/Nekrasov, stock.adobe.com
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New York – Even in optimally equipped clinics, COVID-19 diseases are often fatal. At 2 clinics in Manhattan, more than 1/3 of all patients who had to be treated in intensive care died. According to a cohort study, the most common complications included im Lancet (2020; DOI: 10.1016 / S0140-6736 (20) 31189-2) in addition to lung failure, circulatory or kidney failure.
The Milstein Hospital with 700 beds and the Allen Hospital with 230 beds are among the best equipped clinics in Manhattan. The clinics have several devices for extracorporeal membrane oxygenation (ECMO) and a total of 129 intensive care beds, the number of which increased to 282 during the COVID-19 epidemic.
After the epidemic began in early March, the clinics nonetheless reached the limits of their capacity. Out of 1,150 patients with COVID-19 who were admitted by April 1, 257 had to receive intensive care. Of these, 203 patients (79%) required invasive mechanical ventilation. ECMO was performed in 6 patients (3%).
But respiratory failure (ARDS) wasn’t the patients’ only problem. A total of 170 patients (66%) required vasopressors because of circulatory failure. Renal replacement therapy became necessary in 79 patients (31%) because of acute kidney failure. According to the report by Max O’Donnel of the Mailman School of Public Health, the clinics were reaching the limits of their capacities.
Despite maximum care – which included treatment with hydroxychloroquine in 185 patients (72%) and remdesivir in 23 patients (9%) – 101 patients (39%) did not survive the disease. Another 94 patients (37%) were still in the clinic at the end of April, so mortality could increase even further.
The most important risk factor for a fatal outcome was a history of chronic lung disease with an adjusted hazard ratio (aHR) of 2.94 (95% confidence interval 1.48 to 5.84). Chronic cardiovascular diseases (aHR 1.76; 1.08 to 2.86), a higher age (aHR 1.31; 1.09 to 1.57 per 10 years of age) and a higher concentration of interleukin 6 followed (aHR 1.11; 1.02 to 1.20 per increase of 10%) and an increased D-dimer value (aHR 1.10; 1.01 to 1.19 per 10%) on admission. Men had the same risk of death as women.
The association with interleukin 6 speaks for a strong activation of the immune system in the sense of a cytokine storm. The relatively infrequent use of antagonists such as anakinra (44 patients, 17%) suggests that intensive care physicians underestimated this problem. No information is given on anticoagulation. As elsewhere, the increased risk of thrombosis also seems to have surprised doctors. © rme / aerzteblatt.de
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