Intensive Care Medicine journal announces publication of research to help ICUs facing second wave of COVID-19 pandemic
As the second wave of the COVID-19 pandemic hits countries all over the world, three studies, soon to be published in Intensive Care Medicine, shed light on the characteristics of COVID-19 critically ill patients and explore the accessibility of intensive care and its impact on the COVID-19 case fatality ratio (CFR) in 14 European countries.
The first is a multi-centre prospective cohort study carried out by the REVA network and the COVID-ICU investigators and examined the clinical characteristics and Day-90 Outcomes of 4,244 critically ill adults with COVID-19 in 149 intensive care units (ICUs) in 138 centres across France, Belgium and Switzerland.
The study included 4,244 adult patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to the ICU (26% female, median age 63 years, 41% obese). 2,635 (63%) patients were intubated during the first 24-hours, whereas overall 3,376 (80%) received invasive mechanical ventilation at one point during their ICU stay.
The mortality 90 days after ICU admission was 31% in the whole cohort and 37% in the subgroup of patients who received invasive mechanical ventilation on the day of ICU admission. Among these patients with early intubation, mortality increased with the severity of ARDS at ICU admission (30%, 34%, and 50% for mild, moderate, and severe ARDS, respectively). Overall, mortality was higher in older, diabetic, obese and severe ARDS patients.
In the second study, ICNARC researchers extracted data on patient characteristics, acute illness severity, organ support and outcomes for a prospective cohort of patients with COVID-19 and compared them with a recent retrospective cohort of patients with other viral pneumonias (non-COVID-19) and with other international cohorts of critical care patients with COVID-19, identified from published reports.
10,834 patients with COVID‑19 (70.1% male, median age 60 years, 32.6% non‑white ethnicity, 39.4% obese, 8.2% at least one serious comorbidity) were admitted across 289 critical care units in the UK. Of these, 36.9% had severe ARDS and 72% received invasive ventilation. Acute hospital mortality was 42%, higher than for 5782 critical care patients with other viral pneumonias (non‑COVID‑19) (24.7%), and most COVID‑19 deaths (88.7%) occurred before 30 days.
Critical care patients with COVID‑19 were disproportionately non‑white, from more deprived areas and more likely to be male and obese. Conventional severity scoring appeared not to adequately reflect their acute severity, with the distribution across PaO2 /FiO2 ratio categories indicating acutely severe respiratory disease.
Critical care patients with COVID-19 experience high mortality and place a great burden on critical care services. Accurate and reliable analyses of the epidemiology of COVID-19 in critical care are therefore essential for monitoring patient outcomes and informing planning for future service.
The observed differences when comparing critical care patients with COVID-19 to those with other viral pneumonias (non-COVID-19) demonstrated the difficulty of selecting a likely similar condition when service planning for an impending pandemic of a new disease. Thus, any service planning for a second wave should use accurate and reliable population-level data on patients with COVID-19. To support this, there is a need for greater standardisation in reporting of critical care cohorts internationally.
The third, cross-sectional, analysis research examined access to intensive care beds by deriving a regional ratio of intensive care beds to 100,000 population capita (accessibility index, AI) and the distance to the closest intensive care unit. Results show national-level differences in the levels of access to intensive care beds.
The AI was highest in Germany (AI = 35.3), followed by Estonia (AI = 33.5) and Austria (AI = 26.4), and lowest in Sweden (AI = 5) and Denmark (AI = 6.4). The average travel distance to the closest hospital was highest in Croatia (25.3 min by car) and lowest in Luxembourg (9.1 min). Furthermore, lower accessibility of intensive care is associated with higher COVID-19 case fatality ratios.
In conclusion, some countries (e.g., Germany) are particularly well positioned to manage a swiftly increased need for intensive care, whereas others (e.g., Denmark, Italy or Sweden) have lower numbers of intensive care beds that are also spatially more concentrated, and thus localised shortages are possible during a locally increased need for intensive care.
Together we are intensive care.