COVID-19 Death Rates in ICUs Down

Marcia Frellick

July 16, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Overall mortality of patients with COVID-19 in intensive care units (ICUs) across Europe, Asia, and North America has dropped from nearly 60% at the end of March to nearly 42% at the end of May, according to a systematic review and meta-analysis.

The study by R. A. Armstrong, a fellow at Severn Deanery in Bristol, United Kingdom, and colleagues was published online July 15 in Anaesthesia. It is the first systematic review and meta-analysis of outcomes of patients with COVID-19 in ICUs.

Armstrong and colleagues searched the MEDLINE, EMBASE, PubMed, and Cochrane databases for studies through May that reported ICU mortality for adult patients admitted with COVID-19. The primary outcome measure was death in an ICU as a proportion of completed ICU admissions.

They found 24 relevant observational studies, which included 10,150 patients. They calculated that combined ICU mortality across all the studies was 41.6%, down by about one third from the 59.5% ICU mortality seen in the studies to the end of March.

The authors note that the lower mortality rate is still nearly twice the 22% mortality seen in ICU admissions for other viral pneumonias. They note that mortality is not significantly different across the three continents.

"Sharing Information in Real Time"

Amesh A. Adalja, MD, an infectious disease and critical care physician and senior scholar at Johns Hopkins Center for Health Security in Baltimore, Maryland, told Medscape Medical News the news reflects other information in the field.

"It is clear in July 2020 that we know much more about this virus, the complications it can cause, and how to prevent those complications than we did in March 2020," he said. "We're also much better at managing patients for their oxygen needs using other devices, such as high-flow nasal cannulas, vs mechanical ventilator reflexively."

He also noted that more treatments are now available, such as remdesivir. Although remdesivir has not been demonstrated in clinical trials to reduce mortality, it has been found to be beneficial in getting people out of the ICU faster.

"We're much better at diagnosing these patients faster so we can intervene quicker. We're learning about the cytokine storms and what drugs we can use against that," he said. He noted that it may be that people are becoming infected with lower viral loads because of social distancing.

It will be important to follow patients to ascertain that the decrease is not just transient and that people are not leaving the ICU only to die months later, he said.

He said he wasn't surprised that the results were virtually the same across continents.

"All of us taking care of these patients are on the same team, and everybody is sharing information in real time, so we are learning from each other," he continued.

Virus Is Not Less Deadly

Although the results offer hope, Adalja said, "I wouldn't overinterpret that this virus has now become less deadly. It still has the capacity to kill. It still has the capacity to disrupt your entire hospital and healthcare system.

"We're getting better at treating it, but it still carries substantial mortality, and we should not be satisfied with the level from this study. We want to get it as low as possible, and we want to stop people from even needing the ICU."

Study coauthor Tim Cook, MBBS, consultant in anesthesia and intensive care medicine at Royal United Hospitals, in Bath, United Kingdom, told Medscape Medical News the researchers were limited by the way study results were reported.

"We cannot determine what the entry criteria were for ICU care, nor indeed the discharge criteria," he added.

"We don't know if all patients in different studies had similar baseline characteristics and baseline health, were similarly unwell when admitted to ICU, or what interventions and treatments they received," he said.

That underscores the need for more structured reporting globally, he continued.

Cook said that in March and April, many healthcare systems were close to being overwhelmed by cases and that a contributing factor could be that only the sickest patients were admitted to ICUs. This would help explain the drop over time.

"It is also plausible — but unproven — that systems were so stretched that survival rates fell because it was not possible to maintain the same standards of care as usual," he explained.

But the progress in knowledge is undeniable, Cook said, including that COVID-19 affects many organs and body systems, that patients may be dehydrated and need more fluid, that noninvasive ventilation may have a role, and that prone positioning may improve lung function. In addition, strategies have been developed to decrease high rates of clotting.

He says there are signs mortality rates will continue to improve for reasons such as the use of promising treatments, including the steroid dexamethasone, which has been shown to save lives, especially among the sickest patients with COVID-19. However, use of the drug in the United States has been mixed.

The authors and Adalja have disclosed no relevant financial relationships.

Anaesthesia. Published online July 15, 2020. Full text

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick .

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