.
46. Henry BM, Aggarwal G, Wong J, Benoit S, Vikse J, Plebani M, et al. Lactate dehydrogenase levels predict coronavirus disease 2019 (COVID-19) severity and mortality: a pooled analysis. Am J Emerg Med 2020;38:1722-6.
47. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81.
48. Zou X, Li S, Fang M, Hu M, Bian Y, Ling J, et al. Acute Physiology and Chronic Health Evaluation II Score as a Predictor of Hospital Mortality in Patients of Coronavirus Disease 2019. Crit Care Med 2020;48:e657–65.
49. Kato S, Fujisawa T, Enomoto N, Inui N, Nakamura Y, Suda T. Severe respiratory failure associated with influenza B virus infection. Respirol Case Rep 2015;3:61-3.
50. Beigel JH, Tomashek KM, Dodd LE, Mehta AK, Zingman BS, Kalil AC, et al. Remdesivir for the Treatment of Covid-19 - Final Report. N Engl J Med 2020;383:1813-26.
51. Pan H, Peto R, Abdool Karim Q, Alejandria M. Repurposed antiviral drugs for COVID-19–interim WHO SOLIDARITY trial results. medRxiv 2020.
52. Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet 2020;395:1569-78.
53. Soy M, Keser G, Atagündüz P, Tabak F, Atagündüz I, Kayhan S. Cytokine storm in COVID-19: pathogenesis and overview of anti-inflammatory agents used in treatment. Clin Rheumatol 2020;39:2085-94.
54. Torres A, Sibila O, Ferrer M, Polverino E, Menendez R, Mensa J, et al. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response: a randomized clinical trial. JAMA 2015;313:677-86.
55. Kil HR, Lee JH, Lee KY, Rhim JW, Youn YS, Kang JH. Early corticosteroid treatment for severe pneumonia caused by 2009 H1N1 influenza virus. Crit Care 2011;15:413.
56. Edalatifard M, Akhtari M, Salehi M, et al. Intravenous methylprednisolone pulse as a treatment for hospitalised severe COVID-19 patients: results from a randomised controlled clinical trial. Eur Respir J 2020. (in press)
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| Files | ||
| Issue | Vol 61 No 7 (2023) | |
| Section | Articles | |
| DOI | https://doi.org/10.18502/acta.v61i7.14496 | |
| Keywords | ||
| COVID-19 Mechanical ventilation Extubation Mortality risk factors | ||
| Rights and permissions | |
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Salehi M, Beig Mohammadi M-T, Abtahi SH, Ghazi S-F, Sobati A, Bozorgmehr R, Dehghan Manshadi SA, Jamali Siahkali SR, Mohammadi M, Moradmand Badie B, Sajadifard T, Rahimi E. Risk Factors of Death in Mechanically Ventilated COVID-19 Patients: A Multi-Center Study From Iran. Acta Med Iran. 2023;61(7):408-418.
