Analysis of predictors and outcomes of COVID-19 patients requiring ICU admission from COVID 19 (preprint)

BackgroundSevere Corona virus disease (COVID-19) is associated with high mortality. Although single centre intensive care units (ICU) have reported clinical characteristics and outcomes, no large scale multicentric study from India has been published. The present retrospective, multi-centre study was aimed to describe the predictors and outcomes of COVID-19 patients requiring ICU admission from COVID-19 Registry of Indian council of Medical Research (ICMR), India.MethodsProspectively collected data from multiple participating institutions was entered in the electronic National Clinical Registry of COVID 19. We enrolled patients aged>18 years with COVID-19 pneumonia requiring ICU admission between March 2020 and August 2021. Exclusion criteria were negative RT PCR, death within 24 hours of ICU admission, or patients with incomplete data in the registry Their demographic characteristics, laboratory variables, ICU severity indices, treatment strategies and outcomes were analysed.ResultsA total of 5865 patients, with mean age 56±15 years, with 3840/5865 (65.4%) men, were enrolled in the ICMR registry.. Overall mortality was 2535/5865 (43.5%). Non-survivors were older than survivors (58.2±15.4 years vs 53.6 ±14.7 years; P=0.001). Non-survivors had multiple comorbidities (n=1951, 52.9%) with hypertension (47.2%) and diabetes (45.6%) being the most common, higher creatinine (1.6 ± P=0.001, high D-dimer (1.56 vs 1.37, P=0.001), higher CT severity index (16.8±5.2 vs 13.5 ±5.47 ) compared to  survivors. Non survivors had longer hospital and ICU stay (P=0.001). On multivariate regression analysis, high NLR (HR 1.017, 95% CI 1.005- 1.029, P=0.001), high CRP (HR 1.008, 95% CI 1.006- 1.010, P=0.001), high D dimer ((HR 1.089, 95% CI 1.065- 1.113, P=0.001) were associated with mechanical ventilation while younger age, (HR 0.974, CI 0.965-0.983, p=0.001), high D dimer (HR-1.014, CI 1.001-1.027, P=0.035) and use of prophylactic LMWH (HR 0.647, CI 0.527-0.794, p=0.001) were independently associated with mortality. ConclusionIn this large retrospective study of 5865 critically ill COVID 19 patients admitted to ICU, overall mortality was 2535/5865 (43.5%). Age, high D dimer, CT Severity score and use of prophylactic LMWH were independently associated with mortality. 

Association of Obstructive Sleep Apnea and severity of COVID-19: A hospital based observational study. (preprint)

IntroductionOSA has been postulated to be associated with mortality in COVID19, but studies are lacking thereof. This study was done to estimate prevalence of OSA in patients with COVID-19 using various screening questionnaires and to assess effect of OSA on outcome of disease. MethodologyIn this prospective observational study, consecutive patients with RTPCR confirmed COVID 19 patients were screened for OSA by different questionnaires (STOPBANG, Berlin Questionnaire, NoSAS and Epworth Scale). Association between OSA and outcome (mortality) and requirement for respiratory support was assessed. ResultsIn study of 213 patients; screening questionnaires for OSA {STOPBANG, Berlin Questionnaire (BQ), NoSAS} were more likely to be positive in patients who died compared to patients who survived. On binary logistic yregression analysis, age[≥]55 and STOPBANG score [≥]5 were found to have small positive but independent effect on mortality even after adjusting for other variables. Proportion of patients who were classified as high risk for OSA by various OSA screening tools significantly increased with increasing respiratory support (p<0.001 for STOPBANG, BQ, ESS and p=0.004 for NoSAS). ConclusionThis is one of the first prospective studies of sequentially hospitalized patients with confirmed COVID 19 status who were screened for possible OSA. This study shows that OSA could be an independent risk factor for poor outcome in patients with COVID19.

Whether Early Steroid Dose Is Associated with Lower Mortality in COVID-19 Critically Ill Patients- An Exploratory Chart Review (preprint)

Introduction: Steroids have shown its usefulness in critically ill COVID19 patients. However time of starting steroid and dose tailored to severity remains a matter of inquiry due to still emerging evidences and wide-ranging concerns of benefits and harms. We did a retrospective record analysis in an apex teaching hospital ICU setting to explore optimal doses and duration of steroid therapy which minimizes the hazard of death.Methodology: 114 adults with COVID19-ARDS admitted to ICU between 20th March-15th August 2020 were included in chart review. We did preliminary exploratory analysis(rooted in steroid therapy matrix categorized by dose and duration) to understand the effect of several covariates on survival. This was followed by univariate and multivariate Cox proportion hazard regression analysis and model diagnostics. Results: Exploratory analysis and visualization indicated age, optimal steroid, severity (measured in P/F) of disease and infection status as potential covariates for survival. Univariate cox regression analysis showed significant positive association of age>60 years{2.6 (1.5-4.7)} and protective effect of optimum steroid{0.38(0.2-0.72)} on death (hazard) in critically ill patients. Multivariate cox regression analysis after adjusting effect of age showed protective-effect of optimum steroid on hazard defined as death {0.46(0.23-0.87),LR=17.04,(p=2e-04)}.The concordance was 0.70 and model diagnostics fulfilled the assumption criteria for proportional hazard model.Conclusion: Optimal dose steroid as per defined ‘optimum’ (<24 hours and doses tailored to P/F at presentation) criteria can offer protective effect from mortality which persists after adjusting for age. This protective effect was not found to be negatively influenced by the risk of infection.Funding Statement: No funding was taken for this paper.Declaration of Interests: None of the authors have any conflict of interest. Ethics Approval Statement: Institutional Human Ethics Committee (IHEC) approved the protocol vide LOP Number IHEC-LOP/2020/IM0281, dated 15/07/2020.

Whether Early Pulse Steroid dose is associated with lower mortality in COVID-19 critically ill Patients- A retrospective Chart Review (preprint)

Abstract : Introduction: Steroids have theoretically seems useful in critically ill patients of COVID-19 . However the time of starting steroid and dose remains a matter of concern due to still emerging evidences and wide-ranging concerns of benefits and harms. We did a retrospective record analysis in an apex teaching hospital ICU setting to explore this concern. Methodology: 45 adults age more than 18 years with nasopharyngeal swab PCR-confirmed SARS-CoV-2 infection with ARDS admitted to ICU in between 20th March,2020 to 15th July 2020 were included in chart review. We did a bivariate analysis of age ,comorbidity, infections, severity of disease , timing /dose(appropriate) steroid and presence of infection on survival. In the next step we performed a Bayesian Exact regression to understand the adjusted effect of early appropriate steroid on survival in the presence of age and infections as probable confounder. Results: Bivariate analysis showed the statistically significant effect of age <60 years and steroid dose (early and classified by disease severity) had a favourable effect on outcome. Further Early Pulse Steroid (EPS ) amongst the more severe subgroup was found to be significantly associated with better survival. Conclusion: High dose steroids (more than 500 mg MPS) if given early in the course of disease to COVID19 critically ill patients (P/F<150) can significantly reduce mortality and are not associated with increased infections.