| Abstract |
Background: The number of patients with Covid-19 infection continues to increase
worldwide with a social and economic impact, as well as a large number of deaths. SARS-
CoV-2 infection, especially in elderly patients and in patients with comorbidities, can develop
into severe disease and the need for admission to the Intensive Care Unit. The treatment of
the disease is a challenge, and mainly involves supportive measures to deal with respiratory
failure. Therefore, early recognition of severe forms of SARS-CoV-2 infection is absolutely
necessary for its effective treatment.
Objective: The purpose of this specific study is to determine the risk factors of clinical
deterioration as well as the follow-up indicators of patients who were hospitalized with
Covid-19 infection in the Clinic, Clinic-ICU or only ICU at the Venizeleio General Hospital of
Heraklion and the correlation of their clinical and laboratory data with their outcome. The
identification of predictors of outcome, the combination of characteristics of patients with
Covid-19 disease with their hospital admission symptoms, the characteristics of those who
showed clinical deterioration and required hospitalization in the ICU as well as the
comparison of subgroups of patients with severe disease vs of critically ill patients in terms
of their characteristics (demographic, clinical, laboratory, therapeutic) and their outcome
indicators (hospitalization duration, respiratory support of non-invasive and invasive
ventilation, death) are additional objectives of the study.
Methods: This is a retrospective observational study that included all patients who were
hospitalized at the Covid-19 Clinic and ICU-Covid-19 at Venizeleio G.N.H. with Covid-19
infection, for the period March 2020 to December 2021. Groups were defined as MAK:
patients hospitalized in the Clinic only, MAK-ICU: patients hospitalized in the Clinic,
worsened and admitted to the ICU, ICU: patients admitted to the ICU, not necessarily
admitted from the ICU. Data have been recorded and collected through medical record
review. The data was collected in a recording form and followed by their statistical analysis
with appropriate statistical tests.
Results: MAK vs MAK-ICU patients: For the period we are studying, 8.7% of patients were
vaccinated. A total of 265 patients were studied. 120 patients who were initially hospitalized
in the MAK, deteriorated and were hospitalized in the ICU, of which 57.1% died. Crude
mortality was 32.2% with a statistically significant superiority in the MAK-ICU group
(p<0.001). The days of hospitalization in the ICU did not differ significantly, in contrast to the
days of hospitalization in the hospital in general. Patients who died had an older age
(p<0.001) and a longer hospital stay than those who survived in both groups (p<0.001).
Initial symptoms of fatigue and dyspnea differed between the MAK and MAK-ICU groups
(p<0.001), as did severe hypoxemia (ΜΑΚ SpO2 93% vs ΜΑΚ→ICU SpO2 91%, p=0.027).
Patients in the MAK-ICU group received more upgraded modes of oxygen therapy (HFNC
(p<0.001), ΜΕΜΑ (p=0.008)) and were more often placed in the prone position (p=0.006)
than MAK patients who more often received oxygen therapy with a nasal cannula (p<0.001).
85.9% of patients received steroids. Anticoagulant treatment in a prophylactic dose was
received by 62.4% of patients and a therapeutic dose by 27%. 16 patients received
monoclonal antibodies and all belonged to the MAK-ICU group. 52.4% of patients received
antiviral treatment. Antimicrobial treatment was received by 99.2% of patients, while
treatment was modified based on culture in 14/262 (5.3%) patients. 66.4% of all patients
had developed a complication by the 4th day of hospitalization in the ICU. ICU patients: A
total of 125 patients were studied, of which 76 (60.8%) died in the ICU. Hematologic,
biochemical and gas control differed between patients who survived vs those who died at
days 1,3,7 and 14 (all, p<0.001). Specifically, statistically significant differences were found
over time in the PF ratio (PaO2/FiO2), WBC, neutrophils, PLTs, CRP, Ferritin, PT, urea and
creatinine. In all ICU patients, 99.2% (N=122) had ARDS, 1 patient had a pulmonary
embolism and 44 (35.8%) had septic shock without significant difference in final outcome. 41
patients (35.8%) developed as a complication DIC and 64 (51.2%) renal failure and need for
extrarenal dialysis, with a predominance of patients who died. Independent factors
associated with ICU mortality were found to be comorbitity, respiratory failure (p=0.009)
and renal failure treated with extrarenal dialysis (p=0.004). Prognostic factors for mortality
were found to be older age, respiratory failure and renal failure (all, p<0.001)
Conclusion: Cause of hospitalization of Covid-19 patients was severe hypoxemia, pneumonia
and sepsis. Patients who worsened were treated with upgrade modes of oxygen therapy and
were more often placed in the prone position, while having an increased risk of death. Old
age, respiratory insufficiency and low oxygenation indices on admission, and complication
with sepsis emerged as independent factors for progression to severe disease. Predictors of
mortality were comorbidity, age respiratory failure, sepsis and ICU admission. Independent
mortality factors of patients with severe disease (ICU hospitalization) were age, comorbidity,
respiratory failure (ARDS), and complication with renal failure and need for extrarenal
dialysis. Predictors of mortality in patients with severe disease (ICU hospitalization) were old
age, respiratory failure (ARDS) and complication with renal failure and the need for
extrarenal dialysis.
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