Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome Patients Requiring Invasive Mechanical Ventilation in a Lower Middle-Income Country
, , , , , and | Feb 09, 2022
About this article
Article Category: Research Article
Published Online: Feb 09, 2022
Page range: 23 - 32
Received: Jun 14, 2021
Accepted: Dec 09, 2021
DOI: https://doi.org/10.2478/jccm-2021-0044
Keywords
© 2021 Taymmia Ejaz, Fazal Rehman, Arslan Ahmed, Safia Akhlaq, Sheema Saadia, Adil Aziz, Erfan Hussain, published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
Fig. 1
Laboratory parameters among survivors and non-survivors
| Survivors (n=30) | Non-Survivors (n=41) | All patients (n=71) | p-value | |
|---|---|---|---|---|
| Hemoglobin at 24 hours ( g/dl) N=71 | 13.05(11.5-13.5) | 11.9(9.85-14) | 12.4(10.6-13.7) | 0.34 |
| Hemoglobin at 48 hours( g/dl) N=70 | 12.05(10.7-12.9) | 11.05(9.45-13.15) | 11.75(9.97-12.97) | 0.112 |
| TLC at 24 hours (x10^9/L) | 11.15(8.0-15.1) | 14.3(9.3-18.2) | 12.9(8.9-16.5) | 0.046 |
| TLC at 48 hours (x10^9/L) | 11.15(8.5-14.9) | 13.95(9.3-20.0) | 12.6(12.6-16.07) | 0.133 |
| Platelets count at 24 hours(x10^9/L) | 3310(237.25-363) | 224(157.5-335.5) | 269(198-353) | 0.063 |
| Platelets count at 48 hours(x10^9/L) | 334.5(277.5-406.7)) | 212.5(132.75-317.5) | 269.5(171.25-356.25) | <0.001 |
| Blood Urea Nitrogen(mg/dl) | 25(15.75-43) | 27(22.5-51.5) | 26(19-43) | 0.159 |
| Blood Urea Nitrogen at 48 hours( mg/dl) | 26(21-49.25) | 37.5(28.25-58.25) | 35.5(22.75-54.25) | 0.057 |
| Creatinine at 24 hours ( mg/dl) | 1.25(0.9-1.65) | 1.4(1.1-2.05) | 1.4(1-1.9) | 0.111 |
| Creatinine at 48 hours(mg/dl) | 1(0.7-1.35) | 1.85(0.9-25) | 1.3(0.8-2.35) | 0.007 |
| Sodium 24 hours (mmol/L) | 138.5(131.75-141) | 139(133-143) | 139(133-142) | 0.307 |
| Sodium 48 hours(mmol/l) | 141(136.75-144) | 143(139.25-147.75) | 142.5(138-147) | 0.032 |
| Bicarbonate 24 hours (mmol/L) | 22.3(19.3-24.8) | 20.7(17.5-23.45) | 21.9(18-24) | 0.102 |
| Bicarbonate at 48 hours(mmol/L) | 22.8(21.2-26.8) | 20.65(18.75-22.5) | 21.55(19.9-24.5) | 0.002 |
| C-Reactive Protein 24 hours (n=70) (mg/L) | 160(69-236) | 165(58-203.5) | 161.5(63-214.5) | 0.948 |
| C-Reactive Protein at 48 hours (n=63) (mg/L) | 123(48.5-196) | 192.5(85.5-278) | 165(61-244) | 0.054 |
| C-Reactive Protein Max (n=60) (mg/L) | 201(169-292) | 235(162-317.5) | 230(169.25-301) | 0.6 |
| Ferritin at 24 hours (n=68) (ng/ml) | 879.5(420.75- 2518.5) | 1519(669.75-3183.5) | 1278.5(548.75-2566) | 0.159 |
| Ferritin at 48 hours (n=53) (ng/ml) | 674(304-1883.5) | 2075(896.5-3000.5) | 1287(599.5-2752.75) | 0.008 |
| Ferritin Max (n=61) (ng/ml) | 1169.5(648-4424) | 2282(1193.5-6727) | 1923(758.5-5415) | 0.088 |
| D-Dimer at 24 hours (n=69) (mg/ml) | 1.8(1.05-4) | 3.65(2.1-13.72) | 3.3(1.25-9.5) | 0.038 |
| D-Dimer at 48 hours (n=60) (mg/L ) | 3.2(1.7-11.6) | 8.1(2.35-15.4) | 5.3(1.95-15.3) | 0.045 |
| D-Dimer Max(n=61) (mg/L ) | 5.3(2.5-16.8) | 18.3(6.5-30) | 14.5(4.6-30) | 0.009 |
| Procalcitonin (n=68) (ng/ml) | 0.53(0.209-1.45) | 0.80(0.17-3.58) | 0.603(0.202-2.102) | 0.411 |
| Procalcitonin at 48 hours (n=54) (ng/ml) | 0.51(0.25-2.99) | 2.85(0.48-9.72) | 1.33(0.431-7.47) | 0.077 |
| LDH 24 hours (n=67) (I.U/L) | 650(535-774.5) | 667.5(569.75-867) | 652(569-831) | 0.40 |
| LDH48(n=58) (I.U/L) | 575(430-696.75) | 670(579.25-823) | 618(498-743.5) | 0.004 |
| pH at admission | 7.4(7.35-7.43) | 7.37 (7.25-7.43) | 7.39(7.32-7.43) | 0.21 |
| pH 48 hours | 7.41(7.36-7.45) | 7.34 (7.27-7.41) | 7.39(7.315-7.43) | 0.001 |
Complications observed in patients during the hospital stay
| Complications | Frequency | Percentage(%) |
|---|---|---|
| Septic Shock | 44 | 62.0 |
| Multi-organ Dysfunction | 31 | 43.7 |
| Myocardial injury | 30 | 42.3 |
| Thrombotic complications | 2 | 2.8 |
| Acute kidney Injury | 57 | 80.3 |
| Renal replacement therapy | 16 | 22.5 |
| CRRT | 2.8 | |
| Both CRRT/ Hemodialysis | 8.5 | |
| Intermittent Hemodialysis | 11.3 | |
| Hospital-acquired Pneumonia/VAP. | 38 | 53.5 |
| Acinetobacter | 14 | |
| Stenotrophomonas | ||
| Pseudomonas | ||
| Klebsiella | ||
| E.coli | ||
| Fungal infections | 28 | 39.4 |
| Bacteremia | 13 | 18.3 |
| Catheter-associated urinary tract infection | 8 | 11.3 |
| Pneumothorax | 11 | 15.5 |
| Subcutaneous emphysema | 9 | 12.7 |
| Critical illness myopathy | 5 | 7.2 |
| Bed scores | 2 | 2.9 |
| GI Bleed | 17 | 24.6 |
| Re-intubation | 4 | 5.8 |
| Arrhythmias(new-onset) | 20 | 28.1 |
| CPR with ROSC | 12 | 16.9 |
| Diabetic ketoacidosis | 6 | 8.45 |
Multi-variate regression analysis of predictors of mortality
| Variable | p-value | Odds ratio (95% Confidence interval) |
|---|---|---|
| SOFA score Admission | 0.26 | 1.19(0.8-1.64) |
| APACHE-II score Admission | 0.012 | 1.18(1.03-1.34) |
| PF (PA02/Fi02) ratio Admission | 0.20 | 0.99(0.98-1.003) |
| Dimer>1.5 mg/L | 0.037 | 5.15(1.108-23.96) |
| Acute kidney injury | 0.75 | 0.76(0.13-4.26) |
| PEEP at admission (cmH20) | 0.26 | 1.17(0.88-1.57) |
Univariate analysis of predictors of mortality
| Variable | p-value | Odds ratio (95% Confidence interval) | |
|---|---|---|---|
| Age | 0.52 | 1.01 (0.97-1.04) | |
| Age>60 | 0.65 | 1.24 (0.48-3.21) | |
| PEEP at 48 hours | 0.009 | 1.3 (1.06-1.6) | |
| PEEP at 24 hours | 0.32 | 1.09 (0.91-1.32) | |
| PF ratio admission | 0.032 | 0.99 (0.98-0.99) | |
| PF ratio at 48 hours | 0.56 | 0.99 (0.99-1.003) | |
| APACHE-II at 24 hours | 0.000 | 1.19 (1.08-1.31) | |
| APACHE-II 48 hours | 0.000 | 1.17 (1.07-1.27) | |
| SOFA score at 24 hours | 0.000 | 1.48 (1.19-1.85) | |
| SOFA score at 48 hours | 0.000 | 1.47 (1.2-1.8) | |
| Hypertension | 0.81 | 1.11 (0.434-2.87) | |
| Acute kidney injury | 0.019 | 4.62 (1.28-16.64) | |
| Myocardial injury | 0.416 | 1.49(0.56-3.90) | |
| TLC at 24 hours (x10^9/L | 0.079 | 1.06 (0.99-1.14) | |
| Platelets count at 48 hours(x10^9/L) | 0.001 | 0.99 (0.98-099) | |
| Dimer>1.5 mg/L | 0.031 | 3.1 (1.11-8.71) | |
| D-Dimer Maximum | 0.017 | 1.06 (1.01-1.12) | |
| D-Dimer at 24 hours (n=69) (mg/ml) | 0.067 | 1.05 (0.996-1.12) | |
| D-Dimer at 48 hours (n=60) (mg/L ) | 0.089 | 1.05 (0.99-1.12) | |
| C-Reactive Protein 24 hours (n=70)(mg/L) | 0.923 | 1 (0.996-1.005) | |
| C-Reactive Protein >180 mg/L | 0.80 | 1.12 (0.43-2.9) | |
| Procalcitonin >1 ng/ml | 0.236 | 1.82 (0.67-4.93) | |
| LDH 24 hours (n=67) (I.U/L) | 0.212 | 1.001 (1.00-1.002) | |
| LDH 48 hours (I.U/L) | 0.017 | 1.005(1.001-1.008) |
Demographic and clinical features of the study population
| Variables Median (Interquartile ranges) | Survivors (n=30) | Non-Survivors (n=41) | All patients (n=71) | P-value |
|---|---|---|---|---|
| Age (years) | 55(47.5-64) | 59(46-65) | 56(48-64) | 0.35 |
| Age (years) | 0.86 | |||
| <40 | 41.7%(5) | 58.3%(7) | 16.9%(12) | |
| 41-50 | 55.6%(5) | 44.4%(4) | 12.7%(9) | |
| 51-59 | 41.2%(7) | 58.8%(10) | 23.9%(17) | |
| >60 | 39.4%(13) | 60.6%(20) | 46.5%(33) | |
| Diabetes Mellitus | 38.5%(15) | 61.5%(24) | 54.9%(39) | 0.47 |
| Hypertension | 41%(16) | 59%(23) | 54.9%(39) | 0.81 |
| Ischemic heart disease | 41.7%(10) | 58.3%(14) | 33.8%(24) | 0.94 |
| Chronic kidney disease | 33.3%(3) | 66.7%(6) | 12.7%(9) | 0.72 |
| Proning | 43.9%(18) | 56.1%(23) | 57.7%(41) | 0.74 |
| Vasopressors requirement | 37.5%(15) | 62.5%(25) | 56.3%(40) | 0.35 |
| BMI (kg/m2) | 29.5 (24.04-28.53) | 25.95 (24.04-28.5) | 25.95 (24.22-27.68) | 0.7 |
| ICU Admission SOFA score | 5(4-7) | 12(9-14) | 7(5-9) | <0.001 |
| 48 hours SOFA score | 4(2-6) | 10(9-12) | 6(4-10) | <0.001 |
| ICU Admission APACHE II score | 8(7-10) | 21(14-28) | 15(11-24) | <0.001 |
| APACHE II 48 score hours | 9 (6- 11) | 20 (12-25) | 13(9-23) | <0.001 |
| PEEP ICU Admission | 8(8-10) | 8(6-10) | 10(8-10) | 0.217 |
| PEEP 48 hours | 10(8-11) | 10(8-12) | 10(7.75-12) | 0.007 |
| Tidal volume (ml/kg) at ICU admission | 6(5.62-6.43) | 6.42(5.62-6.84) | 6.17(5.62-6.57) | 0.674 |
| Tidal volume at 48 hours | 6.35(5.9-6.86) | 6.13(5.62-6.85) | 6.27(5.7-6.85) | 0.548 |
| PF ratio ICU admission (PA02/Fi02) | 118(81.09-219.31) | 107.37(65.75-141.25) | 112.5(76.75-160) | 0.041 |
| PF ratio 48 hours(PA02/Fi02) | 164.7(115.03-221.41) | 141.41(108.03-192.75) | 154.55(108.75-199.25) | 0.208 |
| Duration of symptom onset to ER | 7(4-10) | 7(5-10) | 7(4-10) | 0.313 |
| presentation | ||||
| Symptom onset to ICU admission | 9(5.7-11.25) | 9(7-12) | 9(7-12) | 0.472 |
| Length of ICU stay | 6(4-9) | 8(4-11.5) | 8(4-10) | 0.177 |
| Length of ICU stay with IMV | 4.5(3-7) | 8(4-11) | 6(3-10) | 0.008 |
| The total length of stay | 17(10.75-21.25) | 9(7.5-15) | 11(8-20) | 0.001 |
| Acute kidney injury | 66.6%(20) | 90.2%(37) | 80.3%(57) | 0.014 |
Area under ROC curve and cut-off values of APACHE II and SOFA score for prediction of mortality
| Scoring variable | Area under ROC curve (95% confidence interval) | Standard error | p-value | Cut-of value | Sensitivity | Specificity |
|---|---|---|---|---|---|---|
| Admission APACHE II score | 0.803(0.697-0.908) | .054 | 0.000016 | 13.5 | 0.775 | 0.70 |
| 48 hour APACHE II score | 0.795(0.687-0.903) | .055 | 0.000027 | 12.5 | 0.75 | 0.80 |
| Admission SOFA score | 0.763(0.649-0.876) | .058 | 0.000181 | 6.5 | 0.775 | 0.67 |
| 48 hour SOFA score | 0.805(0.699-0.910) | .054 | 0.000014 | 5.5 | 0.80 | 0.70 |