Triage and management of probable Covid-19 patients in the intensive care unit during the pandemic period

Aim: Republic of Turkey Ministry of Health dedicated our hospital as a transplant center during the pandemic period. We admitted probable Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) infection (COVID-19) cases and intensive care unit (ICU) patients from other centers, while confirmed COVID-19 cases were transferred to dedicated pandemic hospitals. The aim of this study was to determine the demographic parameters, clinical courses and outcomes of probable COVID-19 patients and to compare survivors with non-survivors admitted to our ICU. Materials and Methods: After Ethics Committee approval, 93 patients admitted to our ICU between March 23 and May 13 were analyzed retrospectively. Results: Mean age was 68.5y (60.2% male). Dyspnea (67.7%) was the most common symptom and hypertension (68.6%) was the most common comorbidity. None of PCR tests for SARS-CoV-2 were positive. Bilateral ground-glass (25.8%) and consolidation (14%) were the most common signs at chest computed tomography. Mean Acute Physiology and Chronic Health Evaluation System (APACHE II) score was 20.2 at ICU admission. Fifty-seven patients (61.3%) had pneumonia findings in lung X-ray or computerized tomography (CT). Thirty-four patients (36.6%) received low flow oxygen, six (9.7%) had high flow nasal oxygen and 27 (29%) had invasive mechanical ventilation. Forty patients (43%) had vasopressor therapy and 24 (25.8%) patients had renal replacement therapy due to acute kidney injury. Laboratory data including D-dimer, C-reactive protein, ferritin, creatinine kinase and procalcitonin were significantly higher in non-survivors when compared to survivors. The overall ICU mortality rate was 44.1%. Conclusions: A triage protocol of Turkish Study of Scientific Board based on clinical, laboratory and radiological findings for probable COVID-19 patients was applied in our center during the pandemic period. So, we ensured the effective usage of scarce ICU resources. The mortality rate of probable COVID-19 patients admitted to our ICU was found to be higher than the predicted mortality rate according to their APACHE-II score.

PDF

___

1. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
2. Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA 2020;16:1545-46.
3. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020;382:1708-20.
4. World Health Organization. Coronavirus disease (COVID-2019) situation reports.https://www.who. int/emergencies/diseases/novel-coronavirus-2019/ situation-reports
5. World Health Organization. Coronavirus disease (COVID-19) outbreak. https://www.who .int
6. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA 2020;323:1061-9.
7. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Lancet 2020;395:507-13.
8. Tan W, Zhao X, Ma X, et al. A novel coronavirus genome identified in a cluster of pneumonia cases—Wuhan, China 2019−2020. China CDC Weekly 2020;2:61-2.
9. COVID-19 New Coronavirus Disease, Republic of Turkey, Ministry of Health. https://covid19bilgi.saglik. gov.tr/tr/
10. Sprung CL, Joynt GM, Christian MD, et al. Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival. Crit Care Med 2020;48:1196-202.
11. Republic of Turkey Ministry of Health. General Directorate of Public Health. COVID-19 (SARS-CoV-2) infection guideline,Study of Scientific Board. Ankara, Turkey: Republic of Turkey Ministry of Health; 2020. https://hsgm.saglik.gov.tr/en/covid-19-i-ngilizcedokumanlar/rehberler.html
12. World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019- nCoV) infection is suspected: interim guidance 13 March 2020. Geneva, Switzerland:WHO; 2020.
13. Alhazzani W, Moller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med 2020;46:854-87.
14. Garner JS, Jarvis WR, Emori TG, et al. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128-40.
15. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019;200:45-67.
16. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. March 2012. https:// kdigo.org/wp-content/uploads/2016/10/KDIGO2012-AKI-GuidelineEnglish. pdf
17. ARDS Definition Task Force; Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: The Berlin definition. JAMA 2012;307:2526- 33.
18. McGonagle D, O’Donnell JS, Sharif K, et al. Immune mechanisms of pulmonary intravascular coagulopathy in COVID-19 pneumonia. Lancet Rheumatol 2020;2:437-45.
19. Taylor Jr FB, Toh CH, Hoots WK, Wada H, Levi M, Scientific Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haemostasis (ISTH). Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 2001;86:1327-30.
20. Richardson S, Hirsch JS, Narasimhan M, et al. and the Northwell COVID-19 Research Consortium. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA 2020;323:2052-9.
21. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475- 81.
22. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395:1054-62.
23. Xie J, Tong Z, Guan X, et al. Critical care crisis and some recommendations during the COVID-19 epidemic in China. Intensive Care Med 2020;46:837-40.
24. Zhang JJ, Dong X, Cao YY, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy 2020;75:1730-41.
25. Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21critically ill patients with COVID-19 in Washington State. JAMA 2020;323:1612-14.
26. Shang Y, Pan C, Yang X, et al. Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China. Ann Intensive Care 2020;10:73.
27. Verdiner RE, Choukalas CG, Siddiqui S, et al. COVID– Activated Emergency Scaling of Anesthesiology Responsibilities Intensive Care Unit. Anesth Analg 2020;131:365-77.
28. Horby P, Lim WS, Emberson J, et al. RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with COVID-19 –Preliminary Report. N Engl J Med 2020; NEJMoa2021436.
29. Zhao JP, Hu Y, Du RH, et al. Expert consensus on the use of corticosteroid in patients with 2019- nCoV pneumonia. Zhonghua Jie He He Hu Xi Za Zhi 2020;43:183-4.
30. COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available at https:// www.covid19treatmentguidelines.nih.gov/
31. Sanz MAB, Tejedor AH, Estella A, et al. Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19). Med Intensiva 2020;44:371-88.
32. Gautret P, Lagier JC, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: preliminary results of an open-label non-randomized clinical trial. Int J Antimicrob Agents 2020;56:105949.
33. Geleris J, Sun Y, Platt J, et al. Observational Study of Hydroxychloroquine in Hospitalized Patients with Covid-19. N Engl J Med 2020;382:2411-8.
34. Phua J, Weng L, Ling L, et al for the Asian Critical Care Clinical Trials Group. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med 2020;8:506-17.