Baseline characteristics and comorbidities
During the observation period, 34 COVID-19 patients with pulmonary failure were admitted and treated on the ICU. Medium age was 67±13 years, 6 (17.6%) were female.
The medical history of the patients comprised overweight (76.5%), hypertension (52.9%), diabetes (25.3%) and cardiac diseases (23.5% coronary artery disease, 17.6% valve operation or chronic heart failure heart). The number of patients with chronic respiratory precondition was low (Table 1).
Simplified Acute Physiology Score (SAPS) II score was significantly higher in non-survivors compared to survivors (50±7 vs. 42±14; p=0.037). No other significant differences in comorbidities were found.
Assessment of symptoms, vitals on admission, virologic findings, microbiological findings, the laboratory measures and imaging are presented in the supplemental material (Table S1).
ICU resources and management
Length of ICU treatment in non-survivors was 17±7 (2-72) days, patients discharged from ICU were treated 25±22 (1-81) days (Table 2). The dates of arrival, cumulative therapies and outcomes of individual patients are displayed in figure 1.
Half of our patients suffered from moderate, half of severe ARDS. Intubation was performed in 91.2% of the cases, prior to the intubation in 10 patients (29.4%) nasal high flow (NHF) and / or non-invasive ventilation (NIV) was applied.
Three patients (8.8%) were exclusively managed with NHF / NIV. On average, patients were on invasive mechanical ventilation (IMV) for 19±21 (0-79) days. Positive end-expiratory pressure (PEEP) levels were high during the three first treatment days on average 12.5±3 (7-18) mbar. Spontaneous breathing on the ventilator was performed in 73.5% in the first 24 hours. Weaning from the respirator was successfully completed in 12 cases before ICU discharge, 5 patients went to a weaning unit.
Veno-venous extracorporeal membrane oxygenation (ECMO) therapy was installed in 8/34 (23.5%) patients for 20±23 (2-75) days. Three patients were weaned from ECMO therapy. 2 patients died of refractory ARDS and 2 because of intracerebral hemorrhage during ECMO, one patient died with abdominal sepsis and bleeding during ECMO therapy.
Proning was performed in 67.6%. If proning was not indicated, alternative strategies were incomplete prone positioning (135°), pilot´s seat positioning or the use of a rotational bed. Thus, 88.2% of our patients underwent daily therapeutic positioning maneuvers.
Acute kidney injury was noticed in 85.3% of the patients, renal replacement therapy (RRT) was required in 35.3% of all cases. Due to vasoplegic or cardiogenic shock, non-survivors significantly more often required vasopressor therapy (17/17 vs. 11/17; p=0.007) and transfusions (12/17 vs. 5/17; p=0.016).
The initial antiviral treatment followed house-intern expert consensus and was a combination of hydrochloroquine and lopinavir/ritonavir (70.6%) and later on a hydrochloroquine only treatment (23.5%). Five patients received tocilizumab (14.7%). Additional information is presented in the supplements (Table S2).
Resource intense multi-organ replacement ICU treatment was measured in nursing hours using Inpuls®-categories in 25 patients. A time investment of > 20 hours per day was necessary in 96.0% of our patients and required a 1:1 nurse-patient ratio. Additional information is presented in the supplements. The cumulative therapies are displayed in figure 2.
Outcomes and complications
At the end of the follow up, exactly half of our patients were dead, the other half was discharged from ICU, including 5 transferals to weaning units (4 in-house transferals). More than half of the survivors were able to be discharged home (58.8%), 2 went on a rehabilitation therapy without oxygen supply. On average the survival since admission was 60±8 days (51-81 days).
The clinical course was complicated by pneumothorax or pneumomediastinum in 6 (17.6%) cases. Furthermore, 5 (14.7%) patients exhibited non-fatal pulmonary embolism / thrombosis in segmental and sub-segmental lung arteries. Superinfections during treatment in 18 (52.9%) cases were dominated by Serratia marcescens (33.3%). Aspergillus fumigatus superinfection was detected in 2 (11.1%) patients (Table 3). Intracerebral hemorrhage was significantly more often recorded in non-survivors (p=0.015).
Nine (52.9%) patients died because of untreatable multi-organ failure as the main cause of death in the cohort. Three (21.4%) patients died because of refractory ARDS. Notably, 3/17 (17.6%) patients died of fatal intracerebral hemorrhage. Because of SARS-CoV-2 PCR positivity organ donation was impossible in these patients. Two (11.8%) patients did not continue therapy because of “do not resuscitate” (DNR) orders and received palliative treatment. No medical autopsies were carried out in this cohort (Table 3).