Alberto Dariel Ramírez González 1*https://orcid.org/0000-0002-1828-9493
1*University of Medical Sciences of Havana, Faculty of Medical Sciences “Dr. Salvador Allende". Havana Cuba.
At the end of 2019, a new coronavirus, called SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), caused an epidemic of acute respiratory disease in Wuhan, China. (1)
The World Health Organization named this disease coronavirus disease 2019 (COVID-19) (2) and on March 11, 2020, it was declared a pandemic. (3) The same day, it confirmed the first three cases of COVID-19 in Cuba. (4)
As of July 13, 185 countries are reporting cases of COVID-19, with numbers rising to 12,875,963 confirmed cases and 568,628 deaths, for a lethality of 4.41%. The región of the Americas reached up to that date 52.72% of the world reports, with 288 759 deaths, for a lethality of 4.25%. At the end of July 13 in Cuba, it was reported 2,432 positive samples, a cumulative number of 87 deaths, 2 evacuees and 2,258 patients recovered. (5)
The clinical presentation of COVID-19 is variable, from mild to severe forms. Has been reported that 25.9% of patients require admission to intensive care units (ICU), and 20.1% develop adult respiratory distress syndrome (ARDS, acronym in English). (6)
Survival prediction is vital, as it allows defining ICU admission criteria, rationalize medical care according to the degree of need and distribute resources toilets efficiently. (7,8)
The Acute Physiology and Chronic Health Evaluation II (APACHE II) is the system ofdisease severity score most commonly used in ICUs. (9)
In recent years, interest in the CONUT index (nutritional control) has increased,
(10) scoring system of three biochemical indicators, easy to acquire and apply (11)
The authors set themselves the goal of describing the behavior of 20 positive cases
to SARS CoV-2 in the ICU of the Hospital “Dr. Salvador Allende”, given the importance that
Within the framework of this pandemic, the need to increase scientific knowledge
in relation to this topic.
Methods
Observational, descriptive, cohort and prospective study, applied between March and July
of 2020, in the ICU of the Clinical Surgical Hospital "Dr. Salvador Allende” of Havana,
Cuba. The population consisted of all admitted patients, positive to SARS CoV-2 (n= 20).
Inclusion criteria:
-All cases confirmed to SARS CoV-2 by Reverse Transcription and Reaction
Real-time polymerase chain (RT-PCR) test.
Exclusion criteria:
-Cases ruled out for SARS-CoV-2 by RT-PCR.
-Insufficient data collected to complete the necessary variables in this research.
Variables analyzed: age, sex, ICU stay, discharge status, comorbidities, complementary, epidemiological link, invasive mechanical ventilation (IMV), complications, predominant symptoms, pharmacological therapy, APACHE II and CONUT score.
The Microsoft Office Professional Plus 2016 version 16.0 program for Windows was used to prepare the final text and the database. The results were expressed in frequencies
relative, absolute, percentages and measures of dispersion.
A 95% confidence interval (CI) was applied, the p value was found, and in some cases the odds ratio (OR) and relative risk (RR).
Ethical aspects: The research was carried out in accordance with the principles of the Declaration of Helsinki at the 64th General Assembly, Fortaleza, Brazil, October 2013.
Results
In this series, the male sex predominated (55%). The group of 45-64 years stood out by 45%. Values from 29 to 101 years and an average of 64.35 ± 15.21 years (CI 57.7-71) were recorded.
The average length of stay was 10.05 ± 5.5 days (CI 8.9 - 12.1).
The mean APACHE II score was 16.6 ± 8.9 (CI 12.7-20.5) and an adjusted odds ratio of dying ranged from 7.6% to 81%.
The most frequent symptoms were: fever (55%), cough (25%) and dyspnea (20%). Men reported fever more (ratio 6:5). Other manifestations were: anosmia or hyposmia, dysgeusia, asthenia, anorexia, sore throat and headache.
Regarding the epidemiological link, ten patients (50%) had contact with positive cases, and in the other half, the source of infection was unknown at the time of admission.
From the date of onset of symptoms (FIS) to admission to the ICU, the average time was 7.61 ± 2.51 days (CI 6.5 - 8.7).
35% of the cases presented moderate malnutrition and 30% mild. Mild malnutrition predominated in women, and moderate malnutrition in men.
The group of 45-64 years was concentrated between 7-14 points (35%) of the APACHE II score, while scores ≥23 were located in older age groups.
Seven of the cases (35%) presented complications in their evolution: ARDS (20%), co-infection with community-acquired bacterial bronchopneumonia (15%), acute renal failure (15%), septic shock (15%), multiorgan dysfunction syndrome (10%), nosocomial bronchopneumonia (10%), acute myocardial infarction (10%), and upper gastrointestinal bleeding (5%). These incidences only occurred in ≥ 65 years.
30% of the patients required IMV, all were ≥65 years, with a predominance of females. 83.33% (5) died, of which four presented severe ARDS or moderate (RR 16.7) according to the Berlin classification. (12)
The mean use of optimal positive end-expiratory pressure (PEEP) was 16.5 ± 2.1 cmH2O (CI 15.6-17.4), and the initial ventilatory modality was volume-controlled ventilation (VCV). ). One of the cases was placed in the prone position after the first 12 hours of admission to the ICU. It is noteworthy that 5 cmH2O less PEEP was required compared to the supine position. the prone position was contraindicated in the other cases due to hemodynamic instability.
The case in which successful ventilatory weaning was achieved was achieved in BiPAP (positive pressure) mode, which meant less sedation and muscle relaxation requirements, and less IMV time (5 days), despite their advanced age.
Non-invasive ventilation was used in none of the patients.
Regarding deaths (25% of n), ages ranged from 66 to 101 years, with an average of 78.6 ± 17.3 years (CI 71-86.2). When relating this variable to sex, women stood out (3:2 ratio). The stay of the deceased did not change significantly compared to survivors.
The deceased presented APACHE II scores≥23, averaging 28.3 ± 8.6 points (CI 24.5-32.1), with an average probability of dying of 62.9 ± 23.5% (CI 52.6-73.2) (p< 0.05). Four of the deaths (80%) presented some degree of malnutrition. The highest proportion of deceased had between 2-3 comorbidities (15% of n); arterial hypertension (HBP) was the condition most frequently found (OR: 1.71; RR: 1.5).
The most frequent pathological antecedents were: arterial hypertension (50%), bronchial asthma (20%), ischemic heart disease (15) and chronic obstructive pulmonary disease (10%). The following was recorded less frequently: type II diabetes mellitus, hypothyroidism,
chronic adrenocortical insufficiency, cellular immunodeficiency, morbid obesity, senile dementia, Alzheimer's type dementia, prostatic adenocarcinoma with lung meta**stases, pulmonary hypertension, valve disease, and HIV.
Regarding comorbidities, the group with less than two comorbidities stood out (55%), followed by the group with 2-3 (40%); men were slightly superior to women in the first group (ratio of 6:5), and were evenly matched in the group.
The pharmacological treatment was individualized according to the Cuban protocol established for COVID 19 and the guidelines of the institution's expert committee.
All cases received empirical antibiotic therapy with ceftriaxone if there was no hypersensitivity or a higher antibiotic scale. 100% took Kaletra, 80% chloroquine (CLQ), 65% steroids and 55% CIGB 258.
75% of the patients presented bilateral interstitial infiltrates on x-rays of thorax, presenting in 100% of the deceased.
The mean TGP was 65.7 ± 48.3 UI/L (CI 44.5-86.9), almost doubling its value in the deceased (125.4 ± 36.4 UI/L). The average SGRT was 70.9 ± 83.2 UI/L (CI 34.4-107.4), doubling its value in deaths (177 ± 104 UI/L).
LDH increased in a high percentage of cases; for an average of 335.6 ± 240.3 UI/L (CI 230.3-440.9), higher for the deceased (466.8 ± 248 UI/L). His numbers ranged from 229 to 1225 IU/L.
The ESR averaged 65.66 ± 36.2 mm3/s (CI 49.8-81.5). The drop in its value in the deceased is striking (46.4 ± 39.5 mm
3/s), relative to its increase in survivors.
The lymphocyte count decreased in the deceased (1220 ± 861) compared to the survivors and the general average.
The average lactate was conserved in survivors and deceased; remember that these exams were obtained 24 h after admission to the ICU and not evolutionarily.
Serum albumin in the deceased was, on average, slightly decreased.
Average serum cholesterol was preserved.
The average population was aged, which highlights age as a relevant variable that affects therapy, evolution, and prognosis. Male representation predominated.
Several authors have identified age as the main risk factor for severe disease, setting its threshold at 65 years. (16,17,18,19)
Likewise, in a New York study, the average was 62.2 years and 60% were men. (20)
Values similar to those found in this investigation.
ICU stay averaged 10 days, and age proportionally affected the increase in stay. On this, the average hospital stay for Fei Zhou and others was 22 days, (20)
double the value referred to in this investigation.
The high APACHE II scores demonstrate the complexity of the cases attended. Age had a directly proportional relationship with the APACHE II score.
According to Carboni et al., the average APACHE II score on admission was 9, (21) lower than that reported in our work.
The admitted cases were symptomatic or minimally symptomatic; the latter, with radiological, hemogasometric, humoral conditions and comorbidities, which
conditioned their admission.
In a New York study, the most common symptoms were: cough (79.4%), fever (77.1%), and dyspnea (56.5%); (20) similar to what was found in this work.
Chinese research reports fever, cough, sore throat, weakness, myalgia, and gastrointestinal symptoms. (18,22)
In others, anosmia and ageusia are also described.
(23,24) Half of the cases in this study had epidemiological links.
According to Carboni et al in their work, three cases had traveled to affected areas, and another four affected by cluster transmission and one community. (21)
The complications observed occurred at advanced ages. This reaffirms the weight of age in the probability of presenting an unfavorable evolution.
Fei Zhou et al. detected among the most frequent complications sepsis, respiratory failure, ARDS, heart failure and septic shock. (17) similar to this study.
The authors' attention was drawn to the presence of marked hypoxemia (PaO2/FiO2
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