Factors associated with increased mortality in critically ill COVID-19 patients in a Mexican public hospital: the other faces of health system oversaturation

{ 'DOI': '10.1101/2021.03.04.21252084', 'URL': 'http://dx.doi.org/10.1101/2021.03.04.21252084', 'abstract': '<jats:title>ABSTRACT</jats:title><jats:sec><jats:title>BACKGROUND</jats:title><jats:p>The ' 'lethality rate of COVID-19 in Mexico is one of the highest worldwide, but in-hospital factors ' 'associated with this increased rate have yet to be explored. This study aims to evaluate ' 'those factors that could be associated with mortality at 28-days in critically ill COVID-19 ' 'patients in Mexico.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>This ' 'is a retrospective analysis of the patients included in the clinical trial (<jats:ext-link ' 'xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="clintrialgov" ' 'xlink:href="NCT04381858">NCT04381858</jats:ext-link>) which recruited patients with severe ' 'COVID-19 with high oxygen requirement or mechanical ventilation from May to October 2020. The ' 'primary outcome, death at 28, was ' 'analyzed.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Between May ' 'and October 2020, 196 predominantly male patients (n=122, 62.2%) with an average of 58.1 ' 'years (± 15.5), were included in the cohort. Mortality at 28 days was 44.3 % (n= 84). ' 'Patients included in the second trimester had a greater mortality rate when compared with ' 'those recruited in the first trimester (54.1 <jats:italic>vs</jats:italic> 32.1, p&lt; 0.01). ' 'On multivariate analysis, the detected protective factors were the use of fentanyl HR 0.51 ' '(95%CI 0.31 – 0.85, p=0.01), the use of antibiotics HR 0.22 (95% CI 0.13 – 0.36, p&lt;0.01), ' 'and a previously healthy state (no comorbidities other than obesity) HR 0.58 (95%CI 0.35 – ' '0.94, p =0.03); risk factors were severe kidney injury (AKIN3) HR 1.74 (95%CI 1.04 – 2.9, ' 'p=0.035), elevated D-Dimer levels HR 1.02 (95%CI 1.007 – 1.04, p=0.005), shock OR 5.8 (2.4 – ' '13.8, p&lt;0.01), and recruitment in the second trimester OR 2.3 ((1.1 – 4.8, ' 'p=0.02).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>In-hospital ' 'mortality in critically ill COVID-19 patients has increased in our center. The appropriate ' 'use of antibiotics, the type of sedation, and AKIN3 are modifiable factors directly related ' 'to this increased mortality. The increase in mortality observed in the second trimester is ' 'explained by hospital overcrowding that began in August 2020.</jats:p></jats:sec>', 'accepted': {'date-parts': [[2021, 3, 8]]}, 'author': [ {'affiliation': [], 'family': 'Guzmán', 'given': 'Mariana Jocelyn Macías', 'sequence': 'first'}, { 'affiliation': [], 'family': 'Castillo-Gonzalez', 'given': 'Alejandro', 'sequence': 'additional'}, { 'affiliation': [], 'family': 'Gonzalez', 'given': 'Jose Lenin Beltran', 'sequence': 'additional'}, {'affiliation': [], 'family': 'Gámez', 'given': 'Mario González', 'sequence': 'additional'}, { 'affiliation': [], 'family': 'Enciso', 'given': 'Emanuel Antonio Mendoza', 'sequence': 'additional'}, {'affiliation': [], 'family': 'Robles', 'given': 'Itzel Ovalle', 'sequence': 'additional'}, {'affiliation': [], 'family': 'Díaz', 'given': 'Andrea Lucia García', 'sequence': 'additional'}, { 'affiliation': [], 'family': 'Peña', 'given': 'César Mauricio Gutiérrez', 'sequence': 'additional'}, {'affiliation': [], 'family': 'Medina', 'given': 'Lucila Martinez', 'sequence': 'additional'}, { 'affiliation': [], 'family': 'Colin', 'given': 'Victor Antonio Monroy', 'sequence': 'additional'}, { 'affiliation': [], 'family': 'Jose Manuel', 'given': 'Arreola Guerra', 'sequence': 'additional'}], 'container-title': [], 'content-domain': {'crossmark-restriction': False, 'domain': []}, 'created': {'date-parts': [[2021, 3, 8]], 'date-time': '2021-03-08T14:15:11Z', 'timestamp': 1615212911000}, 'deposited': { 'date-parts': [[2021, 3, 9]], 'date-time': '2021-03-09T17:56:50Z', 'timestamp': 1615312610000}, 'group-title': 'Infectious Diseases (except HIV/AIDS)', 'indexed': {'date-parts': [[2022, 4, 1]], 'date-time': '2022-04-01T22:20:44Z', 'timestamp': 1648851644320}, 'institution': [{'name': 'medRxiv'}], 'is-referenced-by-count': 1, 'issued': {'date-parts': [[2021, 3, 8]]}, 'link': [ { 'URL': 'https://syndication.highwire.org/content/doi/10.1101/2021.03.04.21252084', 'content-type': 'unspecified', 'content-version': 'vor', 'intended-application': 'similarity-checking'}], 'member': '246', 'original-title': [], 'posted': {'date-parts': [[2021, 3, 8]]}, 'prefix': '10.1101', 'published': {'date-parts': [[2021, 3, 8]]}, 'publisher': 'Cold Spring Harbor Laboratory', 'reference': [ { 'key': '2021030909551226000_2021.03.04.21252084v1.1', 'unstructured': 'World Health Organization. Director-General’s remarks at the media ' 'briefing on 2019-nCoV on 11 February 2020. ' 'http://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at-the-media-briefing-on-2019-ncov-on-11-february-2020 ' '(Accessed on january 24, 2021)'}, { 'DOI': '10.1001/jama.2020.2648', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.2'}, { 'DOI': '10.1164/rccm.202006-2405OC', 'article-title': 'Case Fatality Rates for Patients with COVID-19 Requiring Invasive ' 'Mechanical Ventilation. A Meta-analysis', 'doi-asserted-by': 'crossref', 'first-page': '54', 'journal-title': 'Am J Respir Crit Care Med', 'key': '2021030909551226000_2021.03.04.21252084v1.3', 'volume': '203', 'year': '2021'}, { 'key': '2021030909551226000_2021.03.04.21252084v1.4', 'unstructured': 'La Secretaria de Salud. Información referente a casos COVID-19 en ' 'México. Gobierno de México: La Secretaría de Salud; 2020 [accessed 2020 ' 'Jul 1]. Available from: ' 'https://datos.gob.mx/busca/dataset/informacion-referente-a-casos-covid-19-en-mexico'}, { 'key': '2021030909551226000_2021.03.04.21252084v1.5', 'unstructured': 'Centers for Disease Control and Prevention. People who are at higher ' 'risk for severe illness ' 'https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html ' '(Accessed on january 24, 2021)'}, { 'DOI': '10.1097/CCM.0000000000004747', 'article-title': 'Improving Survival of Critical Care Patients With Coronavirus Disease ' '2019 in England: A National Cohort Study, March to June 2020', 'doi-asserted-by': 'crossref', 'first-page': '209', 'journal-title': 'Crit Care Med', 'key': '2021030909551226000_2021.03.04.21252084v1.6', 'volume': '49', 'year': '2021'}, { 'DOI': '10.1101/2020.08.11.20172775', 'doi-asserted-by': 'crossref', 'key': '2021030909551226000_2021.03.04.21252084v1.7', 'unstructured': 'Horwitz LI , Jones SA , Cerfolio RJ , et al. Trends in COVID-19 ' 'Risk-Adjusted Mortality Rates. J Hosp Med 2020.'}, { 'key': '2021030909551226000_2021.03.04.21252084v1.8', 'unstructured': 'Coronavirus Resource Center, Johns Hopkins University of Medicine ' 'https://coronavirus.jhu.edu/data/mortality. (Accessed on january 24, ' '2021)'}, { 'key': '2021030909551226000_2021.03.04.21252084v1.9', 'unstructured': 'Coronavirus Resource Center, Johns Hopkins University of Medicine ' 'https://coronavirus.jhu.edu/testing/international-comparison. (Accessed ' 'on january 24, 2021)'}, { 'DOI': '10.1055/s-0040-1710019', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.10'}, { 'DOI': '10.1056/NEJMoa2021436', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.11'}, { 'key': '2021030909551226000_2021.03.04.21252084v1.12', 'unstructured': 'Beltran-Gonzalez JL , Gonzalez-Gamez M , Mendoza Enciso e, et al. ' 'Efficacy and safety of Ivermectin and Hydroxychloroquine in patients ' 'with severe COVID-19. A randomized controlled trialmedRxiv preprint doi: ' 'https://doi.org/10.1101/2021.02.18.21252037;this version ' 'postedFebruary23,2021.'}, { 'DOI': '10.1016/j.hrtlng.2020.10.013', 'article-title': 'Outcomes of patients with COVID-19 in the intensive care unit in ' 'Mexico: A multicenter observational study', 'doi-asserted-by': 'crossref', 'first-page': '28', 'journal-title': 'Heart Lung', 'key': '2021030909551226000_2021.03.04.21252084v1.13', 'volume': '50', 'year': '2021'}, { 'DOI': '10.1371/journal.pone.0245772', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.14'}, { 'DOI': '10.1186/s13054-021-03485-w', 'article-title': 'Case fatality ratio of COVID-19 patients requiring invasive mechanical ' 'ventilation in Mexico: an analysis of nationwide data', 'doi-asserted-by': 'crossref', 'first-page': '68', 'journal-title': 'Crit Care', 'key': '2021030909551226000_2021.03.04.21252084v1.15', 'volume': '25', 'year': '2021'}, { 'DOI': '10.1093/cid/ciaa530', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.16'}, { 'DOI': '10.1016/j.jaci.2020.04.006', 'article-title': 'Risk factors for severity and mortality in adult COVID-19 inpatients in ' 'Wuhan', 'doi-asserted-by': 'crossref', 'first-page': '110', 'journal-title': 'J Allergy Clin Immunol', 'key': '2021030909551226000_2021.03.04.21252084v1.17', 'volume': '146', 'year': '2020'}, { 'DOI': '10.1186/s13054-020-03013-2', 'article-title': 'The challenge of ventilator-associated pneumonia diagnosis in COVID-19 ' 'patients', 'doi-asserted-by': 'crossref', 'first-page': '289', 'journal-title': 'Crit Care', 'key': '2021030909551226000_2021.03.04.21252084v1.18', 'volume': '24', 'year': '2020'}, { 'DOI': '10.1097/CCM.0000000000000330', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.19'}, { 'DOI': '10.1177/0885066620951426', 'article-title': 'Sedation, Analgesia, and Paralysis in COVID-19 Patients in the Setting ' 'of Drug Shortages', 'doi-asserted-by': 'crossref', 'first-page': '157', 'journal-title': 'J Intensive Care Med', 'key': '2021030909551226000_2021.03.04.21252084v1.20', 'volume': '36', 'year': '2021'}, { 'DOI': '10.1097/CCM.0000000000003307', 'article-title': 'Interpreting and implementing the 2018 pain, agitation/sedation, ' 'delirium, immobility, and sleep disruption clinical practice guideline', 'doi-asserted-by': 'crossref', 'first-page': '1464', 'journal-title': 'Crit Care Med', 'key': '2021030909551226000_2021.03.04.21252084v1.21', 'volume': '46', 'year': '2018'}, { 'DOI': '10.1007/BF03018315', 'article-title': 'Sedation with sufentanil in patients receiving pressure support ' 'ventilation has no efects on respiration: a pilot study', 'doi-asserted-by': 'crossref', 'first-page': '494', 'journal-title': 'Can J Anaesth', 'key': '2021030909551226000_2021.03.04.21252084v1.22', 'volume': '51', 'year': '2004'}, { 'DOI': '10.1186/s13054-017-1789-8', 'article-title': 'Could remifentanil reduce duration of mechanical ventilation in ' 'comparison with other opioids for mechanically ventilated patients? A ' 'systematic review and meta-analysis', 'doi-asserted-by': 'crossref', 'first-page': '206', 'journal-title': 'Crit Care', 'key': '2021030909551226000_2021.03.04.21252084v1.23', 'volume': '21', 'year': '2017'}, { 'DOI': '10.1097/CCM.0000000000003259', 'article-title': 'Executive Summary: Clinical Practice Guidelines for the Prevention and ' 'Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep ' 'Disruption in Adult Patients in the ICU', 'doi-asserted-by': 'crossref', 'first-page': '1532', 'journal-title': 'Crit Care Med', 'key': '2021030909551226000_2021.03.04.21252084v1.24', 'volume': '46', 'year': '2018'}, {'key': '2021030909551226000_2021.03.04.21252084v1.25'}, { 'DOI': '10.1007/s00134-012-2796-5', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.26'}, { 'DOI': '10.1097/01.CCM.0000277041.13090.0A', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.27'}, { 'DOI': '10.1186/s13054-020-03009-y', 'article-title': 'Incidence of acute kidney injury in COVID-19 infection: a systematic ' 'review and meta-analysis', 'doi-asserted-by': 'crossref', 'first-page': '346', 'journal-title': 'Crit Care', 'key': '2021030909551226000_2021.03.04.21252084v1.28', 'volume': '24', 'year': '2020'}, { 'DOI': '10.1016/j.phrs.2020.105107', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.29'}, { 'DOI': '10.1007/s00134-020-06153-9', 'article-title': 'Acute kidney injury in critically ill patients with COVID-19', 'doi-asserted-by': 'crossref', 'first-page': '1339', 'issue': '7', 'journal-title': 'Intensive Care Med', 'key': '2021030909551226000_2021.03.04.21252084v1.30', 'volume': '46', 'year': '2020'}, { 'DOI': '10.1007/s00134-017-4832-y', 'doi-asserted-by': 'publisher', 'key': '2021030909551226000_2021.03.04.21252084v1.31'}, { 'DOI': '10.1016/S2213-2600(20)30229-0', 'article-title': 'Management of acute kidney injury in patients with COVID-19', 'doi-asserted-by': 'crossref', 'first-page': '738', 'journal-title': 'Lancet Respir Med', 'key': '2021030909551226000_2021.03.04.21252084v1.32', 'volume': '8', 'year': '2020'}], 'reference-count': 32, 'references-count': 32, 'relation': {}, 'resource': {'primary': {'URL': 'http://medrxiv.org/lookup/doi/10.1101/2021.03.04.21252084'}}, 'score': 1, 'short-title': [], 'source': 'Crossref', 'subject': [], 'subtitle': [], 'subtype': 'preprint', 'title': 'Factors associated with increased mortality in critically ill COVID-19 patients in a Mexican ' 'public hospital: the other faces of health system oversaturation', 'type': 'posted-content'}