Risk Factors Associated With Mortality Among Patients With COVID-19 in Intensive Care Units in Lombardy, Italy

Abstract

IMPORTANCE Many patients with coronavirus disease 2019 (COVID-19) are critically ill and require care in the intensive care unit (ICU). OBJECTIVE To evaluate the independent risk factors associated with mortality of patients with COVID-19 requiring treatment in ICUs in the Lombardy region of Italy. DESIGN, SETTING, AND PARTICIPANTS This retrospective, observational cohort study included 3988 consecutive critically ill patients with laboratory-confirmed COVID-19 referred for ICU admission to the coordinating center (Fondazione IRCCS [Istituto di Ricovero e Cura a Carattere Scientifico] Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy) of the COVID-19 Lombardy ICU Network from February 20 to April 22, 2020. Infection with severe acute respiratory syndrome coronavirus 2 was confirmed by real-time reverse transcriptase-polymerase chain reaction assay of nasopharyngeal swabs. Follow-up was completed on May 30, 2020. EXPOSURES Baseline characteristics, comorbidities, long-term medications, and ventilatory support at ICU admission. MAIN OUTCOMES AND MEASURES Time to death in days from ICU admission to hospital discharge. The independent risk factors associated with mortality were evaluated with a multivariable Cox proportional hazards regression. RESULTS Of the 3988 patients included in this cohort study, the median age was 63 (interquartile range [IQR] 56-69) years; 3188 (79.9%; 95% CI, 78.7%-81.1%) were men, and 1998 of 3300 (60.5%; 95% CI, 58.9%-62.2%) had at least 1 comorbidity. At ICU admission, 2929 patients (87.3%; 95% CI, 86.1%-88.4%) required invasive mechanical ventilation (IMV). The median follow-up was 44 (95% CI, 40-47; IQR, 11-69; range, 0-100) days; median time from symptoms onset to ICU admission was 10 (95% CI, 9-10; IQR, 6-14) days; median length of ICU stay was 12 (95% CI, 12-13; IQR, 6-21) days; and median length of IMV was 10 (95% CI, 10-11; IQR, 6-17) days. Cumulative observation time was 164 305 patient-days. Hospital and ICU mortality rates were 12 (95% CI, 11-12) and 27 (95% CI, 26-29) per 1000 patients-days, respectively. In the subgroup of the first 1715 patients, as of May 30, 2020, 865 (50.4%) had been discharged from the ICU, 836 (48.7%) had died in the ICU, and 14 (0.8%) were still in the ICU; overall, 915 patients (53.4%) died in the hospital. Independent risk factors associated with mortality included older age (hazard ratio [HR], 1.75; 95% CI, 1.60-1.92), male sex (HR, 1.57; 95% CI, 1.31-1.88), high fraction of inspired oxygen (FiO 2) (HR, 1.14; 95% CI, 1.10-1.19), high positive end-expiratory pressure (HR, 1.04; 95% CI, 1.01-1.06) or low PaO 2 :FiO 2 ratio (HR, 0.80; 95% CI, 0.74-0.87) on ICU admission, and history of chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.28-2.19), hypercholesterolemia (HR, 1.25; 95% CI, 1.02-1.52), and type 2 diabetes (HR, 1.18; 95% CI, 1.01-1.39). No medication was independently associated with mortality (angiotensin-converting enzyme inhibitors HR, 1.17; 95% CI, 0.97-1.42; angiotensin receptor blockers HR, 1.05; 95% CI, 0.85-1.29). CONCLUS...

Advanced care planning during the COVID-19 pandemic: ceiling of care decisions and their implications for observational data

“…9 However, these observations have not been con rmed in studies restricted to patients already on ICU in which death was the primary end-point. 29,30 In our patients, prescription of ACEi (but not ARB) was associated with reduced likelihood of being considered appropriate for level three care, but was not associated with an increased risk of death during hospitalisation. These observations may be a result of biases introduced by pre-emptive ceiling of care decisions where those with co-morbidities are not considered for ICU care, and the relative risk of severe disease appears less where this de nition is applied.…”

Effectiveness of Mid-Regional Pro-Adrenomedullin (MR-proADM) as Prognostic Marker in COVID-19 Critically Ill Patients: an Observational Prospective Study

“…We included a population with clinical characteristics that are comparable with others Italian experience [19,44]: a high proportion required mechanical ventilation at ICU admission (66.7%); a median age of 64 years, with a high preponderance of the male sex (87.7%), and at least one comorbidity in the 77.2%. Cardiovascular disease (other than hypertension) represented the most important comorbidity, with a statistically signi cant impact on outcome (p value 0.008) even con rmed by the multivariate analysis (OR 22.2, IC 1.556-316.960).…”

“…Importantly, the mortality from completed episodes of ICU differs considerably from the crude mortality rates in some early reports. For instance, in the Lombardy experience, ICU mortality was 26% as of March 25, 2020 [44] but rose to 48.7% in ICU and 53.4% in hospital as of May 30, 2020 [19].…”

“…All patients were treated according to internal protocols for the management of patients with severe respiratory insu ciency in combination with the new directions emerged from the recent literature about COVID-19 pneumonia [18][19].…”

Effects of Cytokine Blocking Agents on Hospital Mortality in Patients Admitted to ICU With Acute Respiratory Distress Syndrome by SARS-CoV2 Infection: An Observational Cohort Study

“…An Italian case series of 73 intubated patients had a median follow-up time of 19 days with a mortality rate of 23,3% and with almost half of the patients studied still invasively ventilated at that time-point [32]. In the Italian Lombardy ICU Network series, the overall mortality rate of patients admitted in ICU was 48,3% (1926 died and 2062 alive) with 91 (4,4%) patients still in ICU on the date of publication [33]. Among 5700 hospitalized patients in the New York Area, 373 patients needed ICU care with an ICU mortality rate of 78% [34].…”