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Characteristics and risk factors for mortality in critically ill patients with COVID-19 receiving invasive mechanical ventilation: the experience of a private network in Sao Paulo, Brazil

Eduardo Atsushi Osawa
Eduardo Atsushi Osawa
 and 
Alexandre Toledo Maciel
Alexandre Toledo Maciel
   | Aug 12, 2022
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Article Category: Research Article
Published Online: Aug 12, 2022
Page range: 165 - 175
Received: Dec 12, 2021
Accepted: Jun 12, 2022
DOI: https://doi.org/10.2478/jccm-2022-0015
Keywords
© 2022 Eduardo Atsushi Osawa, Alexandre Toledo Maciel, published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Fig.1

Flowchart of the study enrolment. ICU: Intensive Care Unit.
Flowchart of the study enrolment. ICU: Intensive Care Unit.

Fig. 2

Daily distribution of patients according to study events. ICU: Intensive Care Unit; IMV: invasive mechanical ventilation.
Daily distribution of patients according to study events. ICU: Intensive Care Unit; IMV: invasive mechanical ventilation.

Fig. 3

Cummulative percentage of study outcomes within the first 28 days of hospitalization.
Cummulative percentage of study outcomes within the first 28 days of hospitalization.

Fig. 4

ROC curves on the multivariable logistic regression model to identify risk factors for mortality (A) Development cohort (B) Validation cohort. AUC: area under curve; ROC: Receiver Operating Characteristic.
ROC curves on the multivariable logistic regression model to identify risk factors for mortality (A) Development cohort (B) Validation cohort. AUC: area under curve; ROC: Receiver Operating Characteristic.

Laboratory biomarkers measurements obtained at hospital admission.

Variable Overall (N = 215) Discharged from ICU (N = 119) Died in ICU (N = 96) P-value
CRP 113 [55; 201] 112 [44; 184] 118 [58; 221] 0.165
LDH 380 [281; 510] 364 [269; 460] 416 [294; 536] 0.177
Creatinine 1.0 [0.9; 1.4] 1.0 [0.8; 1.2] 1.1 [0.9; 1.6] 0.002
Lymphocyte count 904 [651; 1266] 932 [718; 1284] 829 [545; 1244] 0.021
Neutrophil count 5050 [3462; 7480] 4812 [3407; 6860] 5346 [3497; 9044] 0.301
Platelet count 180 [138; 232] 186 [142; 231] 172 [136; 240] 0.356
D-dimer 0.6 [0.4; 1.0] 0.5 [0.3; 0.8] 0.7 [0.4; 1.7] 0.003
LCR 8 [4; 18] 9 [4; 25] 6 [3; 14] 0.019
NLR 6 [3; 11] 5 [3; 9] 7 [4; 14] 0.005

Baseline characteristics of study patients.

Variable Overall (N = 215) Discharged from ICU (N = 119) Died in ICU (N = 96) P-value
Female gender 69 (32.1) 34 (28.6) 35 (36.5) 0.242
Age, years 62.7 ± 15.4 56.9 ± 13.9 69.9 ± 14.2 < 0.001
Comorbidities
Hypertension 135 (62.8) 68 (57.1) 67 (69.8) 0.066
Diabetes 86 (40.0) 41 (34.5) 45 (46.9) 0.070
COPD 15 (7.0) 3 (2.5) 12 (12.5) 0.006
Smoking 3 (1.4) 0 (0.0) 3 (3.1) 0.087
Obesity 109 (50.7) 75 (63.0) 34 (35.4) <0.001
Heart failure 15 (7.0) 2 (1.7) 13 (13.5) < 0.001
Cirrhosis 1 (0.5) 0 (0.0) 1 (1.0) 0.447
Stroke 6 (2.8) 0 (0.0) 6 (6.2) 0.007
Bariatric surgery 2 (0.9) 2 (1.7) 0 (0.0) 0.503
Hyperlipidemia 47 (21.9) 23 (19.3) 24 (25.0) 0.325
Dementia 5 (2.3) 1 (0.8) 4 (4.2) 0.175
Autoimmune disorder 1 (0.5) 1 (0.8) 0 (0.0) 1.000
HIV 4 (1.9) 3 (2.5) 1 (1.0) 0.630
Solid neoplasm 5 (2.3) 3 (2.5) 2 (2.1) 1.000
Hematological neoplasm 3 (1.4) 1 (0.8) 2 (2.1) 0.587
Asthma 12 (5.6) 8 (6.7) 4 (4.2) 0.554
Non-dialysis CKD 14 (6.5) 6 (5.0) 8 (8.3) 0.408
CKD on dialysis 6 (2.8) 2 (1.7) 4 (4.2) 0.411
Coronary artery disease 24 (11.2) 10 (8.4) 14 (14.6) 0.192
Duration from symptom onset to hospital admission, days 7 [5; 9] 7 [5; 9] 6 [5; 8] 0.084
BMI 30.1 [26.6; 34.2] 31.2 [28.3; 35] 28.3 [25.5; 31.6] <0.001
SpO2 at hospital presentation 91 [86; 95] 92 [88; 96] 90 [82.5; 95] 0.075
SAPS 3 score 49 [44; 55] 47 [42; 51] 54 [48; 59] < 0.001
Duration from hospital admission to intubation date 3 [1; 5] 4 [1; 6] 3 [1; 5] 0.107

Laboratory biomarkers obtained at the date of intubation.

Variable Overall (N = 215) Discharged from ICU (N = 119) Died in ICU (N = 96) P-value
CRP 221 [143; 293] 199 [139; 270] 235 [155; 329] 0.069
LDH 493 [400; 643] 485 [387; 573] 528 [429; 676] 0.073
Creatinine 1.1 [0.8; 1.5] 1.0 [0.8; 1.3] 1.3 [1.0; 2.0] < 0.001
Limphocyte count 866 [560; 1238] 884 [586; 1264] 793 [520; 1142] 0.310
Neutrophil count 8039 [5322; 11509] 6850 [5054; 10847] 10014 [6690; 12617] 0.005
Platelet count 228 [179; 300] 240 [196; 302] 206 [161; 284] 0.025
D-dimer 1.1 [0.6; 2.3] 0.9 [0.6; 1.6] 1.2 [0.7; 2.4] 0.301
LCR 4 [3; 8] 4 [3; 8] 4 [2; 7] 0.124
NLR 10 [6; 16] 8 [6; 13] 12 [7; 19] 0.004

Risk factors for in-hospital mortality.

Variable Estimate Standard Error Odds ratio (OR) 95% CI P value
Age, per year 0.065 0.016 1.07 1.47 to 7.33 < 0.001
Creatinine at intubation day 1.188 0.410 3.28 0.84 to 0.99 0.004
BMI -0.089 0.042 0.91 0.979 to 0.997 0.033
Lowest PF ratio 48 hours post intubation -0.012 0.005 0.988 1.14 to 23.65 0.011
Barotrauma 1.646 0.774 5.18 0.76 to 0.95 0.034
Duration from symptom onset to intubation -0.161 0.059 0.85 1.03 to 1.1 0.006

Suportive treatment received while in ICU and clinical outcomes.

Variable Overall (N = 215) Discharged from ICU (N = 119) Died in iCU (N = 96) P-value
Non-invasive strategies prior to IMV
NIV 115 (53.5) 69 (58.0) 46 (47.9) 0.182
HFNC 75 (34.9) 38 (31.9) 37 (38.5) 0.386
Prone positioning 69 (32.1) 36 (30.3) 33 (34.4) 0.619
Neuromuscular blockade 158 (73.5) 88 (73.9) 70 (72.9) 0.988
Nitric oxide 6 (2.8) 2 (1.7) 4 (4.2) 0.016
ECMO 7 (3.3) 2 (1.7) 5 (5.2) 0.010
Worst parameters within 48 hours post-IMV
PEEP 12 [10; 14] 12 [10; 14] 12 [10; 14] 0.852
P/F ratio 126 [93.5; 162] 140 [104; 174] 110 [87; 138] <0.001
Renal replacement therapy 71 (33) 17 (14.3) 54 (56.2) <0.001
Vasopressor use 206 (95.8) 113 (95.0) 93 (96.9) 0.722
Pharmacological treatment
Tocilizumab 31 (14.4) 25 (21) 6 (6.3) 0.004
Corticosteroid 109 (50.7) 64 (53.8) 45 (46.9) 0.384
Hydroxycloroquine 71 (33) 46 (38.7) 25 (26) 0.070
Tracheostomy 39 (18.1) 20 (16.8) 19 (19.8) 0.699
Reintubation 22 (10.2) 10 (8.4) 12 (12.5) 0.448
Barotrauma 18 (8.4) 4 (3.4) 14 (14.6) 0.007
Duration of NIV before IMV, days 1 [1.0; 3.0] 2 [1.0; 3.0] 2 [1.0; 3.0] 0.861
Duration of HFNC before IMV, days 1 [1.0; 2.0] 1 [1.0; 3.0] 1 [1.0; 2.0] 0.677
Duration of IMV, days 10 [7; 18] 10 [7; 16] 11 [6; 19] 0.876
ICU length of stay, days 15 [10; 24] 17 [11.5; 25.5] 13 [7; 21.2] 0.002
Hospital length of stay, days 21 [15; 30] 27 [19.5; 39.5] 14.5 [7; 22.2] <0.001
Days from hospital admission to intubation 3 [1.0; 5.0] 4 [1.0; 5.5] 3 [1.0; 5.0] 0.111
Days from symptom onset to intubation 9 [7 – 12] 10 [8.0 – 12.5] 8.5 [6 – 12] 0.005
Ventilator-free days 9 [3; 16] 15 [11; 23.5] 2 [0; 4.0] <0.001
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