Prof Giacomo Grasselli Associate Professor of Anesthesiology and Intensive Care Medicine Dept of Pathophysiology and Transplantation University of Milan Medical Director ID: 929315
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Slide1
COVID-19 outbreak in Italy: ICU response and patient characteristics
Prof . Giacomo Grasselli
Associate Professor of
Anesthesiology
and Intensive Care
Medicine
, Dept of
Pathophysiology
and Transplantation,
University
of Milan
Medical
Director
, Intensive Care Unit «E.
V
ecla
»,
Ospedale
Maggiore
Policlinico
Foundation
, Milan
Coordinator
,
Lombardy
COVID-19 ICU Network
Slide2Was
this seasonal flu?
Slide3Background
February 20, 2020:
first patient diagnosed with COVID-19 diagnosed in LombardyMarch 11, 2020:
WHO declares the SARS-CoV-2 outbreak as a pandemic
March 20, 2020: Italy is the second most affected country in the world, after ChinaInformation on the clinical characteristics of critically ill pts is still limited
In China the proportion of hospitalized pts requiring ICU care has varied from 5% to 32%
Knowledge of the baseline characteristics and outcomes of critically ill patients is crucial for Health Care Systems preparedness
Slide4Epidemiological
situation in
Italyhttps://www.epicentro.iss.it/coronavirus/bollettino/Infografica_10 apr%20ENG.pdf
Slide5Epidemiological
situation in
Italyhttps://www.epicentro.iss.it/coronavirus/bollettino/Infografica_10apr%20ENG.pdf
March 9, 2020
April 10, 2020
Slide6The case of
mortality
Testing strategy (denominator)
Population
age
Definition of COVID-19
related
deaths
Onder
et al, JAMA 2020
Slide7February 20:
a healthy 30-year-old man with atypical pneumonia unresponsive to treatment is tested positive in
Codogno
February 21:
36
new positive cases, without links to patient 1
Pre-crisis total regional ICU capacity:
750 beds
(2.9% of total hospital beds)
Emergency task force
by the Government of Lombardy
Grasselli et al., JAMA March 2020
Slide8Grasselli et al., JAMA March 2020
March 20: 1218
pts
in ICU
Slide9The
response
in Lombardy
Increased
ICU surge
capacity
to 1750 ICU beds (250 for non-COVID
pts
)
Network of COVID-19
ICUs
with
central
coordination
Hospital Network
reorganized
:
few
hubs
for
specific
diseases
Stopped
elective
surgical
procedures
Containment
measures
Grasselli et al., JAMA March 2020
Slide10Pts
admitted
to COVID-19
ICUs
95 COVID-
ICUs
in 72 Hospitals
Total
patients
:
3788
Discharged
: 1193
Dead: 1255
Currently
in ICU:
1316
Slide11Pts
admitted
to COVID-19
ICUs
Slide12Take-home
message
: GET READY!!!
Significant
mismatch
between
the
number
of
pts
requiring
ICU
admission
and
available
ICU beds
Increase ICU capacity and establish a network of
cohorted
“COVID-19 ICUs” with central coordination to optimize patient allocation
Healthcare workers
should
be
trained
on the
proper
use of personal
protective
equipments
Define
protocols
for triage and treatment of COVID-19
patients
Slide13Clinical Presentation
COVID-19
typically
presents with systemic and/or respiratory
manifestations
Common
fever
(85-90%)
cough
(65-70%)
fatigue
(35-40%)
sputum
production (30-35%)
shortness
of
breath
(15-20%)
Slide14Clinical Presentation
Attn
: some
individuals
are asymptomatic and can act as
carriers!
LESS COMMON:
myalgia
/
arthralgia
(10-15%)
headaches
(10-15%)
sore
throat
(10-15%)
chills
(10-12%)
pleuritic
pain
RARE:
nausea (<10%)
vomiting
(<10%)
nasal
congestion
(<10%)
diarrhea
(<5%)
palpitations
(<5%)
chest
tightness
(<5%)
Slide15Clinical Presentation
81%
Mild
disease: non-pneumonia and mild
pneumonia.
14%
Severe
disease
:
d
yspnea
, RR ≥ 30/
min
,
blood
oxygen
saturation (SpO2
) ≤ 93%, PaO
2
/FiO
2
ratio or P/F < 300, and/or
lung
infiltrates
> 50%
within
24 to 48 hours.
5%
Critical disease:
r
espiratory
failure
,
septic
shock, and/or multiple
organ
dysfunction (MOD) or failure (MOF)Wu Z, McGoogan JM; JAMA 2020
Slide16Radiological Presentation
Chest
RX:
p
atchy
or diffuse
asymmetric
airspace
opacities
Slide17Radiological Presentation
Chest
CT: g
round-
glass
opacification
with or
without
consolidative
abnormalities
, with
peripheral
distribution
, more
likely
bilateral
and at lower lobes
Slide18Data
collection
: 1591 pts with confirmed SARS-CoV-2 infection admitted to the Lombardy COVID-19 ICU Network from February 20 to March 18Data recorded on an electronic worksheet during daily telephone calls
Data recorded at ICU admission: age, sex and medical comorbidities; mode of respiratory support (PEEP, FiO
2, PaO2, PaO2/FiO
2
); use of ECMO and prone positioning; outcome (dead/alive/still in ICU)
Grasselli et al., JAMA April 2020
Slide19Demographic data: gender
similarly distributed among age groups
Critically ill
Overall population
CFR higher in males (15% vs 8%)
Slide20Demographic data: age
Median (IQR):
63
(56-70) years
Grasselli et al., JAMA April 2020
Slide21Comorbidities
68%
had at least one comorbidity
All patients >80 years and 76% of patients >60 years had at least one comorbidity
Hypertension
was the most common comorbidity (49%)
The second most common comorbidities were
cardiovascular disease
(21%),
other
(20%) and
hypercholesterolemia
(18%)
Only 4% had a previous history of COPD
Grasselli et al., JAMA April 2020
Slide22Respiratory support
Among 1300 patients with available data,
99% needed respiratory support:
88
% required mechanical ventilation11% required non-invasive ventilation
At admission,
27%
of patients were treated with
prone ventilation
(N = 875)
Only 5 patients (
1%
) required
ECMO
(N = 498)
Relatively high compliance (low
Pplat
, low
ΔP) and high MV
Slide23Respiratory support
PEEP (cmH
2
O)
0
2
4
6
8
10
12
14
16
18
20
22
PaO
2
/FiO
2
(mmHg)
50
100
150
200
250
300
350
400
450
500
550
Median:
14
(12-16) mmHg
Median
70%
Median:
160
(114-220) mmHg
N = 999
Not statistically different between ages
Higher in older patients
(median difference -10, P=.006)
Higher in younger patients
(median difference 7, P=.02)
Grasselli et al., JAMA April 2020
Slide24Outcome: mortality
920 (
58%
) of patients were
still admitted
in ICU
256 (
16%
) were
discharged
from ICU
405 (
26%
) had
died
in ICU
ICU mortality
(difference -21 p<.001)
Length of stay in ICU
: 9 (6-13) days
Grasselli et al., JAMA April 2020
Slide25Outcome: ICU length of stay
N
Mean
± SD
Median
(IQR)
Min
Max
Deaths
85 (36%)
9.8
± 5.8
10 (5-15)
0
24
Discharged
86 (37%)
8.3
± 6
7 (3-13)
0
24
Still in ICU
62 (26%)
20
± 5.6
21 (20-23)
2
32
Total
235
12
± 7.6
12 (5-19)
0
32
Pts
admitted
to ICU
until
March 3 – outcome on March 23
Slide26Outcome: ICU length of stay
N
Mean
± SD
Median
(IQR)
Min
Max
Deaths
189 (34%)
8.6
± 5.2
8 (4-12)
0
24
Discharged
173 (31%)
8.3
± 5.4
8 (4-12)
0
24
Still in ICU
191 (35%)
16.8
± 5.3
17 (15-20)
1
32
Total
553
11.4
± 6.6
12 (5-17)
0
32
Pts
admitted
to ICU
until
March 8 – outcome on March 23
Slide27Hypertension
Patients with hypertension were significantly:
older
(66 (60-72)
vs.
62 (54-68)
yrs
; P <0.001)
had
higher PEEP
levels (14 (12-16)
vs.
14 (12-15) cmH
2
O; P = .003)
had
lower PaO
2
/FiO
2
(146 (105-214)
vs.
173 (120-222) mmHg; P = .005)
There was no significant difference in FiO
2
(P = .05)
The incidence of hypertension was
higher in patients died in ICU
compared to those discharged from ICU (63% vs 40%, p<.0001)
Grasselli et al., JAMA April 2020
Slide28Limitations
Retrospective
study
Missing data (difficulty to obtain detailed information due to the critical situation in the Region)
The
follow up
is still
too short
compared to the course of the disease
Grasselli et al., JAMA April 2020
Slide29Conclusions
In this case series of critically ill patients admitted to ICUs in Lombardy with laboratory-confirmed COVID-19:
the majority of patients were
older males
a
large proportion required mechanical ventilation
and relatively high levels of PEEP
ICU mortality was 26%
Grasselli et al., JAMA April 2020