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with a median of 60 years of age &#40;IQR 53&#8211;66&#41; and a predominance of male gender &#40;74&#37;&#41;&#46; Patients with a BMI greater than 30 represented 42&#37; of all admissions&#46; The most common comorbid factor was hypertension with a prevalence of 36&#37;&#44; followed by type 2 diabetes mellitus with a prevalence of 23&#37;&#46; However in 26&#37; of cases there was an absence of any known pre-existing medical conditions&#46; A total of 15&#37; of patients were healthcare workers&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients admitted from the ward spent a median of 2 days &#40;IQR 1&#8211;3&#46;75&#41; there prior to ICU admission&#46; The median time interval from the first reported onset of symptoms to ICU admission was fairly consistent at 10 days &#40;IQR 7&#8211;11&#41;&#46; Patients presented with progressive respiratory failure&#44; hypoxaemia and bilateral pulmonary infiltrates on plain radiograph&#46; Invasive mechanical ventilation was provided in 74&#37; 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observable immediately following the first proning &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The information regarding the response similar in the first proning than in the rests was not obtained&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In terms of other organ supports&#44; vasopressors were required in 54&#37; of cases&#44; 59&#37; developed an acute kidney injury &#40;AKI&#41; using KDIGO definitions&#44; and renal replacement therapy was required in 38&#37; of cases&#46; The ICU mortality in our series is 21&#37; out of the 24 patients who have either died or been discharged from critical care to date&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Those patients who required mechanical ventilation &#40;representing the sickest patients&#41; had significantly higher levels throughout ICU admission in CRP&#44; interleukin 6 &#40;IL-6&#41;&#44; D-dimer&#44; white cell count &#40;WCC&#41; and fibrinogen&#44; and significantly lower lymphocyte counts than non-ventilated patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Initial data from the early stages of this pandemic had suggested that unlike SARS-CoV infection&#44; a severe clinical phenotype was manifested only in the elderly and in those with underlying comorbidities&#46; This has not been borne out by our experience&#44; with a significant minority of our ICU patients relatively young and without any pre-existing risk factors&#46; The complex host immunological response to SARS-CoV-2 is not yet fully understood&#44; but studies of SARS-CoV have demonstrated a dysregulated inflammatory response with elevated levels of pro-inflammatory cytokines&#44; along with increased monocyte&#8211;macrophage and neutrophil accumulation in the lungs as being important factors leading to acute lung injury&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">3&#44;4</span></a> Inflammatory markers such as IL-6&#44; D-dimers&#44; CRP&#44; WCC&#44; lymphocyte count and fibrinogen levels were strong discriminators for a requirement for ventilation in our patients with Covid-19 disease whilst Ferritin and LDH levels were not statistically different in patients with and without mechanical ventilation&#46; This finding is not being found in other case series however probably this is related to a limited sample size&#46; D-dimer&#44; CRP and WCC levels showed the greatest statistical significance&#44; indicating that they may be useful surrogate markers for risk stratification for healthcare systems and ICUs looking after Covid-19 patients&#44; where routine IL-6 assays are not available&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter to the Editor
Clinical and biochemical characteristics of patients admitted to ICU with SARS-CoV-2
Características clínicas y bioquímicas de pacientes ingresados en UCI con SARS-CoV-2
A. Blakea, D. Collinsa, E. O’Connora, C. Berginb, A.M. McLaughlinc, I. Martin-Loechesa,
Autor para correspondencia
drmartinloeches@gmail.com

Corresponding author.
a Department of Intensive Care Medicine, St James's Hospital, Dublin, Ireland
b Department of Infectious Diseases, St James's Hospital, Dublin, Ireland
c Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
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Europe and the UK on the characteristics of patients who are admitted to ICU&#44; it is not yet clear and remains a question of some urgency how to identify those patients who are likely to require high levels of critical care supports&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This was a cross-sectional study&#44; conducted during the period from 23 March to 26 April 2020&#46; We have seen a high level of admissions of critically ill patients with Covid-19 pneumonia to our intensive care unit &#40;ICU&#41; over the past 30 days&#46; Herewith&#44; we present the clinical and biochemical characteristics of a consecutive cohort of patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&#41; with polymerase chain reaction &#40;PCR&#41; proven symptomatic Covid-19 infection admitted to our ICU&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Most patients were generally considered young&#44; with a median of 60 years of age &#40;IQR 53&#8211;66&#41; and a predominance of male gender &#40;74&#37;&#41;&#46; Patients with a BMI greater than 30 represented 42&#37; of all admissions&#46; The most common comorbid factor was hypertension with a prevalence of 36&#37;&#44; followed by type 2 diabetes mellitus with a prevalence of 23&#37;&#46; However in 26&#37; of cases there was an absence of any known pre-existing medical conditions&#46; A total of 15&#37; of patients were healthcare workers&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients admitted from the ward spent a median of 2 days &#40;IQR 1&#8211;3&#46;75&#41; there prior to ICU admission&#46; The median time interval from the first reported onset of symptoms to ICU admission was fairly consistent at 10 days &#40;IQR 7&#8211;11&#41;&#46; Patients presented with progressive respiratory failure&#44; hypoxaemia and bilateral pulmonary infiltrates on plain radiograph&#46; Invasive mechanical ventilation was provided in 74&#37; of cases&#44; and 76&#37; of these required intubation within the first 24<span class="elsevierStyleHsp" style=""></span>h of ICU admission&#46; A rapid deterioration in respiratory function over the several hours preceding ICU admission was common&#46; Proning position was utilised in 79&#37; of patients with a median of 6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>16-hour proning sessions provided per patient&#46; Continuous neuromuscular blockade was provided in 86&#37; of mechanically ventilated patients&#46; Inhaled nitric oxide was delivered to 17&#37; of patients&#44; and one patient was referred for extracorporeal membrane oxygenation &#40;ECMO&#41;&#46; Median PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio on admission was 130<span class="elsevierStyleHsp" style=""></span>mmHg &#40;IQR 97&#46;5&#8211;180&#41; reflecting a high proportion of moderate&#8211;severe ARDS&#46; The majority of patients were prone responsive with a median rise in the PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio of 83<span class="elsevierStyleHsp" style=""></span>mmHg &#40;11<span class="elsevierStyleHsp" style=""></span>kPa&#41; observable immediately following the first proning &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The information regarding the response similar in the first proning than in the rests was not obtained&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In terms of other organ supports&#44; vasopressors were required in 54&#37; of cases&#44; 59&#37; developed an acute kidney injury &#40;AKI&#41; using KDIGO definitions&#44; and renal replacement therapy was required in 38&#37; of cases&#46; The ICU mortality in our series is 21&#37; out of the 24 patients who have either died or been discharged from critical care to date&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Those patients who required mechanical ventilation &#40;representing the sickest patients&#41; had significantly higher levels throughout ICU admission in CRP&#44; interleukin 6 &#40;IL-6&#41;&#44; D-dimer&#44; white cell count &#40;WCC&#41; and fibrinogen&#44; and significantly lower lymphocyte counts than non-ventilated patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Initial data from the early stages of this pandemic had suggested that unlike SARS-CoV infection&#44; a severe clinical phenotype was manifested only in the elderly and in those with underlying comorbidities&#46; This has not been borne out by our experience&#44; with a significant minority of our ICU patients relatively young and without any pre-existing risk factors&#46; The complex host immunological response to SARS-CoV-2 is not yet fully understood&#44; but studies of SARS-CoV have demonstrated a dysregulated inflammatory response with elevated levels of pro-inflammatory cytokines&#44; along with increased monocyte&#8211;macrophage and neutrophil accumulation in the lungs as being important factors leading to acute lung injury&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">3&#44;4</span></a> Inflammatory markers such as IL-6&#44; D-dimers&#44; CRP&#44; WCC&#44; lymphocyte count and fibrinogen levels were strong discriminators for a requirement for ventilation in our patients with Covid-19 disease whilst Ferritin and LDH levels were not statistically different in patients with and without mechanical ventilation&#46; This finding is not being found in other case series however probably this is related to a limited sample size&#46; D-dimer&#44; CRP and WCC levels showed the greatest statistical significance&#44; indicating that they may be useful surrogate markers for risk stratification for healthcare systems and ICUs looking after Covid-19 patients&#44; where routine IL-6 assays are not available&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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