Assessing the need for transfer to the intensive care unit for Coronavirus-19 disease: Epidemiology and risk factors

Abstract

Background: Although many patients with coronavirus disease 2019 (Covid-19) require direct admission to the intensive care unit (ICU), some are sent after admission. Clinicians require an understanding of this phenomenon and various risk stratification approaches for recognizing these subjects. Methods: We examined all Covid-19 patients sent initially to a ward who subsequently required care in the ICU. We examined the timing transfer and attempted to develop a risk score based on baseline variables to predict progressive disease. We evaluated the utility of the CURB-65 score at identifying the need for ICU transfer. Results: The cohort included 245 subjects (mean age 59.0 ± 14.2 years, 61.2% male) and 20% were eventually sent to the ICU. The median time to transfer was 2.5 days. Approximately 1/3rd of patients were not moved until day 4 or later and the main reason for transfer (79.2%) was worsening respiratory failure. A baseline absolute lymphocyte count (ALC) of ≤0.8 10 3 /ml and a serum ferritin ≥1000 ng/ml were independently associated with ICU transfer. Co-morbid illnesses did not correlate with eventual ICU care. Neither a risk score based on a low ALC and/or high ferritin nor the CURB-65 score performed well at predicting need for transfer. Conclusion: Covid-19 patients admitted to general wards face a significant risk for deterioration necessitating ICU admission and respiratory failure can occur late in this disease. Neither baseline clinical factors nor the CURB-65 score perform well as screening tests to categorize these subjects as likely to progress to ICU care.

Investigation of Coagulation Biomarkers to Assess Clinical Deterioration in SARS-CoV-2 Infection

“…A recent study demonstrate that coagulation biomarkers are independent predictors of increased oxygen requirement in COVID-19 patients (49), among them increased fibrinogen and decreased FVIII/VWF:Ag ratio. A study confirmed that D-dimer increase is not associated with intensive care unit transfer (23).…”

“…Only one patient who had developed thrombosis did not have thromboprophylaxis. Median follow up was 20.5 days [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. Each patient completed the follow up.…”

“…This classification tree provided an accuracy of 79%, a sensitivity of 88%, a specificity of 67%, a positive predicted value of 78%, and a negative predicted value of 80% (Figure 2). Several studies predict the occurrence of critical illness (23)(24)(25) and mortality in COVID-19 infection (15,(26)(27)(28). Elderly, increased body mass index, hypertension (29), diabetes, and male gender (30) were demographics and associated comorbidity regularly included in the predictive score.…”

The incremental value of computed tomography of COVID-19 pneumonia in predicting ICU admission

“…Hence prediction of ICU admission has been frequently investigated in studies addressing diagnostic and prognostic models for COVID-19 (5). Among the variables potentially useful for such a purpose, clinical features yielded mixed results (6)(7)(8)(9)(10)(11)(12), while blood laboratory and arterial gas analysis features generally improved the overall prediction capacity (8,10,11,(13)(14)(15)(16).…”

The incremental value of computed tomography of COVID-19 pneumonia in predicting ICU admission

“…Hence prediction of ICU admission has been frequently investigated in studies addressing diagnostic and prognostic models for COVID-19 5 . Among the variables potentially useful for such a purpose, clinical features yielded mixed results 6 – 12 , while blood laboratory and arterial gas analysis features generally improved the overall prediction capacity 8 , 10 , 11 , 13 – 16 .…”