Critically ill patients with COVID-19 in New York City
Authors: Giacomo Grasselli, Alberto Zanella
Journal: The Lancet (2020)

With more than 4·2 million people infected and over 288 000 deaths as of May 12, 2020, COVID-19 is threatening the entire world, with dramatic consequences for global health and the economy. After the initial outbreaks in China1WHOWHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020.https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020Date: March 11, 2020Date accessed: May 5, 2020Google Scholar and Italy,2Grasselli G Pesenti A Cecconi M Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response.JAMA. 2020; 3231545Crossref PubMed Scopus (1507) Google Scholar the virus rapidly spread worldwide and today the USA is one of the most affected country, with more than 1·3 million cases. In the absence of effective containment measures, COVID-19 outbreaks are characterised by an overwhelming number of patients requiring hospital admission, which could exceed the capacity even of well organised health-care systems. Current knowledge of the clinical course of severe forms of COVID-19 is mainly based on retrospective analyses of Chinese, Italian, and US case series.3Azoulay E Pochard F Chevret S et al.Compliance with triage to intensive care recommendations.Crit Care Med. 2001; 29: 2132-2136Crossref PubMed Scopus (154) Google Scholar, 4Bhatraju PK Ghassemieh BJ Nichols M et al.COVID-19 in critically ill patients in the Seattle region — case series.N Engl J Med. 2020; (published online March 30.)DOI:10.1056/NEJMoa2004500Crossref PubMed Scopus (1818) Google Scholar, 5Grasselli G Zangrillo A Zanella A et al.Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy.JAMA. 2020; (published online April 6.)DOI:10.1001/jama.2020.5394Crossref Scopus (3846) Google Scholar, 6Myers LC Parodi SM Escobar GJ Liu VX Characteristics of hospitalized adults with COVID-19 in an integrated health care system in California.JAMA. 2020; (published online April 24.)DOI:10.1001/jama.2020.7202Crossref PubMed Scopus (333) Google Scholar, 7Richardson S Hirsch JS Narasimhan M et al.Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area.JAMA. 2020; (published online April 22.)DOI:10.1001/jama.2020.6775Crossref PubMed Scopus (6446) Google Scholar, 8Wang Y Lu X Chen H et al.Clinical course and outcomes of 344 intensive care patients with COVID-19.Am J Respir Crit Care Med. 2020; (published online April 8.)DOI:10.1164/rccm.202003-0736LECrossref Scopus (374) Google Scholar, 9Zhou F Yu T Du R et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Summary Full Text Full Text PDF PubMed Scopus (18725) Google Scholar These studies show that critically ill patients with COVID-19 are mainly older, mostly men, and have at least one comorbidity (primarily hypertension), and mortality is very high (ranging from 56% to 97%) when invasive mechanical ventilation is required. However, limited data are available on factors independently associated with mortality. In The Lancet, Matthew Cummings and colleagues10Cummings MJ Baldwin MR Abrams D et al.Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.Lancet. 2020; (published online May 19.)https://doi.org/10.1016/S0140-6736(20)31189-2Summary Full Text Full Text PDF Scopus (1500) Google Scholar add to our knowledge by reporting the results of a prospective cohort study describing clinical characteristics, management, and outcomes of 257 critically ill patients (86 [33%] women and 171 [67%] men, median age 62 years) admitted to high-dependency and intensive care units in two hospitals in New York City over a period of 4 weeks. Notably, critically ill patients with COVID-19 represented 22% of all patients admitted. Compared with other reports,5Grasselli G Zangrillo A Zanella A et al.Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy.JAMA. 2020; (published online April 6.)DOI:10.1001/jama.2020.5394Crossref Scopus (3846) Google Scholar in the cohort described by Cummings and colleagues10Cummings MJ Baldwin MR Abrams D et al.Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.Lancet. 2020; (published online May 19.)https://doi.org/10.1016/S0140-6736(20)31189-2Summary Full Text Full Text PDF Scopus (1500) Google Scholar the proportion of patients younger than 50 years of age was relatively high (55 [21%] of 257 patients). This could be explained by the high incidence of obesity, which affected 39 (71%) of those 55 younger patients. Other common comorbidities were hypertension (162 [63%]), diabetes (92 [36%]), chronic cardiovascular disease (49 [19%]), chronic kidney disease (37 [14%]), and chronic pulmonary disease (24 [9%]). 203 (79%) patients required invasive mechanical ventilation, median respiratory system compliance was low (27 mL/cm water), and all patients required a high fraction of inspired oxygen despite having relatively high levels of positive end-expiratory pressure (median 15 cm water). Although obesity might have affected the mechanical properties of the respiratory system, these findings underline that the optimal management of mechanical ventilation in patients with COVID-19 and acute respiratory failure remains poorly understood. The study by Cummings and colleagues10Cummings MJ Baldwin MR Abrams D et al.Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.Lancet. 2020; (published online May 19.)https://doi.org/10.1016/S0140-6736(20)31189-2Summary Full Text Full Text PDF Scopus (1500) Google Scholar confirms that COVID-19 is characterised by a high incidence of multiple organ dysfunction, as shown by the proportion of patients requiring vasopressors (170 [66%]) and renal replacement therapy (79 [31%]). Regarding pharmacological treatments, antibacterial agents were administered empirically to nearly all critically ill patients (229 [89%]) and hydroxychloroquine was administered to 185 (72%), while corticosteroids and interleukin-6 (IL-6) receptor antagonists were administered to fewer patients (68 [26%] received corticosteroids and 44 [17%] received IL-6 receptor antagonists). No data are available on the temporal changes of inflammatory markers in patients receiving immunomodulating treatments. Furthermore, no information is provided about strategies of anticoagulant therapies, which are particularly interesting given the high incidence of thromboembolic complications associated with COVID-19.11Wang T Chen R Liu C et al.Attention should be paid to venous thromboembolism prophylaxis in the management of COVID-19.Lancet Haematol. 2020; 7: e362-e363Summary Full Text Full Text PDF PubMed Scopus (286) Google Scholar With regards to patient outcome, the study conveys important messages. In particular, it shows that the disease is characterised by a high mortality (101 [39%] after a minimum follow-up of 28 days) and prolonged clinical course, as shown by the high percentage of patients still in the hospital (94 [37%]) at the end of follow-up. The multivariable Cox model analysis showed that history of chronic pulmonary disease had the highest adjusted hazard ratio (aHR) for mortality (aHR 2·94 [95% CI 1·48–5·84]). Other independent predictors of death were history of chronic cardiovascular disease (aHR 1·76 [95% CI 1·08–2·86]), older age (aHR 1·31 [95% CI 1·09–1·57]), higher concentrations of IL-6 (aHR 1·11 [95% CI 1·02–1·20] per decile increase), and higher concentrations of D-dimer (aHR 1·10 [95% CI 1·01–1·19] per decile increase) on admission. There appear to be no differences by sex. The association of mortality with higher concentrations of IL-6 and D-dimer is particularly relevant for two reasons. First, it confirms the key pathogenic role played by the activation of systemic inflammation and endothelial-vascular damage in the development of organ dysfunction. Second, it provides the rationale for the design of clinical trials for measuring the efficacy of treatment with immunomodulating and anticoagulant drugs. The study by Cummings and colleagues10Cummings MJ Baldwin MR Abrams D et al.Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.Lancet. 2020; (published online May 19.)https://doi.org/10.1016/S0140-6736(20)31189-2Summary Full Text Full Text PDF Scopus (1500) Google Scholar shows that clinicians can produce high-quality research even when facing an overwhelming clinical workload. However, despite providing important insights, this work leaves us with some unanswered questions. While waiting for the availability of a COVID-19 vaccine, further studies are required to improve and personalise patient treatment, with particular attention to the role of initial non-invasive respiratory support strategies, timing of intubation, optimal setting of mechanical ventilation, and efficacy and safety of immunomodulating agents and anticoagulation strategies. This online publication has been corrected. The corrected version first appeared at thelancet.com on June 4, 2020 This online publication has been corrected. The corrected version first appeared at thelancet.com on June 4, 2020 GG reports personal fees from Biotest, Draeger, Fisher & Paykel, Maquet, Merck Sharp & Dohme, and Pfizer, all outside the area of work commented on here. AZ declares no competing interests. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort studyCritical 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. Full-Text PDF Department of ErrorGrasselli G, Zanella A. Critically ill patients with COVID-19 in New York City. Lancet 2020; 395: 1740–41—In this Comment, the number of participants should have been 86 (33%) women and 171 (67%) men, and median respiratory system compliance should have been 27 mL/cm water. These corrections have been made to the online version as of June 4, 2020, and the printed version is correct. Full-Text PDF