Article Information
Corresponding author : Georges Hatem

Article Type : Research Article

Volume : 4

Issue : 1

Received Date : 24 Dec ,2023


Accepted Date : 13 Jan ,2023

Published Date : 13 Jan ,2023


DOI : https://doi.org/10.38207/JCMPHR/2023/JAN04010102
Citation & Copyright
Citation: Awada S, Hatem G (2023) Assessment of All-Cause Mortality and Need For Mechanical Ventilation Among COVID-19 Patients Taking Corticosteroids In The Intensive Care Unit. J Comm Med and Pub Health Rep 4(01): https://doi.org/10.38207/JCMPHR/2023/JAN04010102

Copyright: © 2023 Georges Hatem. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
  Assessment of All-Cause Mortality and Need For Mechanical Ventilation Among COVID-19 Patients Taking Corticosteroids In The Intensive Care Unit

Sanaa Awada1, Georges Hatem1,2*

1Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Hadat, Lebanon.

2Faculty of Medicine, University of Porto, Porto, Portugal

*Corresponding Author: Georges Hatem, Pharm.D, Ph.D., Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Hadat, Lebanon.

Abstract
Background
:
Hospital admission due to the coronavirus disease of 2019 (COVID-19) is high, imposing several challenges for patient management during intensive care unit (ICU) stay.

Objectives: This communication explores the association between all-cause mortality, the need for mechanical ventilation, and the general characteristics of COVID-19 patients taking corticosteroids in the ICU.

Methods: A cross-sectional study was performed over three months in a tertiary care hospital in Lebanon. Two clinical pharmacists used a uniform form to collect data from patients' medical charts.

Results: Higher all-cause mortality was noted among critical cases, those with dyslipidemia, and those with abnormal glucose levels on admission and discharge. Women, those with abnormal glucose and creatinine levels, and critically-ill patients needed more mechanical ventilation than others.

Conclusion: Taking into account these associations can help doctors in a better assessment of cases to be admitted to the ICU.

Keywords: Intensive care unit; corticosteroids; COVID-19 patients; all-cause mortality; mechanical ventilation

Introduction
Background
Hospital admission due to the coronavirus disease of 2019 (COVID- 19) is high, imposing several challenges for patient management during intensive care unit (ICU) stay [1]. Patients admitted to the ICU for COVID-19 had an increased mortality risk and required mechanical ventilation to manage their respiratory distress [2]. This risk is shown to be higher than usually seen in ICU admissions with other viral cases of pneumonia [3]. Changes in laboratory parameters [4], age, and admission to ICU are the main reported predictors of that risk [5].

In Lebanon, like in other countries, patients were prioritized, and few could access the ICU based on doctors' evaluations [6], creating ethical dilemmas for frontline workers. Understanding the characteristics of patients admitted to the ICU can help better assess cases. Therefore, this communication explores the association between all-cause mortality, the need for mechanical ventilation, and the general characteristics of COVID-19 patients taking corticosteroids in the ICU.

Methods
Study design

A cross-sectional study was performed over three months (May-July 2021) targeting adult COVID-19 patients admitted to the ICU. They were included if they received corticosteroid medication as part of their treatment. Two clinical pharmacists used a uniform form to collect data from patients' medical charts. The research protocol and data collection tool were reviewed and approved by the hospital's institutional review board (See supplementary materials; reference:

CRU329). Data were wholly anonymous and non-identifiable. A different researcher performed data coding and analysis.

Data collection
Data completion took an average of 10 minutes per patient and was updated based on their status. The sex, age, height, weight, and smoking status of the patients were collected. The results of the glucose level, oxygen saturation, blood pressure, creatinine, and the C-reactive protein (CRP) were registered on admission and at discharge. Patients were then classified as critical (septic shock, sepsis, mechanical ventilation, or vasopressor therapy), severe (Oxygen saturation ≤ 90 %, respiratory rate > 30 breaths/min or the existence of signs of severe respiratory distress), and non-severe cases (absence of any signs of harsh or critical COVID-19) [7]. The medical history of the patients was also recorded.

Statistical analysis
Statistical analyses were performed using Statistical Package for Social Sciences (SPSS Inc, Chicago, Illinois) Version 27. The age of the patients is presented using means and standard deviations. In contrast, categorical variables are presented using frequencies and percentages. Bivariate analyses were conducted by taking (i) all-cause mortality and (ii) the need for mechanical ventilation as the independent variable and the general information about the patients and their medical history as dependent variables. Chi-square/Fisher exact tests were used to compare percentages between associate categorical variables. A p-value was considered statistically significant if less than 0.05.

Findings
The sample included 123 patients (61.8 % men and 38.2 % women) with a mean age of 69.2 (13.8) years and a mean of 6.9 (3.6) days of ICU stay. They were classified as non-severe (48.0 %), severe (28.4 %), and critical (23.6 %) cases. Most patients had two or more (62.0 %) comorbidities, and only 16.8 % were smokers. 25 patients (20.3 %) died, and 34 (27.6 %) needed mechanical ventilation. The reported causes of death were heart failure (N=7), septic shock (N=7), respiratory failure (N=4), and pulmonary embolism (N=2), and five patients had an unknown cause. Table 1 presents the association between all-cause mortality, the need for mechanical ventilation, and the characteristics of the patients. All-cause mortality was significantly higher among critical cases (75.9 %), those having dyslipidemia (41.7 %), and patients with glucose levels >126 mg/dL on admission and at discharge. Women (38.3 %) needed more than men (21.1 %) mechanical ventilation in the ICU (p=0.038). The need for mechanical ventilation was also noted among patients with glucose levels >126 mg/dL on admission (37.8 %) and at discharge (35.1 %), creatinine levels > 1.5 mg/dL at admission (39.5 %) or dismissal (43.6 %), and significantly increased with the severity of cases (p < 0.001). Furthermore, 75.0 % of patients with chronic kidney disease needed mechanical ventilation (p=0.002). Patients with SPO2 > 90 % at discharge were those with higher all-cause mortality (34.8 %) and requiring ventilation (43.5 %).

Table 1: Association between all-cause mortality, need for mechanical ventilation, and the general characteristics and the medical history of the patients.

 

All-cause mortality

(N=25)

 

Mechanical ventilation (N=34)

 

General characteristics of the patients

Frequency (%)

p-value

Frequency (%)

p-value

Sex

Man

15 (19.7 %)

0.837

16 (21.1 %)

0.038

 

Woman

10 (21.3 %)

18 (38.3 %)

Age (years)

Mean ±SD

69.2 ±13.8

 

 

 

 

18-60

3 (9.7 %)

 

5 (16.1 %)

 

61-70

5 (22.7 %)

0.231

6 (27.3 %)

0.222

 

More than 70

17 (24.3 %)

 

23 (32.9 %)

 

The glucose level on admission

< 126 mg/dL

5 (11.4 %)

0.005

6 (13.6 %)

0.023

 

> 126 mg/dL

14 (37.8 %)

13 (35.1 %)

The glucose level at discharge

< 126 mg/dL

4 (10.3 %)

0.018

3 (7.7 %)

0.007

(last test)

> 126 mg/dL

15 (33.3 %)

15 (33.3 %)

The oxygen saturation on admission (SPO2 %)

< 90 %

                --

0.343

3 (42.9 %)

0.409

> 90 %

25 (22.5 %)

31 (27.9 %)

The oxygen saturation at discharge

< 90 %

6 (9.0 %)

< 0.001

12 (17.9 %)

0.003

(last test)

> 90 %

16 (34.8 %)

20 (43.5 %)

Blood pressure on admission

< 139/89 mm Hg

16 (19.8 %)

0.962

20 (24.7 %)

0.418

(mmHg)

> 139/89 mm Hg

6 (19.4 %)

10 (32.3 %)

Blood pressure at discharge

< 139/89 mm Hg

13 (15.3 %)

0.121

21 (24.7 %)

0.398

(last test)

> 139/89 mm Hg

7 (29.2 %)

8 (33.3 %)

Creatinine level on admission

< 1.5 mg/dL

13 (17.3 %)

0.284

16 (21.3 %)

0.034

(mg/dL)

> 1.5 mg/dL

11 (25.6 %)

17 (39.5 %)

Creatinine level at discharge

< 1.5 mg/dL

14 (17.9 %)

0.202

16 (20.5 %)

0.009

(last test)

> 1.5 mg/dL

11 (28.2 %)

17 (43.6 %)

CRP level on admission

< 3.0 mg/L

1 (50.0 %)

0.375

1 (50.0 %)

0.481

(mg/L)

> 3.0 mg/L

23 (20.4 %)

31 (27.4 %)

CRP level at discharge

< 3.0 mg/L

5 (19.2 %)

0.975

5 (19.2 %)

0.314

(last test)

> 3.0 mg/L

16 (19.5 %)

24 (29.3 %)

Smoking status

Non-smoker

22 (22.0 %)

0.763

28 (28.0 %)

0.784

 

Smoker

3 (15.0 %)

5 (25.0 %)

Severity of cases

Non-severe

2 (3.4 %)

 

4 (6.8 %)

 

 

Severe

1 (2.9 %)

< 0.001

10 (28.6 %)

< 0.001

 

Critical

22 (75.9 %)

 

20 (69.0 %)

 

Medical history

 

Frequency (%)

p-value

Frequency (%)

p-value

Number of comorbidities

None

4 (17.4 %)

0.576

7 (30.4 %)

0.212

 

One

5 (21.7 %)

5 (21.7 %)

 

Two

7 (15.6 %)

9 (20.0 %)

 

More than two

9 (28.1 %)

13 (40.6 %)

Hypertension

 

16 (19.3 %)

0.677

20 (24.1 %)

0.205

Diabetes

 

7 (16.3 %)

0.414

12 (27.9 %)

0.962

Coronary artery disease

 

7 (17.9 %)

0.655

13 (33.3 %)

0.336

Dyslipidemia

 

5 (41.7 %)

0.053

6 (50.0 %)

0.068

Heart failure

 

1 (10.0 %)

0.685

2 (20.0 %)

0.725

Chronic kidney disease

 

2 (25.0 %)

0.664

6 (75.0 %)

0.002

Discussion
This communication explored the association between all-cause mortality, the need for mechanical ventilation, and the general characteristics of COVID-19 patients admitted to the ICU. The sample included more men than women, in agreement with previous research showing a higher risk for men to be critically-ill and hospitalized [8]. Patients with glucose levels >126 mg/dL and critically-ill ones had higher all-cause mortality risks than others. This finding was also reported in the literature, where the severity of cases and glycemic variability were associated with a higher mortality risk [9]. Women needed more mechanical ventilation than men in contrast with a previous report [10], which may be explained by the fact that women in this study were older and had more comorbidities than men, reported to be predictors of mechanical ventilation use [10]. This use was significantly higher among patients having abnormal laboratory parameters. A result previously revealed [1], namely high creatinine levels. A recent meta-analysis reported 2.84 times poorer outcomes in those with elevated creatinine [11] and, therefore, can be used as one of the predictors of mechanical ventilation use. Most patients with chronic kidney disease required mechanical ventilation in coherence with a retrospective study performed in a similar setting in Jordan [12]. Remarkably, these outcomes were reported in patients with normal oxygen saturation at discharge, possibly due to continuous ICU surveillance and ventilation use.

This study has limitations related to the inclusion of patients from one hospital, which might affect the generalizability of the results to other settings. Data were collected from the medical charts, which could have included missing information. However, it can provide additional information regarding the outcomes of COVID-19 in the ICU by considering the associations above.

Conclusion
Hospital outcomes among COVID-19 patients admitted to the ICU varied with their characteristics. Abnormal glucose levels at admission and discharge and the severity of cases were associated with higher risks of all-cause mortality and the need for mechanical ventilation. Abnormal creatinine levels and chronic kidney disease were also correlated with the need for mechanical ventilation. In future investigations, these factors should be considered to allow informed decision-making for admitting and managing ICU patients with COVID‐19.

List of abbreviations
COVID-19: Coronavirus Disease of 2019

ICU: Intensive Care Unit

CRP: C-reactive protein

SPSS: Statistical Package for Social Sciences

SPO2: Oxygen Saturation

Declarations
Ethics approval and consent to participate
The study protocol, questionnaire, and consent form were reviewed and approved by the institutional review board of Ain Wazein Medical Village on October 13th, 2021 (reference: CRU329).

Consent for publication: Not applicable

Availability of data and materials: Not applicable

Competing interests: The Authors declare that there is no conflict of interest.

Fundings: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions
SA: Conceptualization, data curation, methodology, Writing-review, and editing.
GH: Conceptualization, formal analysis, Validation, and Writing- original draft.

Acknowledgments: Not applicable.

References

  1. Serafim RB, Póvoa P, Souza-Dantas V, Kalil AC, Salluh JIF (2021) Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review. Clinical Microbiology and Infection. 27(1): 47-54.
  2. Grasselli G, Greco M, Zanella A, Albano G, Antonelli M, et al. (2020) Risk factors associated with mortality among patients with COVID-19 in intensive care units in Lombardy, Italy. JAMA Intern Med. 180(10): 1345-1355.
  3. Armstrong RA, Kane AD, Cook TM (2020) Outcomes from intensive care in patients with COVID‐19: a systematic review and meta‐analysis of observational studies. Anaesthesia. 75(10): 1340-1349.
  4. Kiss S, Gede N, Hegyi P, Németh D, Földi M, et al. (2021) Early changes in laboratory parameters are predictors of mortality and ICU admission in patients with COVID-19: a systematic review and meta-analysis. Medical microbiology and immunology. 210(1): 33-47.
  5. Khamis F, Memish Z, Bahrani MA, Dowaiki SA, Pandak N, et al. (2021) Prevalence and predictors of in-hospital mortality of patients hospitalized with COVID-19 infection. Journal of Infection and Public Health. 14(6): 759-65.
  6. Hatem G, Goossens M (2022) Health Care System In Lebanon: A Review Addressing Health Inequalities And Ethical Dilemmas Of Frontline Workers During Covid-19 Pandemic. BAU Journal - Health and Wellbeing. 5(1).
  7. Bhimraj A, Morgan RL, Shumaker AH, Lavergne V, Baden L, et al. (2020) Infectious Diseases Society of America Guidelines on the treatment and management of patients with coronavirus disease 2019 (COVID-19). Clin Infect Dis. ciaa478.
  8. Iaccarino G, Grassi G, Borghi C, Carugo S, Fallo F, et al. (2020) Gender differences in predictors of intensive care units admission among COVID-19 patients: The results of the SARS-RAS study of the Italian Society of Hypertension. PLoS One. 15(10): e0237297.
  9. Hartmann B, Verket M, Balfanz P, Hartmann N-U, Jacobsen M, et al. (2022) Glycaemic variability is associated with all-cause mortality in COVID-19 patients with ARDS, a retrospective subcohort study. Scientific reports. 12(1): 9862.
  10. Li W, Lin F, Dai M, Chen L, Han D, et al. (2020) Early predictors for mechanical ventilation in COVID-19 patients. Therapeutic advances in respiratory disease. 14: 1753466620963017.
  11. Malik P, Patel U, Mehta D, Patel N, Kelkar R, et al. (2021) Biomarkers and outcomes of COVID-19 hospitalisations: systematic review and meta-analysis. BMJ evidence-based medicine. 26(3): 107-108.
  12. Kabbaha S, Al-Azzam S, Karasneh RA, Khassawneh BY, Al- Mistarehi A-H, et al. (2022) Predictors of invasive mechanical ventilation in hospitalized COVID-19 patients: a retrospective study from Jordan. Expert Review of Respiratory Medicine. 16(8): 945-952.