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Arentz M, Yim E, Klaff L, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. Published online March 19, 2020. doi:10.1001/jama.2020.4326
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes, coronavirus disease 2019 (COVID-19), is an emerging health threat.1 Until February 2020, most cases were described in non-US health systems.2,3 One of the first deaths in the US was reported at Evergreen Hospital in Kirkland, Washington. Over the following weeks, multiple cases of COVID-19 were identified in the surrounding community and treated at Evergreen Hospital. Most were attributed to US transmission, and the majority were linked to exposures at a skilled nursing facility.
In this case series, we describe the clinical presentation, characteristics, and outcomes of incident cases of COVID-19 admitted to the intensive care unit (ICU) at Evergreen Hospital to inform other clinicians treating critically ill patients with COVID-19.
Patients with confirmed SARS-CoV-2 infection (positive result by polymerase chain reaction testing of a nasopharyngeal sample) admitted to the ICU at Evergreen Hospital between February 20, 2020, and March 5, 2020, were included. Evergreen Hospital is a 318-bed public hospital with a 20-bed ICU serving approximately 850 000 residents of King and Snohomish counties in Washington State.
Prior to data collection, a waiver was obtained from the Evergreen Healthcare institutional review board. Deidentified patient data were collected and analyzed using Stata version 15.1 (StataCorp). Laboratory testing was reviewed at ICU admission and on day 5. Chest radiographs were reviewed by an intensivist and a radiologist. Patient outcome data were evaluated after 5 or more days of ICU care or at the time of death. No analysis for statistical significance was performed given the descriptive nature of the study.
A total of 21 cases were included (mean age, 70 years [range, 43-92 years]; 52% male). Comorbidities were identified in 18 cases (86%), with chronic kidney disease and congestive heart failure being the most common. Initial symptoms included shortness of breath (76%), fever (52%), and cough (48%) (Table 1). The mean onset of symptoms prior to presenting to the hospital was 3.5 days, and 17 patients (81%) were admitted to the ICU less than 24 hours after hospital admission.
An abnormal chest radiograph was observed in 20 patients (95%) at admission. The most common findings on initial radiograph were bilateral reticular nodular opacities (11 patients [52%]) and ground-glass opacities (10 [48%]). By 72 hours, 18 patients (86%) had bilateral reticular nodular opacities and 14 (67%) had evidence of ground-glass opacities. The mean white blood cell count was 9365 μL at admission and 14 patients (67%) had a white blood cell count in the normal range. Fourteen patients (67%) had an absolute lymphocyte count of less than 1000 cells/μL. Liver function tests were abnormal in 8 patients (38%) at admission (Table 1).
Mechanical ventilation was initiated in 15 patients (71%) (Table 2). Acute respiratory distress syndrome (ARDS) was observed in 15 of 15 patients (100%) requiring mechanical ventilation and 8 of 15 (53%) developed severe ARDS by 72 hours. Although most patients did not present with evidence of shock, vasopressors were used for 14 patients (67%) during the illness. Cardiomyopathy developed in 7 patients (33%). As of March 17, 2020, mortality was 67% and 24% of patients have remained critically ill and 9.5% have been discharged from the ICU.
This study represents the first description of critically ill patients infected with SARS-CoV-2 in the US. These patients had a high rate of ARDS and a high risk of death, similar to published data from China.2 However, this case series adds insight into the presentation and early outcomes in this population and demonstrates poor short-term outcomes among patients requiring mechanical ventilation.
It is unclear whether the high rate of cardiomyopathy in this case series reflects a direct cardiac complication of SARS-CoV-2 infection or resulted from overwhelming critical illness. Others have described cardiomyopathy in COVID-19, and further research may better characterize this risk.4,5
The limitations of this study include the small number of patients from a single center, that the study population included older residents of skilled nursing facilities, and it is likely not to be broadly applicable to other patients with critical illness. However, this study provides some initial experiences regarding the characteristics of COVID-19 in patients with critical illness in the US and emphasizes the need to limit exposure of nursing home residents to SARS-CoV-2.
Corresponding Author: Matthew Arentz, MD, Department of Global Health, University of Washington, 325 Ninth Ave, Seattle, WA 98104 (email@example.com).
Published Online: March 19, 2020. doi:10.1001/jama.2020.4326
Author Contributions: Dr Arentz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Arentz.
Acquisition, analysis, or interpretation of data: Arentz, Yim, Klaff, Lokhandwala, Riedo, Chong, Lee.
Drafting of the manuscript: Arentz, Chong.
Critical revision of the manuscript for important intellectual content: Arentz, Yim, Klaff, Lokhandwala, Riedo, Lee.
Statistical analysis: Arentz, Chong.
Administrative, technical, or material support: Riedo.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Sarah Muni, MD, Michael Bundesmann, MD, and Kristina Mitchell, MD (all with Evergreen Hospital), for their review of the manuscript. They received no compensation for their review. We also acknowledge the clinicians and staff of Evergreen Hospital for their tireless commitment to patient care in the setting of this outbreak.
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