Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.
Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.
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DOI：
10.1101/2020.04.15.20067157
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发表时间：
2020-06-06
期刊：
影响因子：
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通讯作者：
O'Donnell, Max R
中科院分区：
文献类型：
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作者：
Cummings, Matthew J;Baldwin, Matthew R;O'Donnell, Max R
背景：截至2020年4月14日，纽约市已有近3万名冠状病毒病-2019 （COVID-19）患者住院。在这种情况下，需要关于COVID-19危重患者的流行病学、临床过程和结局的数据。方法：我们前瞻性地收集了2020年3月2日至4月1日期间在曼哈顿北部两家医院住院的实验室确诊covid -19重症成人的临床、生物标志物和治疗数据。主要终点是住院死亡率。次要结局包括有创机械通气的频率和持续时间、血管加压剂的使用频率和肾脏替代治疗的频率，以及入院后临床恶化的时间。临床危险因素、生物标志物和住院死亡率之间的关系采用cox -比例风险回归建模。每例患者至少观察14天。结果：在研究期间因COVID-19住院的1150名成年人中，257人（22%）病情危重。中位年龄为62岁（四分位间距[IQR] 51-72）；170例（66%）为男性。212人（82%）患有至少一种慢性疾病，其中最常见的是高血压（63%;162/257）和糖尿病（36%;92/257）。138例（54%）为肥胖，13例（5%）为医护人员。截至2020年4月14日，住院死亡率为33% (86/257)；47%（122/257）的患者仍在住院。231例（79%）患者接受有创机械通气（中位13天[IQR 9-17]）， 54%（138/257）和29%（75/257）患者分别需要血管加压药物和肾脏替代治疗。入院后到临床恶化的中位时间为3天（IQR 1-6）。年龄较大、高血压、慢性肺部疾病和入院时白细胞介素-6和d-二聚体浓度较高与住院死亡率独立相关。结论：在纽约市COVID-19住院患者中，危重疾病很常见，并与有创机械通气的高频率、肺外器官功能障碍和大量住院死亡率相关。背景：截至2020年4月28日，纽约市（美国纽约州）已有4万多名COVID-19患者住院。在这种情况下，需要关于COVID-19危重患者的流行病学、临床过程和结局的数据。方法：这项前瞻性观察队列研究在曼哈顿北部哥伦比亚大学欧文医学中心附属的两家纽约长老会医院进行。前瞻性地选取2020年3月2日至4月1日在两家医院收治的经实验室确诊的COVID-19重症急性低氧性呼吸衰竭的成人患者（年龄≥18岁），收集临床、生物标志物和治疗数据。主要观察指标是住院死亡率。次要结局包括有创机械通气的频率和持续时间、使用血管加压剂和肾脏替代治疗的频率以及入院后住院临床恶化的时间。临床危险因素、生物标志物和住院死亡率之间的关系采用Cox比例风险回归建模。随访时间于2020年4月28日进行right- censorship，以便每位患者至少有28天的观察时间。结果：2020年3月2日至4月1日期间，两家医院共收治了1150名实验室确诊的COVID-19成年人，其中257人（22%）病情危重。患者中位年龄为62岁（IQR 51-72），男性171例（67%）。212例（82%）患者至少有一种慢性疾病，其中最常见的是高血压（162例[63%]）和糖尿病（92例[36%]）。119例（46%）患者有肥胖。截至2020年4月28日，101名（39%）患者死亡，94名（37%）患者仍在住院治疗。203例（79%）患者接受有创机械通气，中位时间为18天（IQR 9-28）， 257例患者中170例（66%）接受血管加压药物治疗，79例（31%）接受肾脏替代治疗。到住院恶化的中位时间为3天（IQR 1-6）。在多变量Cox模型中，年龄增大（校正危险比[aHR] 1.31[1.09 - 1.57] / 10年）、慢性心脏病（aHR 1.76[1.08 - 2.86]）、慢性肺病（aHR 2.94[1.48 - 5.84]）、白细胞介素-6浓度升高（aHR 1.11 [95%CI 1.02 - 1.20] / 10年）、d -二聚体浓度升高（aHR 1.10[1.01 - 1.19] / 10年）与院内死亡率独立相关。解释：在纽约市因COVID-19住院的患者中，危重疾病很常见，并与高频率的有创机械通气、肺外器官功能障碍和大量住院死亡率相关。资助：国家过敏和传染病研究所、国家转化科学推进中心、国家卫生研究院、哥伦比亚大学欧文临床和转化研究所。
BACKGROUND: Nearly 30,000 patients with coronavirus disease-2019 (COVID-19) have been hospitalized in New York City as of April 14th, 2020. Data on the epidemiology, clinical course, and outcomes of critically ill patients with COVID-19 in this setting are needed.METHODS: We prospectively collected clinical, biomarker, and treatment data on critically ill adults with laboratory-confirmed-COVID-19 admitted to two hospitals in northern Manhattan between March 2nd and April 1st, 2020. The primary outcome was in-hospital mortality. Secondary outcomes included frequency and duration of invasive mechanical ventilation, frequency of vasopressor use and renal-replacement-therapy, and time to clinical deterioration following hospital admission. The relationship between clinical risk factors, biomarkers, and in-hospital mortality was modeled using Cox-proportional-hazards regression. Each patient had at least 14 days of observation.RESULTS: Of 1,150 adults hospitalized with COVID-19 during the study period, 257 (22%) were critically ill. The median age was 62 years (interquartile range [IQR] 51-72); 170 (66%) were male. Two-hundred twelve (82%) had at least one chronic illness, the most common of which were hypertension (63%; 162/257) and diabetes mellitus (36%; 92/257). One-hundred-thirty-eight patients (54%) were obese, and 13 (5%) were healthcare workers. As of April 14th, 2020, in-hospital mortality was 33% (86/257); 47% (122/257) of patients remained hospitalized. Two-hundred-one (79%) patients received invasive mechanical ventilation (median 13 days [IQR 9-17]), and 54% (138/257) and 29% (75/257) required vasopressors and renal-replacement-therapy, respectively. The median time to clinical deterioration following hospital admission was 3 days (IQR 1-6). Older age, hypertension, chronic lung disease, and higher concentrations of interleukin-6 and d-dimer at admission were independently associated with in-hospital mortality.CONCLUSIONS: Critical illness among patients hospitalized with COVID-19 in New York City is common and associated with a high frequency of invasive mechanical ventilation, extra-pulmonary organ dysfunction, and substantial in-hospital mortality.BACKGROUND: Over 40 000 patients with COVID-19 have been hospitalised in New York City (NY, USA) as of April 28, 2020. Data on the epidemiology, clinical course, and outcomes of critically ill patients with COVID-19 in this setting are needed.METHODS: This prospective observational cohort study took place at two NewYork-Presbyterian hospitals affiliated with Columbia University Irving Medical Center in northern Manhattan. We prospectively identified adult patients (aged ≥18 years) admitted to both hospitals from March 2 to April 1, 2020, who were diagnosed with laboratory-confirmed COVID-19 and were critically ill with acute hypoxaemic respiratory failure, and collected clinical, biomarker, and treatment data. The primary outcome was the rate of in-hospital death. Secondary outcomes included frequency and duration of invasive mechanical ventilation, frequency of vasopressor use and renal replacement therapy, and time to in-hospital clinical deterioration following admission. The relation between clinical risk factors, biomarkers, and in-hospital mortality was modelled using Cox proportional hazards regression. Follow-up time was right-censored on April 28, 2020 so that each patient had at least 28 days of observation.FINDINGS: Between March 2 and April 1, 2020, 1150 adults were admitted to both hospitals with laboratory-confirmed COVID-19, of which 257 (22%) were critically ill. The median age of patients was 62 years (IQR 51-72), 171 (67%) were men. 212 (82%) patients had at least one chronic illness, the most common of which were hypertension (162 [63%]) and diabetes (92 [36%]). 119 (46%) patients had obesity. As of April 28, 2020, 101 (39%) patients had died and 94 (37%) remained hospitalised. 203 (79%) patients received invasive mechanical ventilation for a median of 18 days (IQR 9-28), 170 (66%) of 257 patients received vasopressors and 79 (31%) received renal replacement therapy. The median time to in-hospital deterioration was 3 days (IQR 1-6). In the multivariable Cox model, older age (adjusted hazard ratio [aHR] 1·31 [1·09-1·57] per 10-year increase), chronic cardiac disease (aHR 1·76 [1·08-2·86]), chronic pulmonary disease (aHR 2·94 [1·48-5·84]), higher concentrations of interleukin-6 (aHR 1·11 [95%CI 1·02-1·20] per decile increase), and higher concentrations of D-dimer (aHR 1·10 [1·01-1·19] per decile increase) were independently associated with in-hospital mortality.INTERPRETATION: Critical illness among patients hospitalised with COVID-19 in New York City is common and associated with a high frequency of invasive mechanical ventilation, extrapulmonary organ dysfunction, and substantial in-hospital mortality.FUNDING: National Institute of Allergy and Infectious Diseases and the National Center for Advancing Translational Sciences, National Institutes of Health, and the Columbia University Irving Institute for Clinical and Translational Research.