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Overall mortality of patients with COVID-19 in intensive care units (ICUs) in Europe, Asia, and North America fell from nearly 60% in late March to nearly 42% in late May, according to a systematic review. and meta-analysis
The study by RA Armstrong, a member of the Severn Deanery in Bristol, UK, and his colleagues was published online on July 15 in Anesthesia. It is the first systematic review and meta-analysis of the results of patients with COVID-19 in the ICU.
Armstrong and colleagues searched the MEDLINE, EMBASE, PubMed, and Cochrane databases for studies through May that reported ICU mortality for adult patients admitted with COVID-19. The primary outcome measure was death in an ICU as a proportion of ICU admissions completed.
They found 24 relevant observational studies, which included 10,150 patients. They calculated that the combined ICU mortality in all studies was 41.6%, a decrease of approximately one third from the ICU mortality of 59.5% observed in the studies until the end of March.
The authors note that the lowest mortality rate remains almost double the 22% mortality seen on ICU admissions from other viral pneumonias. They point out that mortality is not significantly different on the three continents.
“Share information in real time”
Amesh A. Adalja, MD, infectious disease and critical care physician and scholar at the Johns Hopkins Center for Health Safety in Baltimore, Maryland, said Medscape Medical News The news reflects other information in the field.
“It is clear in July 2020 that we know much more about this virus, the complications it can cause, and how to prevent those complications than in March 2020,” he said. “We are also much better at managing patients for their oxygen needs using other devices, such as high-flow nasal cannulas, versus the mechanical reflex ventilator.”
He also noted that more treatments are now available, such as remdesivir. Although remdesivir in clinical trials has not been shown to reduce mortality, it has been found to be beneficial in getting people out of the ICU faster.
“We are much better at diagnosing these patients faster, so we can intervene faster. We are learning about cytokine storms and what medications we can use against that,” he said. He noted that it may be that people become infected with lower viral loads due to social distancing.
It will be important to follow patients to make sure the decline isn’t just transient and that people don’t leave the ICU only to die months later, he said.
He said he was not surprised that the results were practically the same on all continents.
“All of us who care for these patients are on the same team and we all share information in real time, so we are learning from each other,” he continued.
The virus is no less deadly
Although the results offer hope, Adalja said, “I would not over-interpret that this virus has now become less deadly. It still has the ability to kill. It still has the ability to disrupt your entire hospital and health system.”
“We are improving in treatment, but it still carries substantial mortality, and we should not be satisfied with the level of this study. We want it to be as low as possible, and we want to prevent people from even needing the ICU.”
Study co-author Tim Cook, MBBS, consultant in anesthesia and intensive care medicine at Royal United Hospitals in Bath, UK, said Medscape Medical News The researchers were limited by how the study results were reported.
“We cannot determine what were the admission criteria for ICU care, nor the discharge criteria,” he added.
“We do not know if all the patients in different studies had similar baseline characteristics and baseline health, did not feel similarly when they entered the ICU, or what interventions and treatments they received,” he said.
That underscores the need for more structured reporting globally, he continued.
Cook said that in March and April, many health systems were on the verge of being overwhelmed by the cases and that a contributing factor could be that only the sickest patients were admitted to the ICU. This would help explain the fall over time.
“It is also plausible, but not proven, that the systems were so stretched that survival rates fell because it was not possible to maintain the same standards of care as usual,” he explained.
But the progress in knowledge is undeniable, Cook said, including that COVID-19 affects many organs and body systems, that patients may be dehydrated and need more fluid, that noninvasive ventilation may play a role, and that prone positioning can improve lung function. In addition, strategies have been developed to decrease high coagulation rates.
He says there are signs that death rates will continue to improve for reasons such as the use of promising treatments, including the steroid dexamethasone, which has been shown to save lives, especially among the sickest patients with COVID-19. However, the use of the drug in the United States has been mixed.
The authors and Adalja have disclosed no relevant financial relationships.
Anesthesia. Published online July 15, 2020. Full text
Marcia Frellick is a Chicago-based freelance journalist. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, Cincinnati Enquirer, and St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick .
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