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Review article
First published online August 19, 2020

COVID-19-Associated Critical Illness—Report of the First 300 Patients Admitted to Intensive Care Units at a New York City Medical Center

Sudham Chand, MD, Sumit Kapoor, MD, Deborah Orsi, MD, Melissa J. Fazzari, PhD, Tristan G. Tanner, MD, Genevieve C. Umeh, MD, Marjan Islam, MD, and Peter V. Dicpinigaitis, MD https://orcid.org/0000-0001-5318-9060 [email protected]View all authors and affiliations
Volume 35, Issue 10
https://doi.org/10.1177/0885066620946692

Abstract

Background:

The first confirmed case of novel coronavirus (2019-nCoV) infection in the United States was reported from the state of Washington in January, 2020. By March, 2020, New York City had become the epicenter of the outbreak in the United States.

Methods:

We tracked all patients with confirmed coronavirus-19 (COVID-19) infection admitted to intensive care units (ICU) at Montefiore Medical Center (Bronx, NY). Data were obtained through manual review of electronic medical records. Patients had at least 30 days of follow-up.

Results:

Our first 300 ICU patients were admitted March 10 through April 11, 2020. The majority (60.7%) of patients were men. Acute respiratory distress syndrome (ARDS) was documented in 91.7% of patients; 91.3% required mechanical ventilation. Prone positioning was employed in 58% of patients and neuromuscular blockade in 47.8% of mechanically-ventilated patients. Neither intervention was associated with decreased mortality. Vasopressors were required in 77.7% of patients. Acute kidney injury (AKI) was present on admission in 40.7% of patients, and developed subsequently in 36.0%; 50.9% of patients with AKI received renal replacement therapy (RRT). Overall 30-day mortality rate was 52.3%, and 55.8% among patients receiving mechanical ventilation. In univariate analysis, higher mortality rate was associated with increasing age, male sex, hypertension, obesity, smoking, number of comorbidities, AKI on presentation, and need for vasopressor support. A representative multivariable model for 30-day mortality is also presented, containing patient age, gender, body mass index, and AKI at admission. As of May 11, 2020, 2 patients (0.7%) remained hospitalized.

Conclusions:

Mortality in critical illness associated with COVID-19 is high. The majority of patients develop ARDS requiring mechanical ventilation, vasopressor-dependent shock, and AKI. The variation in mortality rates reported to date likely reflects differences in the severity of illness of the evaluated populations.

Introduction

The Novel 2019 coronavirus SARS-CoV-2 (COVID-19) was first reported as a human pathogen in December 2019 after causing an outbreak of severe respiratory illness in Wuhan, China.1 Subsequent spread to pandemic level occurred throughout China and worldwide. The first confirmed case of COVID-19 infection in the United States was reported from the state of Washington in January, 2020.2 As of this writing the United States has suffered the highest number of infected individuals with still increasing trajectory of new cases. By March, 2020, New York City had become the epicenter of the outbreak within the United States.
The clinical manifestations of COVID-19-related illness are heterogeneous, but patients with severe illness necessitating hospitalization and admission to an intensive care unit (ICU) invariably have severe pulmonary involvement causing acute respiratory failure. Other manifestations of critical illness due to COVID-19 infection thus far identified include acute kidney injury,3 thrombotic complications,4 and cardiomyopathy.5 We herein describe the first 300 patients admitted to ICUs within our 3-hospital medical center in New York City between March 10 and April 11, 2020.

Methods

Study Population and Data Collection

Consecutive adult patients aged 18 years and older admitted to 9 ICUs within the 3 main hospitals comprising Montefiore Medical Center (Bronx, NY) with documented SARS-CoV-2 infection were identified and their electronic medical records manually reviewed for extraction of relevant demographic and medical data. Presence of COVID-19 infection was confirmed by reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay of a specimen containing a nasopharyngeal or nasopharyngeal and oropharyngeal swab. This study was approved by the Institutional Review Board (IRB) of the Albert Einstein College of Medicine (IRB Protocol # 2020-11358) and waiver of informed consent was granted.

Study Definitions

Acute Respiratory Distress Syndrome (ARDS) was defined per the Berlin definition6 as mild, moderate or severe, based on the partial pressure of arterial oxygen divided by the fraction of inspired oxygen (PaO2/FiO2) of 200-≤300 mm Hg; 100-≤200 mm Hg; or ≤ 100 mm Hg, respectively (with positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) ≥ 5 cm H2O) in the setting of acute pulmonary infiltrates not fully explained by cardiac failure or fluid overload. Acute kidney injury (AKI) was defined per the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.7

Specimen Collection and Testing

A confirmed case of COVID-19 was defined as a positive result on reverse transcriptase polymerase chain reaction (RT-PCR) assay performed on nasopharyngeal or nasopharyngeal and oropharyngeal swab of suspected patients. Clinical specimens for COVID-19 diagnostic testing were collected in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. Initially, samples were sent to New York State Department of Health sites in Albany and New York City (approximately 10% of patients). The majority of samples were evaluated within our institution by an assay that was developed and validated by Montefiore Medical Center Laboratories in accordance with the manufacturer’s instructions. The assay was performed by extraction of RNA followed by real-time RT- PCR using one of 4 commercial methods. These included the Luminex ARIES, Abbott m2000, Hologic Panther Fusion and Cepheid GeneXpert SARS-COV-2 assays.

Statistical Analysis

Standard summary statistics were computed to describe patient characteristics at hospital admission, laboratory data values, and ICU treatment and outcomes both for the overall cohort and within groups defined by 30-day mortality. Chi-square tests, t-tests, or Wilcoxon Mann-Whitney tests were used as appropriate to compare characteristics between groups and generate p-values. The unadjusted relative risk for 30-day mortality was also estimated for each factor of interest using a binomial regression model, and presented along with 95% confidence intervals. In exploratory analyses, a multivariable model for 30-day mortality was generated using a set of a priori selected features recorded at hospital admission: gender, age, race, BMI, AKI status, laboratory values, smoking status, COVID-19 symptoms, comorbidities and total number of comorbidities. To obtain a final model, an exhaustive search of the model space was conducted and competing models of varying complexity were ranked based on their Akaike Information Criterion (AIC). The final model for 30-day mortality selected is thus representative of other competing models of similar AIC. Statistical analyses were conducted with SAS software, version 9.4 (SAS Institute Inc. Cary, NC, USA).

Results

The first critically ill patient with COVID-19 infection was admitted to an ICU at Montefiore Medical Center on March 10, 2020. By April 11, 2020, the 300th ICU patient was admitted. Of these 300 ICU patients, 159 were admitted directly from the Emergency Department and 31 were transferred from outside hospitals. One hundred ten patients were admitted to ICUs from medical wards after a median pre-ICU hospitalization duration of 4 days (IQR 2-12 days). We captured patient data through May 11, 2020 so as to provide at least 30-day follow up from hospital admission for our population. Distribution of the 300 patients reported herein among our medical center’s 3 campuses was as follows: 156 patients were admitted to the Moses campus; 102 patients admitted to the Einstein campus; and, 42 patients were admitted to the Wakefield campus of Montefiore Medical Center.
Patient characteristics are displayed in Table 1. The majority of patients were men (60.7%) with mean age (±SD) 57.8 ± 12.2 yr. Mean age of women was 58.8 ± 13.2 yr. Increasing age, male sex, and total number of comorbidities were associated with increased mortality. Common comorbidities (% of patients with that comorbidity) that were associated with increased mortality rate were: obesity (85.7% with BMI ≥25.0); hypertension (66.7%); and, current smoking status (22.3%). Although diabetes (44.7%) was not associated with increased mortality, it was a risk factor for presence of AKI on admission (47.8% vs. 34.9%; RR = 1.37; 95% CI: (1.0, 1.8)), which was associated with increased mortality. Increasing age (RR = 1.02; 95% CI: (1.01, 1.03)) and male sex (48.4% vs. 23.8%; RR = 1.68; 95% CI: (1,2, 2.3)) were also risk factors for presentation with AKI. Only 16 patients in our population had end-stage renal disease (ESRD), however 30-day mortality was significantly higher in this subgroup. Mortality did not differ based on race/ethnicity.
Table 1. Patient Characteristics at Baseline.*
  Overall (n = 300) Survivor 30 days post admission (n = 143; 47.7%) Non-survivor 30 days post admission (n = 157; 52.3%) Relative mortality risk€ (95% CI) p-value¥
Male gender—No. (%) 182 (60.7) 76 (53.1) 106 (67.5) 1.35 (1.06,1.71) .01
Age (continuous), mean(SD) [range], years 58.2 (12.6) [26-29] 55.6 (12.1) [27-93] 60.6 (12.6) [26-97] 1.01 (1.01,1.02) .0001
Males 57.8 (12.2) [31-93] 54.1 (11.7) [31-93] 60.4 (11.9) [33-87]    
Females 58.8 (13.2) [26-97] 57.2 (12.4) [27-89] 60.9 (14.0) [26-97]    
Age group—No. (%)          
<30 years 2 (.7) 1 (0.7) 1 (0.6) 0.69 (0.16,2.88) .02
30-39 years 20 (6.7) 10 (7) 10 (6.4)  
40-49 years 53 (17.3) 31 (21.7) 21 (13.4) 0.56 (0.34,0.91)  
50-59 years 83 (27.7) 47 (32.9) 36 (22.9) 0.6 (0.39,0.92)  
60-69 years 88 (29.3) 39 (27.3) 49 (31.2) 0.77 (0.51,1.15)  
70-79 years 44 (14.7) 12 (8.4) 32 (20.4) 1 (0.67,1.5)  
80+ years 11 (3.7) 3 (2.1) 8 (5.1) reference  
Race/Ethnicity—No. (%)          
Black, non-Hispanic 80 (26.7) 37 (25.9) 43 (27.4) 1.01 (0.74,1.38) .33
White, non-Hispanic 41 (13.7) 15 (10.5) 26 (16.6) 1.19 (0.85,1.66)  
— 119 (39.7) 63 (44.1) 56 (35.7) 0.88 (0.65,1.2)  
Other 60 (20.0) 28 (19.6) 32 (20.4) reference  
Current smoker— No. (%) 67 (22.3) 23 (16.1) 44 (28) 1.35 (1.09,1.68) .01
Alcohol use—No. (%) 29 (9.7) 14 (9.8) 15 (9.6) 0.99 (0.68,1.43) .94
Drug abuse—No. (%) 6 (2.0) 4 (2.8) 2 (1.3) 0.63 (0.2,1.97) .35
BMI (continuous), mean (SD) [range], kg/m2 32.3 (7.4) [18-58] 31.6 (7.0) [18-53] 32.9 (7.7) [20-57.9] 1.01 (1,1.03) .02
BMI&—No. (%)          
Underweight <18.5 1 (.3) 1 (0.7) 0 (0) reference .26
Normal 18.5-24.9 41 (13.9) 25 (17.6) 16 (10.4)  
Overweight 25-29.9 91 (30.7) 40 (28.2) 51 (33.1) 1.47 (0.96,2.25)  
Obese I: 30-34.9 117 (39.5) 57 (40.1) 60 (39.0) 1.35 (0.88,2.06)  
Obese II: 35+ 46 (15.5) 19 (13.4) 27 (17.5) 1.54 (0.98,2.43)  
Presenting symptoms— No. (%)          
Fever 208 (69.3) 98 (68.5) 110 (70.1) 1.04 (0.82,1.31) .64
Shortness of Breath 250 (83.3) 119 (83.2) 131 (83.4) 1.01 (0.75,1.35) .77
Cough 225 (75.0) 109 (76.2) 116 (73.9) 0.94 (0.74,1.2) .96
Gastrointestinal 64 (21.3) 30 (21) 34 (21.7) 1.02 (0.79,1.32) .89
AKI at admission—No. (%) 122 (40.7) 43 (30.0) 79 (50.0) 1.5 (1.20,1.80) .0003
Total no. comorbidities—median [range] 2 [0-6] 1 [0-5] 2 [0-6] 1.09 (1.01,1.16) .01
Comorbidities—No. (%)          
None 57 (19.0) 35 (24.5) 22 (14) 0.69 (0.49,0.98) .02
Cirrhosis 2 (.7) 1 (0.7) 1 (0.6) 0.96 (0.24,3.84) .95
Diabetes 134 (44.7) 61 (42.7) 73 (46.5) 1.08 (0.87,1.34) .50
Hypertension 200 (66.7) 85 (59.4) 115 (73.2) 1.37 (1.06,1.77) .01
Asthma 39 (13.0) 22 (15.4) 17 (10.8) 0.81 (0.56,1.18) .24
COPD 17 (5.7) 6 (4.2) 11 (7) 1.25 (0.87,1.81) .29
CAD 41 (13.7) 17 (11.9) 24 (15.3) 1.14 (0.86,1.52) .38
ESRD on HD 16 (5.3) 4 (2.8) 12 (7.6) 1.47 (1.1,1.99) .01
CKD 39 (13.0) 17 (11.9) 22 (14.0) 1.09 (0.81,1.48) .57
HIV 5 (1.7) 3 (2.1) 2 (1.3) 0.76 (0.26,2.24) .58
HFrEF 16 (5.3) 5 (3.5) 11 (7) 1.34 (0.94,1.9) .18
HFpEF 8 (2.7) 1 (0.7) 7 (4.5) 1.7 (1.28,2.26) .04
Cancer 18 (6.0) 5 (3.5) 13 (8.3) 1.41 (1.04,1.93) .08
* Percentages may not total 100 because of rounding. ICU: intensive care unit; AKI: acute kidney injury; COPD: chronic obstructive pulmonary disease; CAD: coronary artery disease; ESRD on HD: End-stage renal disease on hemodialysis; CKD: Chronic kidney disease; HIV: human immunodeficiency virus; HFrEF: heart failure with reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction
&n = 4 patients missing BMI were excluded before computing percentages. ¥Corresponding to a chi-square test for overall association if categorical or 2-sample t-test for approximately normally distributed continuous variables (age, BMI) and Wilcoxon-Mann-Whitney test for total number of comorbidities. €Based on a binomial regression model for death within 30 days post hospital admission
Laboratory data at admission and during ICU stay are displayed in Table 2. Blood urea nitrogen (BUN), creatinine and troponin levels at the time of admission, and peak levels during ICU admission, were both significantly higher in non-survivors vs. survivors. In addition, peak levels of procalcitonin, C-reactive protein, troponin, creatine phosphokinase (CPK), N-terminal pro b-type natriuretic peptide (proBNP), D-dimer, lactate, lactic dehydrogenase (LDH), and aspartate aminotransferase (AST) were higher in non-survivors. White blood cell count and lymphocyte percentage on admission, as well as levels of ferritin and fibrinogen during ICU admission, did not differ between survivors and non-survivors. The lowest recorded value of pO2/FiO2, reflecting severity of hypoxemia, was significantly lower in non-survivors.
Table 2. Laboratory Data.*
  No. Overall (n = 300) Survivor 30 days post admission (n = 143; 47.7%) Non-survivor 30 days post admission (n = 157; 52.3%) p-value¥
At Admission:          
White blood cell counts (K/μl) 300 8.1 (6,11.1) [1.7,45] 8.3 (5.6,11.7) [1.7,45] 8.1 (6.2,10.8) [3.3,27.9] .85
Lymphocyte (%) 299 11 (8,17) [0.7,56] 11.5 (8,18) [0.7,38] 10 (8,17) [1,56] .72
Platelets (K/μl) 293 204 (156,259) [25,967] 204 (158,253) [25,967] 204 (153,262) [71,704] .72
Urea nitrogen (mg/dl) 299 19 (13,33) [5,144] 16 (11,28) [5,141] 23 (15,35) [7,144] <.0001
Creatinine (mg/dl) 300 1.17 (0.825,1.76) [0.28,22.67] 0.97 (0.73,1.55) [0.28,14.4] 1.3 (0.94,1.99) [0.41,22.67] <.0001
Lactate (mmol/liter) 286 2 (1.5,3) [1,20] 1.9 (1.4,2.7) [1,12.4] 2.2 (1.6,3.4) [1,20] .01
Troponin (ng/mL) 293 0.01 (0.01,0.03) [0.01,2.31] 0.01 (0.01,0.02) [0.01,2.31] 0.01 (0.01,0.06) [0.01,1.51] <.0001
During ICU stay:          
pO2/FiO2—nadir 281 95 (67,130) [29,517] 110.5 (74,146) [29,517] 85 (64,122) [31,324] .001
Urea nitrogen (mg/dl)—peak 296 83 (45,132) [5,255] 67 (31,132) [5,238] 93 (58,133) [11,255] .002
Creatinine (mg/dl)—peak 298 4.94 (1.61,8.2) [0.52,1223] 2.4 (1.1,7.2) [0.52,19.1] 6.28 (3.47,9.1) [0.8,1223] <.0001
Lactate (mmol/liter)—peak 288 3 (2.2,4.6) [1,20] 2.6 (2,3.4) [1,12.4] 3.4 (2.35,6.25) [1,20] <.0001
Procalcitonin (ng/ml)-peak 250 3.4 (0.7,12) [0.1,50] 2.2 (0.4,8.45) [0.1,50] 5.5 (1.8,22.7) [0.1,50] <.0001
Ferritin (ng/ml)-peak 237 1762 (915,3659) [1.22,100000] 1649 (720,3103) [1.22,29788] 1944 (1151,3705) [1.38,100000] .10
LDH (U/liter)-peak 284 695 (503.5,904) [1.119,11827] 628.5 (454,814) [1.407,11827] 772 (570,992) [1.119,7547] <.0001
C-reactive protein (mg/dl)-peak 261 30.3 (16.7,40.2) [0.5,100] 24.9 (15.3,36.5) [0.5,62.1] 33.2 (23,44.6) [0.7,100] <.0001
D-dimer (microg/mL)—peak 240 11.905 (5.1,20) [0.55,31.9] 9.96 (3.98,20) [0.55,31.9] 15.89 (6.19,20) [0.68,25.9] .01
Fibrinogen (mg/dL)– peak 195 734 (575,878) [1.109,1800] 758 (605,885) [1.109,1800] 710.5 (553.5,865) [4.4,1383] .16
Total creatine phosophokinase (U/L)- peak 280 489 (183,1670.5) [3,72360] 381 (131,1587.5) [3,72360] 526.5 (249.5,1670.5) [51,38979] .04
Troponin (ng/mL)—peak 289 0.03 (0.01,0.19) [0.01,7.42] 0.01 (0.01,0.12) [0.01,6.23] 0.07 (0.01,0.26) [0.01,7.42] <.0001
Pro BNP (pg/mL)—peak 219 681 (133,3732) [13.1,15000] 406 (96.5,3064) [13.1,15000] 951 (246,4542) [60,15000] .010
AST (U/liter)—peak 289 100 (63,201) [15,10000] 88 (56,164) [15,10000] 117 (73,258) [21,10000] <.0001
ALT (U/liter)—peak 288 77 (41,142) [10,6399] 84 (40,137) [10,5381] 70 (42,145) [12,6399] .73
Bilirubin (mg/dl)—peak 290 0.9 (0.5,1.7) [0.2,23.3] 0.8 (0.5,1.6) [0.2,6.9] 1 (0.6,2) [0.2,23.3] .08
* Data are presented as median (IQR) [range] for all summaries; ¥Corresponding to a Wilcoxon Mann-Whitney test
Table 3 lists management and therapeutic interventions during ICU admission. Mechanical ventilation was provided to 274 (91.3%) patients; mortality in this group was 55.8%. The 26 patients who were not intubated and did not receive mechanical ventilation were managed with high-flow nasal cannula oxygen therapy. Mortality at 30 days among this subgroup was 15.4%. At least 1 day of prone positioning was employed in 63.1% of non-survivors and 52.4% of survivors. Among the 26 patients who did not receive mechanical ventilation, prone positioning was employed in 9 (34.6%). Neuromuscular blockade was administered to 58% of non-survivors and 28.0% of survivors. A significantly higher percentage of non-survivors (89.8%) received vasopressor support than did survivors (64.3%). Two patients received extracorporeal membrane oxygenation (ECMO). One patient received 16 days of ECMO and was discharged alive from the ICU; the other patient received 25 days of ECMO, had ECMO discontinued, and at the time of this writing remained in hospital. At least 1 day of hydroxychloroquine therapy was administered to 93.0% of patients, and 56.4% of patients received at least 1 dose of systemic corticosteroids. There was no significant difference in the percentage of patients receiving these drugs between survivors and non-survivors.
Table 3. ICU Management.*
  Overall (n = 300) Survivor 30 days post admission (n = 143; 47.7%) Nonsurvivor 30 days post admission (n = 157; 52.3%) Relative mortality risk€ (95% CI) p-value¥
Therapy:          
Mechanical ventilation—No. (%) 274 (91.3) 121 (84.6) 153 (97.5) 3.63 (1.5,9.00) <.0001
No. days—median [range] 9.5 [1-58] 11 [1-58] 8 [1-29]    
No mechanical ventilation (HFNC) 26 (7.7) 22 (15.4) 4 (2.6) .28 (.11,.68) <.0001
ECMO 2 (.6) 2 (1.4) 0 (0)    
NM blockade use 131 (43.7) 40 (28.0) 91 (58.0) 1.78 (1.43,2.22) <.0001
NM blockade use in MV patients 131/274 (47.8) 40/121 (33.1) 91/153 (59.5) 1.60 (1.29,1.99) <.0001
No. days—median [range] 2 [1-20] 3 [1-20] 2 [1-13]    
Prone positioning—No. (%) 174 (58.0) 75 (52.4) 99 (63.1) 1.24 (0.98,1.55) .06
No. days—median [range] 3 [1-31] 3 [1-31] 3 [1-16]    
Medication—No. (%)          
Any vasopressor support: 233 (77.7) 92 (64.3) 141 (89.8) 2.53 (1.93, 3.93) <.0001
Norepinephrine 226 (75.3) 88 (61.5) 138 (87.9) 2.38 (1.59,3.55) <.0001
Phenylephrine 89 (29.7) 36 (25.2) 53 (33.8) 1.21 (0.97,1.50) .10
Vasopressin 104 (34.7) 23 (16.1) 81 (51.6) 2.01 (1.64,2.46) <.0001
Epinephrine 25 (8.3) 6 (4.2) 19 (12.1) 1.51 (1.18,1.94) .01
Chloroquine 28 (9.4) 12 (8.6) 16 (10.2) 1.1 (0.78,1.54) .61
≥1 day of Hydroxychloroquine 279 (93.0) 136 (95.1) 143 (91.1) 0.77 (0.56,1.06) .17
Systemic steroids 167 (56.4) 83 (59.3) 84 (53.8) 0.9 (0.73,1.12) .35
*IQR: interquartile range, HFNC: high flow nasal cannula; ECMO: Extracorporeal Membrane Oxygenation; NM blockade: neuromuscular blockade; MV: mechanical ventilation. €Based on a binomial regression model for death within 30 days post hospital admission. ¥Corresponds to a chi-square test for association
Overall 30-day mortality was 52.3%. Two additional patients died in hospital >30 days after admission. In patients receiving mechanical ventilation, mortality was 55.8%. As shown in Table 4, 91.7% of patients met criteria for ARDS. Of our 300 patients, 122 (40.7%) had AKI on presentation, and 108 (36.0%) developed AKI after admission. Thus, 230 (76.7%) patients had AKI associated with their illness. Renal replacement therapy (intermittent hemodialysis or continuous renal replacement therapy) was provided to 117 (50.9%) of the patients with AKI. Presence of AKI on admission was associated with higher mortality. Among patients with AKI, the need for RRT was not associated with increased mortality. One hundred forty-one (47.0%) patients were discharged from the ICU. As of May 11, 2020 (30 days after the final study subject was admitted), only 2 patients (0.7%) remained hospitalized. For patients who died in-hospital, total hospital length of stay (survival time) was ≤ 5 days for 12.7% of patients, ≤ 10 days for 48% of patients, and ≤ 15 days for 71.3% of patients.
Table 4. Clinical Events and Outcomes.*
  Overall (n = 300) Survivor 30 days post admission
(n = 143; 47.7%)		 Non-survivor 30 days post admission (n = 157; 52.3%) Relative mortality risk€ (95% CI) p-value¥
ARDS—No. (%)          
Not present 25 (8.3) 21 (14.9) 4 (2.5) reference <.0001
Mild 13 (4.3) 11 (7.8) 2 (1.3) .96 (.20,4.6) .96
Moderate 106 (35.3) 51 (36.2) 55 (34.6) 3.18 (1.3,8.0) .01
Severe 156 (52.0) 58 (41.1) 98 (61.6) 3.89 (1.6,9.6) .003
Acute kidney injury (AKI)          
AKI at admission or during ICU—No. (%) 230 (76.7) 93 (65.0) 138 (87.9) 2.17 (1.46,3.23) <.0001
Development of AKI during ICU 108 (36.0) 50 (35.0) 58 (37.0) 1.04 (0.83,1.3) .72
Renal replacement therapy 133 (44.3) 51 (35.7) 82 (52.2) 1.37 (1.11,1.7) .004
In patients with AKI (n = 230) 117/230 (50.9) 47/93 (50.5) 70/137 (51.1) 1.01 (.74,1.39) .93
Died in hospital—No. (%) 157 (52.3) 0 (0) 157 (100)    
Discharged from ICU—No. (%) 141 (47.0) 141 (98.6) 0 (0)    
Total hospital LOS, days—median [range] 15 [1-58] 25 [2-58] 11 [1-30]    
0-5 days—No. (%) 28 (9.3) 8 (5.6) 20 (12.7)    
6-10 days 69 (23.0) 13 (9.1) 56 (35.7)    
11-15 days 60 (20.0) 24 (16.8) 36 (22.9)    
16-20 days 36 (12.0) 13 (9.1) 23 (14.7)    
21-25 days 27 (9.0) 16 (11.2) 11 (7.0)    
 Days 26 (8.7) 15 (10.5) 11 (7.0)    
>30 days 54 (18.0) 54 (37.8) 0 (0)    
* ARDS: Acute respiratory distress syndrome; AKI: Acute kidney injury; ICU: intensive care unit; LOS: length of stay. €Based on a binomial regression model for death within 30 days post hospital admission. ¥Corresponding to a Wald chi-square test for association
Table 5 presents a multivariable model for 30-day mortality. Consistent with the unadjusted estimates in Table 1, increasing age and BMI were associated with a statistically significant increased risk in 30-day mortality. Additionally, men had a 28% higher risk of death compared to women, even after accounting for age and BMI (relative risk: 1.23; 95% CI: (1.02, 1.60)). Men also had a higher risk of AKI at hospital admission compared to women (48.4% vs. 28.8%). Presenting with AKI was associated with a 25% increased risk of death (relative risk: 1.25; 95% CI: (1.02, 1.52)), independent of gender, BMI, and age. Although 48% of patients with diabetes presented with AKI at admission compared to 35% without diabetes, diabetes was not a statistically significant risk factor in univariate or adjusted models for this cohort of patients. Hypertension, though associated with an increase in 30-day mortality in univariate analysis, was not associated with mortality after adjustment for age, gender, and BMI. Similarly, having a greater number of comorbidities was associated with a higher risk of death in univariate analysis, but did not retain statistical significance in the final multivariable model.
Table 5. Multivariable Model for 30-Day Mortality.
Patient characteristic Relative mortality risk€ (95% CI) p-value¥
Age (per year) 1.01 (1.01,1.02) <.0001
Male gender
Ref: female gender		 1.28 (1.02,1.6) 0.03
BMI (per kg/m2) 1.02 (1.01,1.04) 0.004
AKI at admission
Ref: no AKI at admission		 1.25 (1.02,1.52) 0.03
€Based on a binomial regression model for death within 30 days post hospital admission. Final representative model was selected via an “all subsets” model selection approach; ¥Corresponding to a Wald chi-square test for association.

Discussion

In our population of 300 critically ill patients with COVID-19 infection admitted to ICUs within our medical center, overall 30-day mortality was 52.3%. Patient characteristics associated with a higher mortality rate were consistent with those reported previously, including increasing age, male sex, obesity, hypertension and active cigarette smoking status. Diabetes was not associated with increased mortality in our population, but was associated with the presence of AKI on admission. Higher levels of inflammatory markers, including procalcitonin, and C-reactive protein (CRP), as well as higher serum levels of D-dimer, lactate, LDH, and AST were observed in non-survivors. Differences in CRP, LDH and AST, though statistically significant, are of questionable clinical significance. Laboratory values reflecting myocardial injury, including troponin, CPK and proBNP were also significantly higher in non-survivors. Presentation with AKI and need for vasopressor support were associated with higher mortality.
Our patient cohort represents a more severely ill population than has been reported in previous studies. Of our 300 patients, 275 (91.7%) met criteria for ARDS and 274 (91.3%) received mechanical ventilation. Among those receiving mechanical ventilation, the mortality rate was 55.8%. Non-survivors had a lower nadir value of pO2/FiO2, reflecting more severe hypoxemia. Of 143 patients alive at 30 days or more after admission, 121 (84.6%) had received mechanical ventilation. Of non-survivors at 30 days, 97.5% had received mechanical ventilation. Furthermore, 77.7% of our patients required vasopressor support for septic shock; 40.7% presented with AKI; 36.0% developed AKI after admission; and, 50.9% of patients with AKI required RRT.
Mortality data have been reported in several previous studies of critically ill patients with COVID-19 infection. Three small studies to date from Wuhan, China have reported a 28-day mortality rate of 61.5% among 52 patients8; a mortality rate of 65.7% among 67 patients requiring mechanical ventilation9; and, a mortality rate of 66.7% among 78 critically ill patients.10 A description of 24 patients admitted to ICUs in Seattle, WA, USA reported 50% mortality within the first 18 days of ICU admission.11 A larger study of 344 critically-ill patients admitted to ICUs in Wuhan reported a 28-day mortality rate of 38.7%.12 This group of patients appears to have been less severely ill than our cohort, as evidenced by a lower prevalence of ARDS (42%), septic shock (33%), AKI (25%) and treatment with invasive mechanical ventilation (29%). A case series of 5700 patients admitted to 12 hospitals in New York City and its suburbs was published 18 days after the last patients were enrolled, and, while the majority of the study population was still hospitalized, so 28-day or 30-day mortality data were not able to be provided.13 However, the authors reported, in the subgroup of patients who had been discharged alive or had died, a mortality rate of 88.1% among patients who had received invasive mechanical ventilation.13 A more recent report from New York City described 1150 hospitalized patients among whom 257 (22%) were critically ill.14 An overall 28-day mortality rate of 39% and a 41% mortality rate among patients receiving mechanical ventilation were reported. That population had a lower prevalence of hypertension, diabetes and obesity, and, fewer patients required mechanical ventilation (79%), vasopressor support (66%) and RRT (31%) compared with our cohort reported herein.
Based on recent clinical trial data, critical care physicians have embraced the use of prone positioning15-17 and, perhaps to a lesser degree, neuromuscular blockade16-18 in the management of patients with ARDS, especially moderate-to-severe ARDS. Recent guidelines published jointly by Society of Critical Care Medicine and the European Society of Intensive Care Medicine on the management of critically ill adults with COVID-19 suggest the use of prone positioning and neuromuscular blockade in patients with COVID-19 infection and moderate to severe ARDS (weak recommendation, low quality evidence).19 The majority of our patients (58.0%) received 1 or more sessions of prone positioning, and 47.8% of mechanically ventilated patients received a period of neuromuscular blockade. Neither intervention was associated with improved outcome. In fact, a higher percentage of non-survivors received prone positioning and neuromuscular blockade, which likely reflects selection of patients who were more severely ill or demonstrated a faster trajectory of clinical decompensation. Among the 300 patients described in this study, ventilator management of ARDS, initiation of prone positioning, and use of neuromuscular blockade were not protocolized, but left to the discretion of the treating physician.
We observed a high prevalence and incidence of AKI and need for RRT in our population. Of our 300 patients admitted to ICUs, 122 (40.7%) presented with AKI and 108 (36.0%) developed AKI after admission; 117 (50.9%) of patients with AKI required RRT. Increased risk for AKI at admission was associated with increasing age, male sex, and diabetes. As mentioned above, diabetes was not associated with increased mortality, but presence of AKI on admission was associated with increased mortality risk.
Initial published impressions were that the prevalence of AKI in COVID-19 is low,20 based on observational studies such as one reporting AKI in 0.5% of 1099 patients evaluated throughout mainland China.21 A Chinese study of only hospitalized patients reported the presence of AKI in 5.1% of that population,3 whereas a large case series of 5449 hospitalized patients from 13 New York City area hospitals reported AKI on presentation, or developing after admission, in 36.6% and need for RRT in 14.3% of patients.22 In studies specifically evaluating critically ill patients with COVID-19 from China,8,12,23 and Italy,24 AKI was reported in 25%-29% of patients. We suspect that the higher incidence of AKI and need for RRT that we observed reflects the severity of illness in our patient population. It is notable that in the aforementioned study of 5449 hospitalized patients,22 AKI was reported in 89.7% of the patients requiring mechanical ventilation. It remains to be elucidated whether AKI developing during severe COVID-19-related illness reflects ischemic injury (acute tubular necrosis) as seen with septic shock-induced multiorgan failure or, whether the renal injury is instead, or additionally, due to specific viral-induced renal pathology.25
As was the case at other institutions in the United States and New York City in particular, the sudden presentation of a tremendous number of COVID-19-associated critically ill patients rapidly overwhelmed the ICU capacity of our medical center. Makeshift ICUs were created out of hospital wards, operating rooms, recovery rooms and previously non-clinical space. The patients we report in this study represent the first 300 patients admitted to 8 established ICUs within our hospitals, and 1 additional ICU created to address the surge of critically-ill patients. Electronic medical records of each patient were manually reviewed by the co-authors of this study for careful extraction of relevant data. We believe this case series represents the largest description to date of patients with COVID-19 infection admitted to ICUs in the United States for whom 30-day mortality data are provided.
Many clinical questions remain to be elucidated as we learn in real time about COVID-19-associated critical illness. Are standard ARDS management strategies optimal for this patient population? Do the high prevalence and incidence of AKI observed in these patients reflect vasodilatory shock-induced ischemic injury, or virus-induced renal pathology? Similarly, do our relatively frequent observations of thrombotic events and cardiomyopathy in this population reflect COVID-19-specific mechanisms or simply manifestations of severe sepsis-induced multiorgan dysfunction? Ongoing clinical experience and, ideally, prospective clinical trials will inform these and other questions as we strive to provide optimal care to this challenging patient population.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Peter V. Dicpinigaitis, MD https://orcid.org/0000-0001-5318-9060

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Published In

Volume 35, Issue 10
Pages: 963 - 970
Article first published online: August 19, 2020
Issue published: October 2020

Keywords

  1. SARS-CoV-2
  2. COVID-19
  3. novel coronavirus
  4. acute respiratory distress
  5. syndrome (ARDS)
  6. critical illness

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© The Author(s) 2020.
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PubMed: 32812834

Authors

Affiliations

Sudham Chand, MD
Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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Sumit Kapoor, MD
Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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Deborah Orsi, MD
Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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Melissa J. Fazzari, PhD
Department of Epidemiology and Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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Tristan G. Tanner, MD
Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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Genevieve C. Umeh, MD
Department of Obstetrics and Gynecology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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Marjan Islam, MD
Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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Peter V. Dicpinigaitis, MD
Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
https://orcid.org/0000-0001-5318-9060
[email protected]
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Notes

Peter V. Dicpinigaitis, Weiler Division/Montefiore Medical Center, 1825 Eastchester Road, Bronx, NY 10461, NY, USA. Email: [email protected]

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