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the RRS was reinforced with a second physician&#46; Patient admission to the MCCU was guided by the major&#47;minor ATS&#47;IDSA criteria for severe community pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">All consecutive SARS-CoV-2 positive patients &#40;&#8805;18 years old&#41; admitted to our MCCU were included in the study&#46; A confirmed case of COVID-19 was defined by a positive result on a reverse-transcriptase-polymerase-chain-reaction &#40;RT-PCR&#41; assay of a specimen collected from airway secretion or from a nasopharyngeal swab&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> The first patient was admitted on the 16<span class="elsevierStyleSup">th</span> of March and the last one on the 9<span class="elsevierStyleSup">th</span> of April 2020&#46; Patients were followed until hospital discharge or death&#59; study follow-up was closed 3<span class="elsevierStyleSup">rd</span> of June&#46; Patients were distinguished between those with clinical pneumonia due to SARS-CoV-2 and those who were admitted to MCCU because of other disease unrelated to SARS-CoV-2 positivity&#46; Patients in whom ARDS diagnosis&#44; management and prognosis could not be evaluated due to treatment withdrawal or very early death at CCU admission &#40;&#60;6<span class="elsevierStyleHsp" style=""></span>hours&#41; were excluded from the final analysis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We obtained demographic data&#44; coexisting conditions information&#44; data on clinical symptoms or signs at CCU admission and follow-up&#44; and laboratory and radiological results during CCU stay&#46; All laboratory and radiological assessments were performed at responsible physician discretion&#46; COVID-19 treatments and life support measures were recorded&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Bacterial co-infection at hospital admission was assessed&#46; Nosocomial infection and multi-drug resistant bacteria &#40;MDRB&#41; colonization was proactively sought during CCU stay according to a pre-established infection control program including weekly MDRB surveillance cultures&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> Infections due to opportunistic microorganisms were prospectively discarded in those patients with prolonged invasive mechanical ventilation &#40;&#8805; one week&#41; and signs or symptoms of respiratory or infectious deterioration of unclear origin&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Study definitions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Acute respiratory distress syndrome &#40;ARDS&#41; was defined as acute-onset hypoxemia &#40;ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen &#40;PaO2&#47;FiO2&#41; &#60;<span class="elsevierStyleHsp" style=""></span>300&#41; with bilateral pulmonary opacities on chest imaging not explained by congestive heart failure&#46; ARDS patients who required invasive mechanical ventilation were managed agreeing to the guidelines with a protective ventilation &#40;tidal volume &#8804;6<span class="elsevierStyleHsp" style=""></span>ml&#47;Kg&#44; plateau pressure &#60;<span class="elsevierStyleHsp" style=""></span>30 cmH<span class="elsevierStyleInf">2</span>O and driving pressure &#60;<span class="elsevierStyleHsp" style=""></span>15 cmH<span class="elsevierStyleInf">2</span>O&#41; and rescue therapies when necessary &#40;prone position&#44; recruitment manoeuvres&#44; nitric oxide &#40;NO&#41; and&#47;or extracorporeal membrane oxygenation &#40;ECMO&#41;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Nosocomial infections diagnosis was established according to the Centers for Disease Control criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> Invasive pulmonary aspergillosis was diagnosed according to EORTC criteria modified by Blot <span class="elsevierStyleItalic">et al</span> for critically ill patients&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> CMV reactivation was identified by a clinical picture of sepsis&#47;pneumonia besides the presence of<span class="elsevierStyleHsp" style=""></span>&#62;400 copies&#47;ml in plasma or positive PCR in bronchoalveolar lavage&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> HSV pneumonia was diagnosed in the absence of other aetiology besides positivity for HSV PCR in alveolar fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Descriptive statistics were used to summarize the results&#59; reported as means and standard deviations or medians and interquartile ranges&#44; as appropriate&#46; Categorical variables were expressed as counts and percentages&#46; Categorical variables were compared using the Chi square test&#46; Comparison of numerical variables was performed with the Mann&#8211;Whitney U test&#46; The statistical significance was set at 0&#46;05 &#40;95&#37; confidence interval&#41;&#46; Analysis was performed with SPSS 16&#46;0&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study was approved by our hospital Ethical Committee and informed consent was waived due to the retrospective nature of the study&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Demographic&#44; clinical and laboratory characteristics</span><p id="par0065" class="elsevierStylePara elsevierViewall">During the study period 573 patients were admitted to hospital for COVID-19 &#40;at present 351 &#40;61&#37;&#41; had been discharged&#44; 88 &#40;15&#37;&#41; had died and 150 &#40;26&#37;&#41; remain hospitalized&#41;&#46; Seventy-four &#40;13&#37;&#41; patients were admitted to CCU&#59; 58 to medical CCU and 16 to surgical CCU&#46; Six patients were admitted to MCCU because of a disease unrelated to SARS-COV-2 positivity and therefore were excluded from the analysis&#46; Four patients were initially admitted to MCCU and were suffering respiratory failure&#44; but due to do not resuscitate orders &#40;DNRO&#41; supportive treatment was withdrawn because of the following situations&#58; patient admitted because of traumatic brain injury who developed irreversible brain damage&#44; patient with malignant hemopathy non-responding to quemotherapy&#44; patient with severe co-morbidities who was not intubated and patient with irreversible post-anoxic encephalopathy due to cardiorespiratory arrest after iatrogenic haemopericardium&#46; Three patients died in less of 6<span class="elsevierStyleHsp" style=""></span>hours because of haemorrhagic shock&#44; fulminant myocarditis and non-responding asthma crisis respectively&#59; ARDS diagnosis and management could not be evaluated and therefore these patients were not included&#46; And one SDRA patient was RT-PCR negative in four different determinations and COVID-19 diagnosis was finally obtained by means of immunoglobulin assay &#40;positive IgM and IgG followed by negative IgM&#47;positive IgG&#41;&#59; this patient was excluded from the analysis&#46; Therefore&#44; data concerning 44 patients admitted to MCCU under the care of intensivist will be presented in this study &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Demographic and clinical characteristics are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Most patients were male &#40;n 32&#44; 72&#46;7&#37;&#41;&#44; mean age was 61&#46;5 &#91;53&#46;2-67&#93;&#46; Arterial hypertension &#40;23&#44; 52&#46;3&#37;&#41;&#44; dyslipidaemia &#40;16&#44; 36&#46;4&#37;&#41; and diabetes &#40;6&#44; 13&#46;6&#37;&#41; were the most frequent co-morbidities&#46; Time in days between the onset of symptoms and hospital admission was 6&#46;5 &#91;5-8&#93; and between hospital admission and MCCU admission was 2 &#91;0-4&#93;&#46; SAPS3 punctuation was 50 &#91;43&#46;5-59&#93;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Laboratory findings at MCCU admission are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Inflammatory biomarkers were elevated in most patients&#46; However&#44; only 8 patients &#40;18&#46;2&#37;&#41; presented with IL<span class="elsevierStyleInf">6</span> above 200 pg&#47;ml&#46; Five patients &#40;11&#46;4&#37;&#41; had procalcitonin &#40;PCT&#41; higher than 1ng&#47;ml although none bacterial co-infection could be demonstrated in these patients&#46; C-reactive protein &#40;CRP&#41; had a more homogeneous behaviour&#44; all patients had values above the normal range and only 7 &#40;16&#37;&#41; were below 100<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#46; Ferritin was available only in four patients&#46; Albumin below or equal to 3<span class="elsevierStyleHsp" style=""></span>g&#47;dl was present in 8 patients &#40;18&#46;2&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Lymphopenia &#40;&#8804;1000 cell&#47;mm<span class="elsevierStyleSup">3</span>&#41; was detected in most of the patients &#40;86&#46;4&#37;&#44; n 38&#41;&#59; severe lymphopenia &#40;&#8804;500 cell&#47;mm<span class="elsevierStyleSup">3</span>&#41; occurred in 7 patients &#40;16&#37;&#41;&#46; Thrombocytopenia &#40;&#8804;150&#46;000 cell&#47;mm<span class="elsevierStyleSup">3</span>&#41; was present in 7 patients but only one case had less than 100&#46;000 cell&#47;mm<span class="elsevierStyleSup">3</span>&#46; Augmented D-dimers &#40;&#8805;500 ng&#47;ml&#41; occurred in 28 patients &#40;63&#46;6&#37;&#41; but only 3 cases &#40;6&#46;8&#37;&#41; were higher than 3&#46;000 ng&#47;ml&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">All patients had a bilateral diffuse infiltrate on the initial chest radiograph&#46; Median PaO<span class="elsevierStyleInf">2</span>&#58;FiO<span class="elsevierStyleInf">2</span> ratio was 83 &#91;60&#46;6-117&#93;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">COVID-19 treatments and life support measures</span><p id="par0090" class="elsevierStylePara elsevierViewall">Almost all patients were treated with chloroquine and azithromycine &#40;100&#37; and 95&#46;5&#37; respectively&#41;&#46; Other treatments directed towards the virus are depicted in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Immunomodulation was attempted in all patients except two &#40;95&#46;5&#37;&#41;&#59; steroids in 35 cases &#40;79&#46;5&#37;&#41; &#40;&#8805;1<span class="elsevierStyleHsp" style=""></span>mg&#47;Kg&#47;day in 93&#46;2&#37; of all treated patients&#41;&#44; tocilizumab in 36 cases &#40;81&#46;8&#37;&#41; and baricitinib in 4 cases &#40;9&#37;&#41;&#46; All patients were under prophylactic low molecular weight heparin and only two received therapeutic anticoagulant treatment due to the presence of an aortic prosthetic valve and to the development of a venous thrombosis related to the presence of a central catheter&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Thirty-four patients needed invasive mechanical ventilation &#40;77&#46;3&#37;&#41;&#59; of them 13 &#40;38&#37;&#41; were intubated the same day they were admitted to the MCCU and 21 &#40;67&#46;8&#37;&#41; were intubated after a median of 2 &#91;1-2&#93; days of delay&#46; Not intubated patients and those with a delay until intubation were supported with high flow nasal cannula &#40;HFNC&#41;&#46; None patient received non-invasive mechanical ventilation&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Among ventilated patients all coupled with moderate-severe ARDS definition &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> &#60;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46; All mechanically ventilated patients received protective ventilation&#46; Prone-position ventilation was performed in 33 patients &#40;97&#37;&#41; &#40;median of 3 sessions &#91;2-5&#93; per patient&#41; achieving an improvement in oxygenation in all patients &#40;at least temporarily&#41;&#44; recruitment manoeuvres were realized in 25 patients &#40;73&#46;5&#37;&#41; and nitric oxide was administered to 7 patients &#40;20&#46;6&#37;&#41;&#46; Extracorporeal membrane oxygenation &#40;ECMO&#41; was used in 3 cases &#40;8&#46;8&#37;&#41;&#59; 2 veno-venous systems and 1 veno-arterial system because of heart failure&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Norepinephrine was used in 28 patients &#40;63&#46;6&#37;&#41; because of hypotension unresponsive to fluid administration &#40;and avoiding fluid overload in SDRA context&#41; but none of them attended with serum lactate<span class="elsevierStyleHsp" style=""></span>&#62; 2 mmol&#47;l&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Only one patient under VA-ECMO needed extracorporeal renal replacement&#46; However 36&#37; of our patients &#40;n 16&#41; coupled with AKIN stage 1 criteria due to urine output &#60;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>ml&#47;Kg during 6<span class="elsevierStyleHsp" style=""></span>hours&#46; All patients responded to fluid administration and none of them progressed to more severe AKIN stages&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Microbiological and infectious diseases assessment</span><p id="par0115" class="elsevierStylePara elsevierViewall">None bacterial co-infection could be demonstrated at hospital or ICU admission&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">ICU-nosocomial infection was detected 16 times in 13 patients &#40;29&#46;5&#37;&#41;&#46; Ventilator-associated pneumonia &#40;VAP&#41; was the most common infection&#59; 8 of 34 ventilated patients &#40;23&#46;5&#37;&#41;&#46; Ventilated-associated tracheobronchitis &#40;TAVM&#41; was diagnosed in 1 patient &#40;2&#46;9&#37;&#41;&#46; Catheter-related bacteraemia &#40;CRB&#41; occurred in three patients &#40;6&#46;8&#37;&#41; and primary bacteremia in one patient &#40;2&#46;3&#37;&#41;&#46; Most common aetiologies were&#58; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> &#40;n 7&#59; 46&#46;7&#37;&#41;&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;n 3&#59; 20&#37;&#41; and <span class="elsevierStyleItalic">Escherichia coli</span> &#40;n 1&#59; 6&#46;7&#37;&#41;&#46; Opportunistic infections were diagnosed in 5 patients&#59; 4 cases of HSV pneumonia &#40;one of them co-infecting with CMV&#41; and 1 pulmonary invasive aspergillosis&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Outcomes</span><p id="par0125" class="elsevierStylePara elsevierViewall">At study closing all patients had been discharged from the CCU and only two &#40;4&#46;5&#37;&#41; remained in hospital ward&#46; MCCU length of stay was 18 days &#91;10-27&#93; and hospital length of stay was 28 days &#91;19-39&#93;&#46; Mortality at study closing was 20&#44;5&#37; &#40;n 9&#41;&#46; All deaths occurred in CCU after a median of 17 days &#91;12-24&#93;&#46; If we include all COVID19 patients &#40;SARS-CoV-2 positive without disease and patients with DNRO&#41; mortality will rise to 28&#37; &#40;16 deaths in 57 patients&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Mechanical ventilation duration for the 34 ventilated patients was 16 days &#91;11-28&#93;&#46; All ventilated patients were treated with neuromuscular blockers for a median of 5 days &#91;3-14&#93;&#46; Tracheostomy was performed in ten patients &#40;29&#46;4&#37;&#41; after a median of 21 days &#91;19&#46;3-23&#46;5&#93;&#46; Five patients &#40;14&#46;7&#37;&#41; presented spontaneous pneumothorax during mechanical ventilation&#46; Mortality among ARDS ventilated patients was 26&#46;5&#37;&#46; Death in ventilated patients occurred after a median of 17 days &#91;12-24&#93;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Four patients &#40;9&#37;&#41; required readmission to the MCCU after discharge&#46; Three of them presented haemorrhagic shock related with anticoagulation treatment and were managed with arterial embolization&#46; The fourth patient was readmitted because of respiratory worsening due to pulmonary fibrosis secondary to ARDS and finally died&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">In this time of uncertainty about the management and prognosis of critically ill patients due to COVID-19 we aimed to present our experience&#46; Thirteen per cent of COVID-19 patients admitted to hospital had to be treated in CCU&#46; ARDS due to COVUD-19 could be analysed in 44 patients from MCCU&#44; 77&#46;2&#37; of these patients undergo invasive mechanical ventilation and 23&#46;5&#37; of them finally died&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">SARS-CoV-2 directed treatment and immunomodulation was administered to our patients attending to incoming data from literature and <span class="elsevierStyleItalic">in vitro</span> results&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> However&#44; as previously reported by other authors&#44; IL<span class="elsevierStyleInf">6</span>&#44; CRP and PCT figures were not as high as described in other circumstances such as septic shock&#44; severe pancreatitis or burn patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">22&#8211;25</span></a> Even more&#44; the most remarkable finding was the low lymphopenia present in most of the patients&#46; High dose steroids &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;Kg&#41; and tocilizumab were administered to the majority of the patients&#44; and nowadays several critical voices are rising against the use of treatments lacking any medical evidence of efficacy and that entail potential harmful&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> In fact&#44; nosocomial infections&#44; mainly ventilator-associated pneumonia&#44; were three times more common in COVID-19 patients than previously registered in our MCCU&#46; Only Yang <span class="elsevierStyleItalic">et al</span> reported data concerning nosocomial infections in CCU patients&#44; describing a prevalence of 22&#37; among their patients&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Most patients admitted to CCU needed intubation and mechanical ventilation &#40;77&#37;&#41; and this seems to be in agreement with published series from Italy and USA &#40;88&#37;&#44; 71&#37; and 75&#37; respectively&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">8&#44;9&#44;11</span></a> Heterogeneous and even lower percentages &#40;from 71&#37; to 30&#37;&#41; were reported by researchers from China&#44;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#8211;6</span></a> but in at least one of the published series a deficit in the number of CCU beds and ventilators was admitted&#44; affecting more than 50&#37; of potential patients&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Mortality rate among COVID-19 ARDS ventilated patients is one of the most disheartening published results&#46; Chinese mortality among critically ill patients was reported from 67 to 97&#37; of ventilated patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;5</span></a> Mortality from 320 ventilated patients in New York was informed to be 88&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Unfinished information from Italy &#40;58&#37; of critically ill patients remained in CCU at study publication&#41; related a mortality of 26&#37;&#44; however as mortality among COVID-19 ventilated patients seems to be late &#40;17 days &#91;12-24&#93; after mechanical ventilation onset in our series&#41; we should beware of possible changes&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> The lower mortality &#40;23&#46;5&#37;&#41; observed in our series could be explained by some aspects&#46; First&#44; by means of the implementation of a contingency plan&#44; CCU beds and mechanical ventilation were available for all candidates&#46; Second&#44; our RRS was able to early detect patients at risk &#40;closely working with emergency specialists&#44; internists&#44; and pulmonologists&#41; and patients were admitted to MCCU after a median of 2 &#91;0-4&#93; days in hospital&#46; Third&#44; in agreement with some experts recommendations&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> no delay for intubation and mechanical ventilation was admissible when excessive respiratory work appeared&#44; patients were intubated after a median of 2 days &#91;1-2&#93; in MCCU&#46; And finally&#44; 97&#37; of our ventilated patients needed ventilation in the prone position&#46; The closest percentage of ventilation in the prone position for ARDS COVID19 patients comes from the publication from Mart&#237;n-Loeches et al&#44; with a rate of 79&#37; in 29 ventilated patients and a final mortality rate of 15&#37; &#40;5 deaths in 39 patients&#44; 29 under mechanical ventilation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> However&#44; data from Italy indicate a use of the prone position in only 27&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> The use of this manoeuvre was even lower in China &#40;11&#46;5&#37; of patients&#41; and Richardson <span class="elsevierStyleItalic">et al</span> do not report data regarding the use of this ventilator intervention&#46; In line with the results from clinical trials <a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a>we do believe in the beneficial effects that these manoeuvres have in the ARDS COVID-19 patient&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; This is a relatively small series of COVID-19 patients coming from a single hospital&#46; Nevertheless&#44; most published data comes from countries with very different health systems from ours and most published series remain unfinished in patient follow-up&#44; and therefore we decided to present and share our results&#46; The effect on the incidence of nosocomial infection and the potential relationship with immunosuppressive treatment will require larger studies or at least a comparison with similar patients in terms of mechanical ventilation duration and presence of ARDS&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In conclusion&#44; COVID-19 ARDS patient management has been challenging for critical care specialists&#46; All technological and knowledge resources have been required but finally mortality rate has not been as high as described in other publications&#46; Finally&#44; we would like to share our doubts about the relevance of the immunosuppressive treatment in this infectious disease and about its potential implication in the observed higher incidence of nosocomial infection&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Authors contributions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Dr Ram&#237;rez had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis&#46; Drs Grasselli and Zangrillo equally contributed to this work&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Concept and design&#58; Ram&#237;rez&#44; Gord&#243;n&#44; Mart&#237;n-Cerezulea&#44; Castellanos</p><p id="par0180" class="elsevierStylePara elsevierViewall">Acquisition&#44; analysis&#44; or interpretation of data&#58; Ram&#237;rez&#44; Gord&#243;n&#44; Mart&#237;n-Cerezulea&#44; Villarreal&#44; Padr&#243;s&#44; Sancho&#44; Molina&#44; Leiva&#44; Gimeno</p><p id="par0185" class="elsevierStylePara elsevierViewall">Drafting of the manuscript&#58; Ram&#237;rez&#44; Gord&#243;n</p><p id="par0190" class="elsevierStylePara elsevierViewall">Critical revision of the manuscript&#58; Ramirez&#44; Castellanos</p><p id="par0195" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; Gord&#243;n&#44; Mart&#237;n-Cerezuela&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165"><span class="elsevierStyleBold">Funding&#47;Support</span></span><p id="par0200" class="elsevierStylePara elsevierViewall">No funding to be declare</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170"><span class="elsevierStyleBold">Conflict of interest disclosure</span></span><p id="par0205" class="elsevierStylePara elsevierViewall">No disclosures regarding this publication from any author</p></span></span>"
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              "titulo" => "Study population&#44; setting and data collection"
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    "fechaRecibido" => "2020-05-07"
    "fechaAceptado" => "2020-06-12"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Information from critically ill coronavirus disease 2019 &#40;COVID-19&#41; patients is limited and in many cases coming from health systems approaches different from the national public systems existing in most countries in Europe&#46; Besides&#44; patient follow-up remains incomplete in many publications&#46; Our aim is to characterize acute respiratory distress syndrome &#40;ARDS&#41; patients admitted to a medical critical care unit &#40;MCCU&#41; in a referral hospital in Spain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Retrospective case series of consecutive ARDS COVID-19 patients admitted and treated in our MCCU&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">36-bed MCCU in referral tertiary hospital&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients and participants</span><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">SARS-CoV-2 infection confirmed by real-time reverse transcriptase&#8211;polymerase chain reaction &#40;RT-PCR&#41; assay of nasal&#47;pharyngeal swabs&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">None</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables of interest</span><p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical data were collected&#44; including data on clinical management&#44; respiratory failure&#44; and patient mortality&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">Forty-four ARDS COVID-19 patients were included in the study&#46; Median age was 61&#46;50 &#40;53&#46;25 &#8211; 67&#41; years and most of the patients were male &#40;72&#46;7&#37;&#41;&#46; Hypertension and dyslipidemia were the most frequent co-morbidities &#40;52&#46;3 and 36&#46;4&#37; respectively&#41;&#46; Steroids &#40;1mg&#47;Kg&#47;day&#41; and tocilizumab were administered in almost all patients &#40;95&#46;5&#37;&#41;&#46; 77&#46;3&#37; of the patients needed invasive mechanical ventilation for a median of 16 days &#91;11-28&#93;&#46; Prone position ventilation was performed in 33 patients &#40;97&#37;&#41; for a median of 3 sessions &#91;2-5&#93; per patient&#46; Nosocomial infection was diagnosed in 13 patients &#40;29&#46;5&#37;&#41;&#46; Tracheostomy was performed in ten patients &#40;29&#46;4&#37;&#41;&#46; At study closing all patients had been discharged from the CCU and only two &#40;4&#46;5&#37;&#41; remained in hospital ward&#46; MCCU length of stay was 18 days &#91;10-27&#93;&#46; Mortality at study closing was 20&#46;5&#37; &#40;n 9&#41;&#59; 26&#46;5&#37; among ventilated patients&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">The seven-week period in which our MCCU was exclusively dedicated to COVID-19 patients has been challenging&#46; Despite the severity of the patients and the high need for invasive mechanical ventilation&#44; mortality was 20&#46;5&#37;&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La informaci&#243;n de pacientes cr&#237;ticos con enfermedad por coronavirus 2019 &#40;COVID-19&#41; es limitada y&#44; en muchos casos&#44; proviene de sistemas de salud diferentes a la organizaci&#243;n p&#250;blica de la mayor&#237;a de los pa&#237;ses de Europa&#46; Adem&#225;s&#44; el seguimiento del paciente sigue siendo incompleto en muchas publicaciones&#46; Nuestro objetivo es caracterizar a los pacientes con s&#237;ndrome de distres respiratorio agudo &#40;SDRA&#41; ingresados en una unidad de cuidados cr&#237;ticos m&#233;dicos &#40;MCCU&#41; en un hospital de referencia en Espa&#241;a&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">Serie retrospectiva de casos de pacientes consecutivos con SDRA por COVID-19 ingresados y tratados en nuestra MCCU&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Lugar</span><p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">UCC de 36 camas en un hospital terciario de referencia</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes y participantes</span><p id="spar0170" class="elsevierStyleSimplePara elsevierViewall">Infecci&#243;n por SARS-CoV-2 confirmada por ensayo en tiempo real de la transcriptasa inversa-reacci&#243;n en cadena de la polimerasa &#40;RT-PCR&#41; de hisopos nasales&#47;far&#237;ngeos&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0175" class="elsevierStyleSimplePara elsevierViewall">Ninguna</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Principales variables de inter&#233;s</span><p id="spar0180" class="elsevierStyleSimplePara elsevierViewall">Se recopilaron datos demogr&#225;ficos y cl&#237;nicos&#44; incluidos datos sobre manejo cl&#237;nico&#44; insuficiencia respiratoria y mortalidad del paciente&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0185" class="elsevierStyleSimplePara elsevierViewall">Cuarenta y cuatro pacientes con SDRA por COVID-19 fueron incluidos en el estudio&#46; La mediana de edad fue de 61&#46;50 &#40;53&#46;25 - 67&#41; a&#241;os y la mayor&#237;a de los pacientes eran hombres &#40;72&#46;7&#37;&#41;&#46; La hipertensi&#243;n y la dislipidemia fueron las comorbilidades m&#225;s frecuentes &#40;52&#44;3 y 36&#44;4&#37;&#44; respectivamente&#41;&#46; Se administraron esteroides &#40;1mg&#47;kg&#47;d&#237;a&#41; y tocilizumab en casi todos los pacientes &#40;95&#44;5&#37;&#41;&#46; El 77&#44;3&#37; de los pacientes necesitaron ventilaci&#243;n mec&#225;nica invasiva durante una mediana de 16 d&#237;as &#91;11-28&#93;&#46; La ventilaci&#243;n en posici&#243;n prono se realiz&#243; en 33 pacientes &#40;97&#37;&#41; con una mediana de 3 sesiones &#91;2-5&#93; por paciente&#46; Se diagnostic&#243; una infecci&#243;n nosocomial en 13 pacientes &#40;29&#44;5&#37;&#41;&#46; La traqueotom&#237;a se realiz&#243; en diez pacientes &#40;29&#44;4&#37;&#41;&#46; Al cierre del estudio&#44; todos los pacientes hab&#237;an sido dados de alta de la MCCU y solo dos permanec&#237;an hospitalizados&#46; La estancia en MCCU fue de 18 d&#237;as &#91;10-27&#93;&#46; La mortalidad al cierre del estudio fue del 20&#44;5&#37; &#40;n 9&#41;&#59; 26&#46;5&#37; para pacientes ventilados&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0190" class="elsevierStyleSimplePara elsevierViewall">El per&#237;odo de siete semanas en el que nuestra MCCU se dedic&#243; exclusivamente a pacientes con COVID-19 ha sido un gran desaf&#237;o&#46; A pesar de la gravedad de los pacientes y la elevada necesidad de ventilaci&#243;n mec&#225;nica invasiva&#44; la mortalidad fue del 20&#44;5&#37;&#46;</p></span>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;52&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;870&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;13&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;14&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;703&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dyslipidemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;36&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;38&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;634&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic corticotherapy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;432&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Immunodeficiency&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;432&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pneumopathy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 &#40;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;328&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Delay between onset of symptoms and hospitalization</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46;5 &#40;5 &#8211; 8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;4 &#8211; 7&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;5 &#40;6 &#8211; 9&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;050&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Delay between hospitalization and MCCU admission</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2 &#40;0 &#8211; 4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;5 &#40;0 &#8211; 3&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;1&#46;75 &#8211; 5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;142&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">SAPS3</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">50 &#40;43&#46;50 &#8211; 59&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">53 &#40;42&#46;75 &#8211; 62&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">45&#46;5 &#40;44 &#8211; 49&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;052&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Norepinephrine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">28 &#40;63&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27 &#40;79&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">RRT</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;2&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;703&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">MCCU stay</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14 &#40;8 &#8211; 23&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">19 &#40;13 &#8211; 25&#46;75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;4&#46;75 &#8211; 8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hospital stay</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">23 &#40;15 &#8211; 28&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">26 &#40;19&#46;29&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17&#46;5 &#40;14&#46;25 &#8211; 22&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;079&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Mortality</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8 &#40;18&#46;1&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;23&#46;5&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;080&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">251&#46;7 &#40;142&#46;9 &#8211; 330&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Ferritin &#40;ng&#47;ml&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Albumin &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3&#46;3 &#40;3&#46;15 &#8211; 3&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46;3 &#40;3 &#8211; 3&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">3&#46;5 &#40;3&#46;35 &#8211; 3&#46;75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;065&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">LDH &#40;UI&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leukocytes&#40;&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;685 &#40;5&#44;227 &#8211; 8&#44;505&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;182&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lymphocytes&#40;&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">700 &#40;535 &#8211; 825&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">690 &#40;530 &#8211; 780&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">795 &#40;635 &#8211; 1&#44;037&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Platelets &#40;&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">206&#44;000 &#40;172&#44;000 &#8211; 271&#44;000&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">273&#44;500 &#40;244&#44;500 &#8211; 301&#44;750&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;036&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D-dimers &#40;ng&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">825 &#40;509 &#8211; 1&#44;282&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">516 &#40;329&#46;5 &#8211; 812&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lopinavir&#47;ritonavir&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Remdesivir&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;331&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Baricitinib&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;172&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Interferon &#946;-1b&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;61&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;920&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tocilizumab&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">29 &#40;85&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vitamin C&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;557&nbsp;\t\t\t\t\t\t\n
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                  "referenciaCompleta" => "WHO&#46; Coronavirus disease&#46; World Heal Organ &#91;Internet&#93;&#46; 2020&#59; 2019&#40;March&#41;&#58;2633&#46; Available from&#58; https&#58;&#47;&#47;www&#46;who&#46;int&#47;emergencies&#47;diseases&#47;novel-coronavirus-2019&#46;"
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                  "referenciaCompleta" => "Covid- I&#46; Informe sobre la situaci&#243;n de COVID-19 en Espa&#241;a&#46; 2020&#59;1-15&#46; Available from&#58; https&#58;&#47;&#47;www&#46;mscbs&#46;gob&#46;es&#47;profesionales&#47;saludPublica&#47;ccayes&#47;alertasActual&#47;nCov-China&#47;situacionActual&#46;htm&#46;"
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                      "titulo" => "Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#40;SEMICYUC&#41; for the management of adult critically ill patients in the coronavirus disease &#40;COVID-19&#41; &#91;published online ahead of print&#44; 2020 Apr 8&#93;"
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                          "etal" => true
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                            0 => "Ballesteros Sanz M&#193;"
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                  "contribucion" => array:1 [
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                      "titulo" => "Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan China&#58; a single-centered&#44; retrospective&#44; observational study"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "X&#46; Yang"
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                    0 => array:1 [
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                      "titulo" => "Clinical Characteristics of 138 Hospitalized Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan China"
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Acute respiratory distress syndrome due to COVID-19. Clinical and prognostic features from a medical Critical Care Unit in Valencia, Spain
Síndrome de dificultad respiratoria aguda asociado a la COVID-19. Características clínicas y de pronóstico en una unidad de cuidados intensivos de Valencia, España
P. Ramíreza,
Autor para correspondencia
Ramirez_pau@gva.es

Autor para correspondencia.
, M. Gordóna, M. Martín-Cerezuelaa, E. Villarreala, E. Sanchoa, M. Padrósa, J. Frasquetb, G. Leyvaa, I. Molinaa, M. Barriosa, S. Gimenoa, Á. Castellanosa
a Critical care department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
b Microbiology Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
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        "titulo" => "S&#237;ndrome de dificultad respiratoria aguda asociado a la COVID-19&#46; Caracter&#237;sticas cl&#237;nicas y de pron&#243;stico en una unidad de cuidados intensivos de Valencia&#44; Espa&#241;a"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Since the initial identification of SARS-CoV-2 in Wuhan the virus has worldwide widespread causing more than three million infected patients and more than two hundred and thousand deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> Spain has become the most affected European country by the pandemic with more than two hundred and thousand people affected and a mortality rate currently situated at 11&#44;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Consequently&#44; critical care resources have been intensely exploited and clinical recommendations have been created&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> However&#44; accurate information concerning critically ill COVID-19 patients is scarce and in most cases incomplete&#46; Although national and local registers are underway&#44; published series come mainly from China and USA&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#8211;10</span></a> In those studies critical care unit &#40;CCU&#41; admission ranged from 7 to 14&#37;&#44; invasive mechanical ventilation was used in 29&#37; to 75&#37; of these critically ill patients and mortality of ventilated patients was extremely variable&#44; ranging from 12&#37; to 81&#37;&#46; Public and private health systems in those countries may differ considerably from our national approach and therefore epidemiological extrapolation is hazardous&#46; Information coming from Italy seems to be more resembling to our situation&#59; however 58&#37; of the critically ill patients included in the Italian report were still in the CCU at the end of the follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> At this point&#44; the reported mortality rate &#40;26&#37;&#41; could undergo major changes&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">This present study aimed at reporting a complete critically ill COVID-19 patient series from a CCU of a tertiary hospital&#44; Hospital Universitario y Polit&#233;cnico la Fe&#44; from Valencian Community&#44; Spain&#46; Our main objective was to assess COVID-19 ARDS patient&#39;s management and prognosis&#46; Valencian Community has nearly five million inhabitants and&#44; unlike other areas of Spain&#44; the expansion of SARS-CoV-2 has been moderate&#46; Right now 11&#44;254 people have been identified as positive to SARS-CoV-2 &#40;225 positives every 100&#44;000 habitants&#41; and 601 patients have been admitted to CCUs&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> We present a detailed description and follow-up of all critically ill patients admitted to our medical critical care unit &#40;MCCU&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110"><span class="elsevierStyleBold">Methods</span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Study population&#44; setting and data collection</span><p id="par0015" class="elsevierStylePara elsevierViewall">This is a retrospective&#44; unicentric&#44; and observational study&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Hospital Universitario y Polit&#233;cnico la Fe has two critical care units for adults&#59; a 36-bed medical critical care unit &#40;MCCU&#41; carried by intensivists and a 36-bed surgical critical care unit &#40;SCCU&#41; carried by anaesthesiologists in which patients recovering from surgery or severe trauma are admitted&#46; Due to SARS-CoV-2 pandemics COVID-19 patients were also admitted to the SCCU once all MCCU beds were occupied&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">MCCU has a rapid response service &#40;RRS&#41; that daily evaluates patients admitted to the ward and identifies those who&#44; due to a high NEWS score punctuation&#44; would be eligible for admission to the unit&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> During the SARS-CoV-2 pandemic&#44; the RRS was reinforced with a second physician&#46; Patient admission to the MCCU was guided by the major&#47;minor ATS&#47;IDSA criteria for severe community pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">All consecutive SARS-CoV-2 positive patients &#40;&#8805;18 years old&#41; admitted to our MCCU were included in the study&#46; A confirmed case of COVID-19 was defined by a positive result on a reverse-transcriptase-polymerase-chain-reaction &#40;RT-PCR&#41; assay of a specimen collected from airway secretion or from a nasopharyngeal swab&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> The first patient was admitted on the 16<span class="elsevierStyleSup">th</span> of March and the last one on the 9<span class="elsevierStyleSup">th</span> of April 2020&#46; Patients were followed until hospital discharge or death&#59; study follow-up was closed 3<span class="elsevierStyleSup">rd</span> of June&#46; Patients were distinguished between those with clinical pneumonia due to SARS-CoV-2 and those who were admitted to MCCU because of other disease unrelated to SARS-CoV-2 positivity&#46; Patients in whom ARDS diagnosis&#44; management and prognosis could not be evaluated due to treatment withdrawal or very early death at CCU admission &#40;&#60;6<span class="elsevierStyleHsp" style=""></span>hours&#41; were excluded from the final analysis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We obtained demographic data&#44; coexisting conditions information&#44; data on clinical symptoms or signs at CCU admission and follow-up&#44; and laboratory and radiological results during CCU stay&#46; All laboratory and radiological assessments were performed at responsible physician discretion&#46; COVID-19 treatments and life support measures were recorded&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Bacterial co-infection at hospital admission was assessed&#46; Nosocomial infection and multi-drug resistant bacteria &#40;MDRB&#41; colonization was proactively sought during CCU stay according to a pre-established infection control program including weekly MDRB surveillance cultures&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> Infections due to opportunistic microorganisms were prospectively discarded in those patients with prolonged invasive mechanical ventilation &#40;&#8805; one week&#41; and signs or symptoms of respiratory or infectious deterioration of unclear origin&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Study definitions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Acute respiratory distress syndrome &#40;ARDS&#41; was defined as acute-onset hypoxemia &#40;ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen &#40;PaO2&#47;FiO2&#41; &#60;<span class="elsevierStyleHsp" style=""></span>300&#41; with bilateral pulmonary opacities on chest imaging not explained by congestive heart failure&#46; ARDS patients who required invasive mechanical ventilation were managed agreeing to the guidelines with a protective ventilation &#40;tidal volume &#8804;6<span class="elsevierStyleHsp" style=""></span>ml&#47;Kg&#44; plateau pressure &#60;<span class="elsevierStyleHsp" style=""></span>30 cmH<span class="elsevierStyleInf">2</span>O and driving pressure &#60;<span class="elsevierStyleHsp" style=""></span>15 cmH<span class="elsevierStyleInf">2</span>O&#41; and rescue therapies when necessary &#40;prone position&#44; recruitment manoeuvres&#44; nitric oxide &#40;NO&#41; and&#47;or extracorporeal membrane oxygenation &#40;ECMO&#41;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Nosocomial infections diagnosis was established according to the Centers for Disease Control criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> Invasive pulmonary aspergillosis was diagnosed according to EORTC criteria modified by Blot <span class="elsevierStyleItalic">et al</span> for critically ill patients&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> CMV reactivation was identified by a clinical picture of sepsis&#47;pneumonia besides the presence of<span class="elsevierStyleHsp" style=""></span>&#62;400 copies&#47;ml in plasma or positive PCR in bronchoalveolar lavage&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> HSV pneumonia was diagnosed in the absence of other aetiology besides positivity for HSV PCR in alveolar fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Descriptive statistics were used to summarize the results&#59; reported as means and standard deviations or medians and interquartile ranges&#44; as appropriate&#46; Categorical variables were expressed as counts and percentages&#46; Categorical variables were compared using the Chi square test&#46; Comparison of numerical variables was performed with the Mann&#8211;Whitney U test&#46; The statistical significance was set at 0&#46;05 &#40;95&#37; confidence interval&#41;&#46; Analysis was performed with SPSS 16&#46;0&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study was approved by our hospital Ethical Committee and informed consent was waived due to the retrospective nature of the study&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Demographic&#44; clinical and laboratory characteristics</span><p id="par0065" class="elsevierStylePara elsevierViewall">During the study period 573 patients were admitted to hospital for COVID-19 &#40;at present 351 &#40;61&#37;&#41; had been discharged&#44; 88 &#40;15&#37;&#41; had died and 150 &#40;26&#37;&#41; remain hospitalized&#41;&#46; Seventy-four &#40;13&#37;&#41; patients were admitted to CCU&#59; 58 to medical CCU and 16 to surgical CCU&#46; Six patients were admitted to MCCU because of a disease unrelated to SARS-COV-2 positivity and therefore were excluded from the analysis&#46; Four patients were initially admitted to MCCU and were suffering respiratory failure&#44; but due to do not resuscitate orders &#40;DNRO&#41; supportive treatment was withdrawn because of the following situations&#58; patient admitted because of traumatic brain injury who developed irreversible brain damage&#44; patient with malignant hemopathy non-responding to quemotherapy&#44; patient with severe co-morbidities who was not intubated and patient with irreversible post-anoxic encephalopathy due to cardiorespiratory arrest after iatrogenic haemopericardium&#46; Three patients died in less of 6<span class="elsevierStyleHsp" style=""></span>hours because of haemorrhagic shock&#44; fulminant myocarditis and non-responding asthma crisis respectively&#59; ARDS diagnosis and management could not be evaluated and therefore these patients were not included&#46; And one SDRA patient was RT-PCR negative in four different determinations and COVID-19 diagnosis was finally obtained by means of immunoglobulin assay &#40;positive IgM and IgG followed by negative IgM&#47;positive IgG&#41;&#59; this patient was excluded from the analysis&#46; Therefore&#44; data concerning 44 patients admitted to MCCU under the care of intensivist will be presented in this study &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Demographic and clinical characteristics are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Most patients were male &#40;n 32&#44; 72&#46;7&#37;&#41;&#44; mean age was 61&#46;5 &#91;53&#46;2-67&#93;&#46; Arterial hypertension &#40;23&#44; 52&#46;3&#37;&#41;&#44; dyslipidaemia &#40;16&#44; 36&#46;4&#37;&#41; and diabetes &#40;6&#44; 13&#46;6&#37;&#41; were the most frequent co-morbidities&#46; Time in days between the onset of symptoms and hospital admission was 6&#46;5 &#91;5-8&#93; and between hospital admission and MCCU admission was 2 &#91;0-4&#93;&#46; SAPS3 punctuation was 50 &#91;43&#46;5-59&#93;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Laboratory findings at MCCU admission are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Inflammatory biomarkers were elevated in most patients&#46; However&#44; only 8 patients &#40;18&#46;2&#37;&#41; presented with IL<span class="elsevierStyleInf">6</span> above 200 pg&#47;ml&#46; Five patients &#40;11&#46;4&#37;&#41; had procalcitonin &#40;PCT&#41; higher than 1ng&#47;ml although none bacterial co-infection could be demonstrated in these patients&#46; C-reactive protein &#40;CRP&#41; had a more homogeneous behaviour&#44; all patients had values above the normal range and only 7 &#40;16&#37;&#41; were below 100<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#46; Ferritin was available only in four patients&#46; Albumin below or equal to 3<span class="elsevierStyleHsp" style=""></span>g&#47;dl was present in 8 patients &#40;18&#46;2&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Lymphopenia &#40;&#8804;1000 cell&#47;mm<span class="elsevierStyleSup">3</span>&#41; was detected in most of the patients &#40;86&#46;4&#37;&#44; n 38&#41;&#59; severe lymphopenia &#40;&#8804;500 cell&#47;mm<span class="elsevierStyleSup">3</span>&#41; occurred in 7 patients &#40;16&#37;&#41;&#46; Thrombocytopenia &#40;&#8804;150&#46;000 cell&#47;mm<span class="elsevierStyleSup">3</span>&#41; was present in 7 patients but only one case had less than 100&#46;000 cell&#47;mm<span class="elsevierStyleSup">3</span>&#46; Augmented D-dimers &#40;&#8805;500 ng&#47;ml&#41; occurred in 28 patients &#40;63&#46;6&#37;&#41; but only 3 cases &#40;6&#46;8&#37;&#41; were higher than 3&#46;000 ng&#47;ml&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">All patients had a bilateral diffuse infiltrate on the initial chest radiograph&#46; Median PaO<span class="elsevierStyleInf">2</span>&#58;FiO<span class="elsevierStyleInf">2</span> ratio was 83 &#91;60&#46;6-117&#93;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">COVID-19 treatments and life support measures</span><p id="par0090" class="elsevierStylePara elsevierViewall">Almost all patients were treated with chloroquine and azithromycine &#40;100&#37; and 95&#46;5&#37; respectively&#41;&#46; Other treatments directed towards the virus are depicted in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Immunomodulation was attempted in all patients except two &#40;95&#46;5&#37;&#41;&#59; steroids in 35 cases &#40;79&#46;5&#37;&#41; &#40;&#8805;1<span class="elsevierStyleHsp" style=""></span>mg&#47;Kg&#47;day in 93&#46;2&#37; of all treated patients&#41;&#44; tocilizumab in 36 cases &#40;81&#46;8&#37;&#41; and baricitinib in 4 cases &#40;9&#37;&#41;&#46; All patients were under prophylactic low molecular weight heparin and only two received therapeutic anticoagulant treatment due to the presence of an aortic prosthetic valve and to the development of a venous thrombosis related to the presence of a central catheter&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Thirty-four patients needed invasive mechanical ventilation &#40;77&#46;3&#37;&#41;&#59; of them 13 &#40;38&#37;&#41; were intubated the same day they were admitted to the MCCU and 21 &#40;67&#46;8&#37;&#41; were intubated after a median of 2 &#91;1-2&#93; days of delay&#46; Not intubated patients and those with a delay until intubation were supported with high flow nasal cannula &#40;HFNC&#41;&#46; None patient received non-invasive mechanical ventilation&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Among ventilated patients all coupled with moderate-severe ARDS definition &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> &#60;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46; All mechanically ventilated patients received protective ventilation&#46; Prone-position ventilation was performed in 33 patients &#40;97&#37;&#41; &#40;median of 3 sessions &#91;2-5&#93; per patient&#41; achieving an improvement in oxygenation in all patients &#40;at least temporarily&#41;&#44; recruitment manoeuvres were realized in 25 patients &#40;73&#46;5&#37;&#41; and nitric oxide was administered to 7 patients &#40;20&#46;6&#37;&#41;&#46; Extracorporeal membrane oxygenation &#40;ECMO&#41; was used in 3 cases &#40;8&#46;8&#37;&#41;&#59; 2 veno-venous systems and 1 veno-arterial system because of heart failure&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Norepinephrine was used in 28 patients &#40;63&#46;6&#37;&#41; because of hypotension unresponsive to fluid administration &#40;and avoiding fluid overload in SDRA context&#41; but none of them attended with serum lactate<span class="elsevierStyleHsp" style=""></span>&#62; 2 mmol&#47;l&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Only one patient under VA-ECMO needed extracorporeal renal replacement&#46; However 36&#37; of our patients &#40;n 16&#41; coupled with AKIN stage 1 criteria due to urine output &#60;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>ml&#47;Kg during 6<span class="elsevierStyleHsp" style=""></span>hours&#46; All patients responded to fluid administration and none of them progressed to more severe AKIN stages&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Microbiological and infectious diseases assessment</span><p id="par0115" class="elsevierStylePara elsevierViewall">None bacterial co-infection could be demonstrated at hospital or ICU admission&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">ICU-nosocomial infection was detected 16 times in 13 patients &#40;29&#46;5&#37;&#41;&#46; Ventilator-associated pneumonia &#40;VAP&#41; was the most common infection&#59; 8 of 34 ventilated patients &#40;23&#46;5&#37;&#41;&#46; Ventilated-associated tracheobronchitis &#40;TAVM&#41; was diagnosed in 1 patient &#40;2&#46;9&#37;&#41;&#46; Catheter-related bacteraemia &#40;CRB&#41; occurred in three patients &#40;6&#46;8&#37;&#41; and primary bacteremia in one patient &#40;2&#46;3&#37;&#41;&#46; Most common aetiologies were&#58; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> &#40;n 7&#59; 46&#46;7&#37;&#41;&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;n 3&#59; 20&#37;&#41; and <span class="elsevierStyleItalic">Escherichia coli</span> &#40;n 1&#59; 6&#46;7&#37;&#41;&#46; Opportunistic infections were diagnosed in 5 patients&#59; 4 cases of HSV pneumonia &#40;one of them co-infecting with CMV&#41; and 1 pulmonary invasive aspergillosis&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Outcomes</span><p id="par0125" class="elsevierStylePara elsevierViewall">At study closing all patients had been discharged from the CCU and only two &#40;4&#46;5&#37;&#41; remained in hospital ward&#46; MCCU length of stay was 18 days &#91;10-27&#93; and hospital length of stay was 28 days &#91;19-39&#93;&#46; Mortality at study closing was 20&#44;5&#37; &#40;n 9&#41;&#46; All deaths occurred in CCU after a median of 17 days &#91;12-24&#93;&#46; If we include all COVID19 patients &#40;SARS-CoV-2 positive without disease and patients with DNRO&#41; mortality will rise to 28&#37; &#40;16 deaths in 57 patients&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Mechanical ventilation duration for the 34 ventilated patients was 16 days &#91;11-28&#93;&#46; All ventilated patients were treated with neuromuscular blockers for a median of 5 days &#91;3-14&#93;&#46; Tracheostomy was performed in ten patients &#40;29&#46;4&#37;&#41; after a median of 21 days &#91;19&#46;3-23&#46;5&#93;&#46; Five patients &#40;14&#46;7&#37;&#41; presented spontaneous pneumothorax during mechanical ventilation&#46; Mortality among ARDS ventilated patients was 26&#46;5&#37;&#46; Death in ventilated patients occurred after a median of 17 days &#91;12-24&#93;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Four patients &#40;9&#37;&#41; required readmission to the MCCU after discharge&#46; Three of them presented haemorrhagic shock related with anticoagulation treatment and were managed with arterial embolization&#46; The fourth patient was readmitted because of respiratory worsening due to pulmonary fibrosis secondary to ARDS and finally died&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">In this time of uncertainty about the management and prognosis of critically ill patients due to COVID-19 we aimed to present our experience&#46; Thirteen per cent of COVID-19 patients admitted to hospital had to be treated in CCU&#46; ARDS due to COVUD-19 could be analysed in 44 patients from MCCU&#44; 77&#46;2&#37; of these patients undergo invasive mechanical ventilation and 23&#46;5&#37; of them finally died&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">SARS-CoV-2 directed treatment and immunomodulation was administered to our patients attending to incoming data from literature and <span class="elsevierStyleItalic">in vitro</span> results&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> However&#44; as previously reported by other authors&#44; IL<span class="elsevierStyleInf">6</span>&#44; CRP and PCT figures were not as high as described in other circumstances such as septic shock&#44; severe pancreatitis or burn patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">22&#8211;25</span></a> Even more&#44; the most remarkable finding was the low lymphopenia present in most of the patients&#46; High dose steroids &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;Kg&#41; and tocilizumab were administered to the majority of the patients&#44; and nowadays several critical voices are rising against the use of treatments lacking any medical evidence of efficacy and that entail potential harmful&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> In fact&#44; nosocomial infections&#44; mainly ventilator-associated pneumonia&#44; were three times more common in COVID-19 patients than previously registered in our MCCU&#46; Only Yang <span class="elsevierStyleItalic">et al</span> reported data concerning nosocomial infections in CCU patients&#44; describing a prevalence of 22&#37; among their patients&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Most patients admitted to CCU needed intubation and mechanical ventilation &#40;77&#37;&#41; and this seems to be in agreement with published series from Italy and USA &#40;88&#37;&#44; 71&#37; and 75&#37; respectively&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">8&#44;9&#44;11</span></a> Heterogeneous and even lower percentages &#40;from 71&#37; to 30&#37;&#41; were reported by researchers from China&#44;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#8211;6</span></a> but in at least one of the published series a deficit in the number of CCU beds and ventilators was admitted&#44; affecting more than 50&#37; of potential patients&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Mortality rate among COVID-19 ARDS ventilated patients is one of the most disheartening published results&#46; Chinese mortality among critically ill patients was reported from 67 to 97&#37; of ventilated patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;5</span></a> Mortality from 320 ventilated patients in New York was informed to be 88&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Unfinished information from Italy &#40;58&#37; of critically ill patients remained in CCU at study publication&#41; related a mortality of 26&#37;&#44; however as mortality among COVID-19 ventilated patients seems to be late &#40;17 days &#91;12-24&#93; after mechanical ventilation onset in our series&#41; we should beware of possible changes&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> The lower mortality &#40;23&#46;5&#37;&#41; observed in our series could be explained by some aspects&#46; First&#44; by means of the implementation of a contingency plan&#44; CCU beds and mechanical ventilation were available for all candidates&#46; Second&#44; our RRS was able to early detect patients at risk &#40;closely working with emergency specialists&#44; internists&#44; and pulmonologists&#41; and patients were admitted to MCCU after a median of 2 &#91;0-4&#93; days in hospital&#46; Third&#44; in agreement with some experts recommendations&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> no delay for intubation and mechanical ventilation was admissible when excessive respiratory work appeared&#44; patients were intubated after a median of 2 days &#91;1-2&#93; in MCCU&#46; And finally&#44; 97&#37; of our ventilated patients needed ventilation in the prone position&#46; The closest percentage of ventilation in the prone position for ARDS COVID19 patients comes from the publication from Mart&#237;n-Loeches et al&#44; with a rate of 79&#37; in 29 ventilated patients and a final mortality rate of 15&#37; &#40;5 deaths in 39 patients&#44; 29 under mechanical ventilation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> However&#44; data from Italy indicate a use of the prone position in only 27&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> The use of this manoeuvre was even lower in China &#40;11&#46;5&#37; of patients&#41; and Richardson <span class="elsevierStyleItalic">et al</span> do not report data regarding the use of this ventilator intervention&#46; In line with the results from clinical trials <a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a>we do believe in the beneficial effects that these manoeuvres have in the ARDS COVID-19 patient&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; This is a relatively small series of COVID-19 patients coming from a single hospital&#46; Nevertheless&#44; most published data comes from countries with very different health systems from ours and most published series remain unfinished in patient follow-up&#44; and therefore we decided to present and share our results&#46; The effect on the incidence of nosocomial infection and the potential relationship with immunosuppressive treatment will require larger studies or at least a comparison with similar patients in terms of mechanical ventilation duration and presence of ARDS&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In conclusion&#44; COVID-19 ARDS patient management has been challenging for critical care specialists&#46; All technological and knowledge resources have been required but finally mortality rate has not been as high as described in other publications&#46; Finally&#44; we would like to share our doubts about the relevance of the immunosuppressive treatment in this infectious disease and about its potential implication in the observed higher incidence of nosocomial infection&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Authors contributions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Dr Ram&#237;rez had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis&#46; Drs Grasselli and Zangrillo equally contributed to this work&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Concept and design&#58; Ram&#237;rez&#44; Gord&#243;n&#44; Mart&#237;n-Cerezulea&#44; Castellanos</p><p id="par0180" class="elsevierStylePara elsevierViewall">Acquisition&#44; analysis&#44; or interpretation of data&#58; Ram&#237;rez&#44; Gord&#243;n&#44; Mart&#237;n-Cerezulea&#44; Villarreal&#44; Padr&#243;s&#44; Sancho&#44; Molina&#44; Leiva&#44; Gimeno</p><p id="par0185" class="elsevierStylePara elsevierViewall">Drafting of the manuscript&#58; Ram&#237;rez&#44; Gord&#243;n</p><p id="par0190" class="elsevierStylePara elsevierViewall">Critical revision of the manuscript&#58; Ramirez&#44; Castellanos</p><p id="par0195" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; Gord&#243;n&#44; Mart&#237;n-Cerezuela&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165"><span class="elsevierStyleBold">Funding&#47;Support</span></span><p id="par0200" class="elsevierStylePara elsevierViewall">No funding to be declare</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170"><span class="elsevierStyleBold">Conflict of interest disclosure</span></span><p id="par0205" class="elsevierStylePara elsevierViewall">No disclosures regarding this publication from any author</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Information from critically ill coronavirus disease 2019 &#40;COVID-19&#41; patients is limited and in many cases coming from health systems approaches different from the national public systems existing in most countries in Europe&#46; Besides&#44; patient follow-up remains incomplete in many publications&#46; Our aim is to characterize acute respiratory distress syndrome &#40;ARDS&#41; patients admitted to a medical critical care unit &#40;MCCU&#41; in a referral hospital in Spain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Retrospective case series of consecutive ARDS COVID-19 patients admitted and treated in our MCCU&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">36-bed MCCU in referral tertiary hospital&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients and participants</span><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">SARS-CoV-2 infection confirmed by real-time reverse transcriptase&#8211;polymerase chain reaction &#40;RT-PCR&#41; assay of nasal&#47;pharyngeal swabs&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">None</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables of interest</span><p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical data were collected&#44; including data on clinical management&#44; respiratory failure&#44; and patient mortality&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">Forty-four ARDS COVID-19 patients were included in the study&#46; Median age was 61&#46;50 &#40;53&#46;25 &#8211; 67&#41; years and most of the patients were male &#40;72&#46;7&#37;&#41;&#46; Hypertension and dyslipidemia were the most frequent co-morbidities &#40;52&#46;3 and 36&#46;4&#37; respectively&#41;&#46; Steroids &#40;1mg&#47;Kg&#47;day&#41; and tocilizumab were administered in almost all patients &#40;95&#46;5&#37;&#41;&#46; 77&#46;3&#37; of the patients needed invasive mechanical ventilation for a median of 16 days &#91;11-28&#93;&#46; Prone position ventilation was performed in 33 patients &#40;97&#37;&#41; for a median of 3 sessions &#91;2-5&#93; per patient&#46; Nosocomial infection was diagnosed in 13 patients &#40;29&#46;5&#37;&#41;&#46; Tracheostomy was performed in ten patients &#40;29&#46;4&#37;&#41;&#46; At study closing all patients had been discharged from the CCU and only two &#40;4&#46;5&#37;&#41; remained in hospital ward&#46; MCCU length of stay was 18 days &#91;10-27&#93;&#46; Mortality at study closing was 20&#46;5&#37; &#40;n 9&#41;&#59; 26&#46;5&#37; among ventilated patients&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">The seven-week period in which our MCCU was exclusively dedicated to COVID-19 patients has been challenging&#46; Despite the severity of the patients and the high need for invasive mechanical ventilation&#44; mortality was 20&#46;5&#37;&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La informaci&#243;n de pacientes cr&#237;ticos con enfermedad por coronavirus 2019 &#40;COVID-19&#41; es limitada y&#44; en muchos casos&#44; proviene de sistemas de salud diferentes a la organizaci&#243;n p&#250;blica de la mayor&#237;a de los pa&#237;ses de Europa&#46; Adem&#225;s&#44; el seguimiento del paciente sigue siendo incompleto en muchas publicaciones&#46; Nuestro objetivo es caracterizar a los pacientes con s&#237;ndrome de distres respiratorio agudo &#40;SDRA&#41; ingresados en una unidad de cuidados cr&#237;ticos m&#233;dicos &#40;MCCU&#41; en un hospital de referencia en Espa&#241;a&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">Serie retrospectiva de casos de pacientes consecutivos con SDRA por COVID-19 ingresados y tratados en nuestra MCCU&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Lugar</span><p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">UCC de 36 camas en un hospital terciario de referencia</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes y participantes</span><p id="spar0170" class="elsevierStyleSimplePara elsevierViewall">Infecci&#243;n por SARS-CoV-2 confirmada por ensayo en tiempo real de la transcriptasa inversa-reacci&#243;n en cadena de la polimerasa &#40;RT-PCR&#41; de hisopos nasales&#47;far&#237;ngeos&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0175" class="elsevierStyleSimplePara elsevierViewall">Ninguna</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Principales variables de inter&#233;s</span><p id="spar0180" class="elsevierStyleSimplePara elsevierViewall">Se recopilaron datos demogr&#225;ficos y cl&#237;nicos&#44; incluidos datos sobre manejo cl&#237;nico&#44; insuficiencia respiratoria y mortalidad del paciente&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0185" class="elsevierStyleSimplePara elsevierViewall">Cuarenta y cuatro pacientes con SDRA por COVID-19 fueron incluidos en el estudio&#46; La mediana de edad fue de 61&#46;50 &#40;53&#46;25 - 67&#41; a&#241;os y la mayor&#237;a de los pacientes eran hombres &#40;72&#46;7&#37;&#41;&#46; La hipertensi&#243;n y la dislipidemia fueron las comorbilidades m&#225;s frecuentes &#40;52&#44;3 y 36&#44;4&#37;&#44; respectivamente&#41;&#46; Se administraron esteroides &#40;1mg&#47;kg&#47;d&#237;a&#41; y tocilizumab en casi todos los pacientes &#40;95&#44;5&#37;&#41;&#46; El 77&#44;3&#37; de los pacientes necesitaron ventilaci&#243;n mec&#225;nica invasiva durante una mediana de 16 d&#237;as &#91;11-28&#93;&#46; La ventilaci&#243;n en posici&#243;n prono se realiz&#243; en 33 pacientes &#40;97&#37;&#41; con una mediana de 3 sesiones &#91;2-5&#93; por paciente&#46; Se diagnostic&#243; una infecci&#243;n nosocomial en 13 pacientes &#40;29&#44;5&#37;&#41;&#46; La traqueotom&#237;a se realiz&#243; en diez pacientes &#40;29&#44;4&#37;&#41;&#46; Al cierre del estudio&#44; todos los pacientes hab&#237;an sido dados de alta de la MCCU y solo dos permanec&#237;an hospitalizados&#46; La estancia en MCCU fue de 18 d&#237;as &#91;10-27&#93;&#46; La mortalidad al cierre del estudio fue del 20&#44;5&#37; &#40;n 9&#41;&#59; 26&#46;5&#37; para pacientes ventilados&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0190" class="elsevierStyleSimplePara elsevierViewall">El per&#237;odo de siete semanas en el que nuestra MCCU se dedic&#243; exclusivamente a pacientes con COVID-19 ha sido un gran desaf&#237;o&#46; A pesar de la gravedad de los pacientes y la elevada necesidad de ventilaci&#243;n mec&#225;nica invasiva&#44; la mortalidad fue del 20&#44;5&#37;&#46;</p></span>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">All &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IMV &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HFNC &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;50 &#40;53&#46;25 &#8211; 67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;53&#46;75 &#8211; 67&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#46;5 &#40;48&#46;5 &#8211; 63&#46;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;320&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Male</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;72&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;73&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;826&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">BMI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;25&#46;6 &#8211; 31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;55 &#40;24&#46;5 &#8211; 31&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;7 &#40;27&#46;5 &#8211; 31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;408&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbidities</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Arterial hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;52&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;52&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;870&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;13&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;14&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;703&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;36&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;38&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;634&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic corticotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;432&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Immunodeficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;432&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pneumopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;328&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Delay between onset of symptoms and hospitalization</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5 &#40;5 &#8211; 8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;4 &#8211; 7&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;5 &#40;6 &#8211; 9&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;050&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Delay between hospitalization and MCCU admission</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0 &#8211; 4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5 &#40;0 &#8211; 3&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#46;75 &#8211; 5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;142&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">SAPS3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;43&#46;50 &#8211; 59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53 &#40;42&#46;75 &#8211; 62&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;5 &#40;44 &#8211; 49&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;052&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Norepinephrine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;63&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Baricitinib&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Interferon &#946;-1b&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">6 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0210" class="elsevierStylePara elsevierViewall">We will like to thank all staff from our MCCU who have made a valiant effort to do everything possible in the care of our patients from a health and human perspective&#46; We would also like to thank the efforts of the services involved in the care of COVID-19 patients&#44; especially the staff of the Microbiology and Clinical Analysis Departments&#46;</p>"
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ISSN: 02105691
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