Pubblicato in: Medicina e Biologia, Stati Uniti

Covid-19. 88% dei pazienti ventilati muore. – Jama.

Giuseppe Sandro Mela.

2020-05-19.

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Le Tabelle sono riportate in calce.


«Sta accadendo qualcosa di strano nei contagiati dal covid-19 che i medici non riescono a spiegare: nell’ultimo mese un numero crescente di persone, arrivate in ospedale con un livello di ossigeno sotto la soglia di sicurezza, riesce a riprendersi senza bisogno dell’aiuto di ventilatori.»

«Fino a poche settimane fa la scarsa presenza di ossigeno, sotto il 95 per cento, era il primo segnale di un quadro clinico destinato al peggioramento: nel giro di pochi giorni i pazienti sarebbero andati incontro a una grave crisi respiratoria, al danneggiamento degli organi e, infine, alla morte»

«le persone riprendono a respirare senza bisogno di aiuto, al punto che i medici stanno cominciando a pensare a terapie alternative, che non prevedono il ricorso ai preziosi ventilatori.»

«In passato …. partivi dall’idea che senza intubarli, li avresti persi”.»

«Nel Regno Unito il 58,8 per cento di contagiati bisognosi di ventilatori è morto, quasi il doppio rispetto alle vittime per altre patologie respiratorie come la polmonite»

«A New York l’88 per cento dei 320 pazienti sottoposti a ossigenazione meccanica non ce l’ha fatta, mentre tra quelli che non ne hanno avuto bisogno il tasso di mortalità è stato dell’11,7»

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«A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female).»

«The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%).»

«373 patients (14.2%) (median age, 68 years [IQR, 56-78]; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, …. and 553 (21%) died.»

«Older persons, men, and those with preexisting hypertension and/or diabetes were highly prevalent in this case series and the pattern was similar to data reported from China»

«The findings of high mortality rates among ventilated patients are similar to smaller case series reports of critically ill patients in the US»

«Mortality rates are calculated only for patients who were discharged alive or died by the study end point»

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Questi dati sono simili a quelli previamente riportati dall’Istituto Superiore di Sanità:

ISS. Analisi dei pazienti deceduti per coronavirus. Elaborati 68,801 casi.

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La Tabella 5 è chiara. Dei 320 pazienti messi sotto ventilazione invasiva sono morti 107 pazienti di età compresa tra i 18 – 65 anni e 175 soggetti di età superiore ai 65 anni. Il tasso di mortalità in questo gruppo di pazienti è quindi 100 * (107 + 175) / 320 = 88.1%.

Caratteristiche di questi pazienti sono l’età superiore ai 60 anni, e le comorbidità: ipertensione arteriosa (56.6%), obesità (41.7%) e diabete mellito (33.8%)

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In questi pazienti il panno interstiziale causato dal coronavirus diminuisce la superficie ventilante polmonare ancora capace di scambiare l’ossigeno al punto tale da rendere inefficace la ventilazione forzata.

Questi studi aprono il problema di come selezionare i pazienti da mettere sotto ventilazione assistita.

Nel contempo ripropongono con forza la necessità per tutta la popolazione di tenere sotto controllo l’ipertensione arteriosa, il diabete mellito, e di ritornare sul peso corporeo accettabile.

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Safiya Richardson, MD, MPH; Jamie S. Hirsch, MD, MA, MSB; Mangala Narasimhan, DO; et al

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.

JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775

«Importance  There is limited information describing the presenting characteristics and outcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19).

Objective  To describe the clinical characteristics and outcomes of patients with COVID-19 hospitalized in a US health care system.

Design, Setting, and Participants  Case series of patients with COVID-19 admitted to 12 hospitals in New York City, Long Island, and Westchester County, New York, within the Northwell Health system. The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates.

Exposures  Confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample among patients requiring admission.

Main Outcomes and Measures  Clinical outcomes during hospitalization, such as invasive mechanical ventilation, kidney replacement therapy, and death. Demographics, baseline comorbidities, presenting vital signs, and test results were also collected.

Results  A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female). The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%). At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/min, and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%. Outcomes were assessed for 2634 patients who were discharged or had died at the study end point. During hospitalization, 373 patients (14.2%) (median age, 68 years [IQR, 56-78]; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553 (21%) died. As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital. The median postdischarge follow-up time was 4.4 days (IQR, 2.2-9.3). A total of 45 patients (2.2%) were readmitted during the study period. The median time to readmission was 3 days (IQR, 1.0-4.5) for readmitted patients. Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years [IQR, 54-75]), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1).

Conclusions and Relevance  This case series provides characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area.»

«Discussion

To our knowledge, this study represents the first large case series of sequentially hospitalized patients with confirmed COVID-19 in the US. Older persons, men, and those with preexisting hypertension and/or diabetes were highly prevalent in this case series and the pattern was similar to data reported from China. However, mortality rates in this case series were significantly lower, possibly due to differences in thresholds for hospitalization. This study reported mortality rates only for patients with definite outcomes (discharge or death), and longer-term study may find different mortality rates as different segments of the population are infected. The findings of high mortality rates among ventilated patients are similar to smaller case series reports of critically ill patients in the US.

ACEi and ARB medications can significantly increase mRNA expression of cardiac angiotensin-converting enzyme2(ACE2), leading to speculation about the possible adverse, protective, or biphasic effects of treatment with these medications. This is an important concern because these medications are the most prevalent antihypertensive medications among all drug classes. However, this case series design cannot address the complexity of this question, and the results are unadjusted for known confounders, including age, sex, race, ethnicity, socioeconomic status indicators, and comorbidities such as diabetes, chronic kidney disease, and heart failure.

Mortality rates are calculated only for patients who were discharged alive or died by the study end point. This biases our rates toward including more patients who died early in their hospital course. Most patients in this study were still in hospital at the study end point (3066, 53.8%).We expect that as these patients complete their hospital course, reported mortality rates will decline.»


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