| Abstract |
Background: The new infectious acute respiratory disease, caused by SARS-CoV-2, is characterized by a long incubation period and low pathogenicity. The clinical presentation ranges from mild common-cold illness to life-threatening critical illness. COVID-19 pandemic is a public health emergency of international concern with a high mortality rate, and it is imperative to identify risk factors associated with critical illness and increased mortality. Τhe selection of reliable monitoring indicators is also crucial since they will promptly indicate signs of impending clinical deterioration, guide early interventions and anticipate the physicians for the possibility of an adverse outcome, so that they can modify or appropriately upgrade patients' treatment.
Objective: The aim of this study is to monitor laboratory and clinical indicators of the disease process, and to identify risk factors and prognostic factors of deterioration and mortality. The sub-objectives included the comparison of characteristics and outcome indicators of patients hospitalized only in COVID-clinic vs ICU patients.
Methods: This is a single-center, retrospective study conducted in the COVID-clinic and ICU of PAGNI during the period January - October 2021. The inclusion criterion was the positive confirmed diagnosis of COVID-19 infection. Demographic, clinical, and laboratory data as well as medication or other treatments were recorded in order to correlate these parameters with patient outcome. The data were entered in an electronic record sheet EXCEL and their statistical analysis was performed using SPSS 28.
Results: 184 patients were studied in COVID-19 clinic, out of whom 57.6% were treated only in COVID-clinic (clinic group) and 39.7% worsened and transferred to the ICU (clinic→ICU group). The crude mortality was 21.7% with a statistically significant predominance in the clinic→ICU group (p <0.001). The two groups differed significantly in terms of age (clinic→ICU 67 ± 13.5 vs clinic 62.3 ± 13 years, p = 0.008), the hospital stay (clinic→ICU 29.4 ± 21 vs clinic 8.6 ± 6.5 days, p <0.001) , gender (clinic→ICU men 64.4% versus clinic men 49.5%, p = 0.05). The presence of co-morbidity was found to be statistically significant for clinical deterioration (p = 0.009), especially smoking (p = 0.03), arterial hypertension (p = 0.041), heart disease (p = 0.001) and thyroid disease (p = 0.0021). The majority (70%) of the patients in the clinic→ICU group received more frequent upgraded oxygen therapy with high flow nasal cannula (HFNC) (p <0.001). The clinic→ICU group had more often pathological values on the 1st and 3rd day of hospitalization than the clinic group: increase in WBC, LDH (p = 0.003), neutrophils, PT, INR, CRP, IL-6 (p <0.001), glucose (p = 0.02), urea (p = 0.002), ESR (p = 0.004) and ferritin (p = 0.04). Oxygenation factors were significantly differed PF ratio, ROX-index, ROX-HR index between the two groups on the 1st and 3rd day of hospitalization (all p <0.001). Independent risk factors for clinical deterioration were found to be oxygenation with HFNC (p = 0.013), PF ratio on day 1 (p <0.001) and co-morbidity (p = 0.007). Predictive indicators of clinical deterioration were the use of HFNC, the reduced values of PF ratio, ROX index, ROX-HR index on the 1st day as well as the high values of PT, INR and IL-6.
During the same period, 120 patients were hospitalized in the ICU, out of which 53 (44.2%) died. The mean age of the non-surviving ICU group was higher than that of the surviving ICU (73.2 ± 10.9 vs 60.7 ± 17.9 years, p <0.001), as was the duration of mechanical ventilation (MV) (28.4 ± 21.9 vs 14.3 ± 13.5 days). p <0.001) and the ICU stay (28.1 ± 21.9 vs 12.3 ± 13.3 days, p <0.001) and were predominantly male (71.7% vs 52.2%, p = 0.023). The presence of co-morbidity was found to be statistically significant for the outcome (p = 0.021). Laboratory values and oxygenation factors differed significantly on the 1st, 3rd, 7th, 14th day and over time between the two groups (p <0.001). Independent risk factors for mortality were found to be age (p <0.001), PF ratio on day 1 (p = 0.05), duration of MV (p = 0.001) and WBC (p = 0.013). Prognostic indicators of mortality were age, reduced PF ratio on day 3 and duration of MV.
Conclusions: In the present study risk factors for severe COVID-19 disease were found to be: male sex, age, co-morbidity, HFNC oxygen therapy, increased values in WBC, PT, INR, CRP, ESR, LDH, IL-6, neutrophils, ferritin, and urea as well as the reduced values of PF-ratio, ROX and ROX-HR index. Independent risk factors for clinical deterioration were co-morbidity, PF-ratio on day 1 and HFNC oxygen therapy. Elevated PT / INR, IL-6, HFNC oxygen therapy and low PF-ratio, ROX index, ROX-HR index on day 1 were very good predictors of deterioration. While in ICU, mortality risk factors were found to be age, co-morbidity, prolonged duration of MV and ICU stay. Independent risk factors for mortality were age, MV duration, PF-ratio on day 1 and WBCs. Age, duration of MV and PF-ratio on day 3 were very good prognostic factors for mortality.
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