Can we predict which COVID-19 patients will get critically ill in advance? 

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

Back from my night shift at AVA (Our Emergency Ward), and the onslaught of COVID-19 patients having hit all the emergency hospitals of Stockholm are now filling up the wards including ours (our ward increased its capacity from 16 to 20 patients over night). The difference from just a couple days ago is staggering.

What we have seen when it comes to COVID-19 is that they seem to tilt from stable to unstable much more quickly than other viral diseases such as the flu. Looking to predict the crisis before it arrives, makes us look for clinical and lab markers that can give us a heads up before the patient crashes.

COVID-19, like all pathologies, has us clinicians looking for the signal in the midst of all the patient data noise.

The Lancet published a retrospective cohort study 2020-03-11, looking at the clinical course and risk factors for mortality of 191 adult patients with laboratory-confirmed COVID-19 in Wuhan, China, and found several interesting markers. * Some of the significant markers seem to be:

• D-dimer
• (LOW) lymphocyte count
• Serum Ferritin
• Lactate dehydrogenase
• High-sensitive cardiac troponin I
• IL-6

They study in The Lancet found that:

Baseline lymphocyte count was significantly higher in survivors than non-survivors; in survivors, lymphocyte count was lowest on day 7 after illness onset and improved during hospitalisation, whereas severe lymphopenia was observed until death in non-survivors. Levels of d-dimer, high-sensitivity cardiac troponin I, serum ferritin, lactate dehydrogenase, and IL-6 were clearly elevated in non-survivors compared with survivors throughout the clinical course, and increased with illness deterioration (figure 2). In non-survivors, high-sensitivity cardiac troponin I increased rapidly from day 16 after disease onset, whereas lactate dehydrogenase increased for both survivors and non-survivors in the early stage of illness, but decreased from day 13 for survivors.

Figure 2 Temporal changes in laboratory markers from illness onset in patients hospitalized with COVID-19 

Figure shows temporal changes in d-dimer (A), lymphocytes (B), IL-6 (C), serum ferritin (D), high-sensitivity cardiac troponin I (E), and lactate dehydrogenase (F). Differences between survivors and non-survivors were significant for all timepoints shown, except for day 4 after illness onset for d-dimer, IL-6, and high-sensitivity cardiac troponin I. For serum ferritin (D), the median values after day 16 exceeded the upper limit of detection, as indicated by the dashed line. COVID-19=coronavirus disease 2019. IL-6=interleukin-6.
— Lancet 2020-03-11. *

For predictors in our patients we currently take, besides basic labs (that include lymphocytes), also Ferritin, LD, & (sometimes) D-dimer.

Basically a patient with low lymphocytes and/or elevated Ferritin, LD, or D-Dimer is at increased risk for getting critically ill.

Predictive markers help us consider intensive care and or antiviral treatment sooner in the patients we think are at risk, hopefully staying ahead of the crash and thereby increasing the odds of a more favourable outcome in each individual confirmed COVID-19 case.     

COVID-19 Numbers Sweden 2020-03-26 *

• 66 deaths nationally
  • 42 of them in Stockholm
• 2 806 confirmed cases nationally
  
  (Number of COVID-19 cases over time in Sweden, updates during mornings so todays numbers are not yet complete until the next day).
• Intensive care: *
  • 200 patients
  • 9,3 days from symptoms to ICU
  • 25,5 % women
    
    Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than double each week, 5 →  24  → 127 → (251 this week up until now, however since it’s only thursday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-03-26 at 10:00 CET) *

• 20 832 confirmed deaths
• 462 684 confirmed cases
• 199 countries , areas or territories with cases

New Resources Added to ※ CTSOP 

• STAIRS [SWE] podcast – on ARDS with focus on COVID-19
• COVID-19 One Step Resource Page – made by Critical Care Northampton

COVID-19 Image: COVID-19 Sheet *

That’s it until tomorrow, keep calm and stay safe!