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Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy

Educational Objective
To understand what are the baseline characteristics and outcomes of patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.
1 Credit CME
Key Points

Question  What are the baseline characteristics and outcomes of patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to intensive care units (ICUs) in Lombardy, Italy?

Findings  In this retrospective case series that involved 1591 critically ill patients admitted from February 20 to March 18, 2020, 99% (1287 of 1300 patients) required respiratory support, including endotracheal intubation in 88% and noninvasive ventilation in 11%; ICU mortality was 26%.

Meaning  In this case series of critically ill patients admitted to ICUs in Lombardy, Italy, with laboratory-confirmed coronavirus disease 2019 (COVID-19), a high proportion required mechanical ventilation and ICU mortality was 26% as of March 25, 2020.

Abstract

Importance  In December 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) emerged in China and has spread globally, creating a pandemic. Information about the clinical characteristics of infected patients who require intensive care is limited.

Objective  To characterize patients with coronavirus disease 2019 (COVID-19) requiring treatment in an intensive care unit (ICU) in the Lombardy region of Italy.

Design, Setting, and Participants  Retrospective case series of 1591 consecutive patients with laboratory-confirmed COVID-19 referred for ICU admission to the coordinator center (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy) of the COVID-19 Lombardy ICU Network and treated at one of the ICUs of the 72 hospitals in this network between February 20 and March 18, 2020. Date of final follow-up was March 25, 2020.

Exposures  SARS-CoV-2 infection confirmed by real-time reverse transcriptase–polymerase chain reaction (RT-PCR) assay of nasal and pharyngeal swabs.

Main Outcomes and Measures  Demographic and clinical data were collected, including data on clinical management, respiratory failure, and patient mortality. Data were recorded by the coordinator center on an electronic worksheet during telephone calls by the staff of the COVID-19 Lombardy ICU Network.

Results  Of the 1591 patients included in the study, the median (IQR) age was 63 (56-70) years and 1304 (82%) were male. Of the 1043 patients with available data, 709 (68%) had at least 1 comorbidity and 509 (49%) had hypertension. Among 1300 patients with available respiratory support data, 1287 (99% [95% CI, 98%-99%]) needed respiratory support, including 1150 (88% [95% CI, 87%-90%]) who received mechanical ventilation and 137 (11% [95% CI, 9%-12%]) who received noninvasive ventilation. The median positive end-expiratory pressure (PEEP) was 14 (IQR, 12-16) cm H2O, and Fio2 was greater than 50% in 89% of patients. The median Pao2/Fio2 was 160 (IQR, 114-220). The median PEEP level was not different between younger patients (n = 503 aged ≤63 years) and older patients (n = 514 aged ≥64 years) (14 [IQR, 12-15] vs 14 [IQR, 12-16] cm H2O, respectively; median difference, 0 [95% CI, 0-0]; P = .94). Median Fio2 was lower in younger patients: 60% (IQR, 50%-80%) vs 70% (IQR, 50%-80%) (median difference, −10% [95% CI, −14% to 6%]; P = .006), and median Pao2/Fio2 was higher in younger patients: 163.5 (IQR, 120-230) vs 156 (IQR, 110-205) (median difference, 7 [95% CI, −8 to 22]; P = .02). Patients with hypertension (n = 509) were older than those without hypertension (n = 526) (median [IQR] age, 66 years [60-72] vs 62 years [54-68]; P < .001) and had lower Pao2/Fio2 (median [IQR], 146 [105-214] vs 173 [120-222]; median difference, −27 [95% CI, −42 to −12]; P = .005). Among the 1581 patients with ICU disposition data available as of March 25, 2020, 920 patients (58% [95% CI, 56%-61%]) were still in the ICU, 256 (16% [95% CI, 14%-18%]) were discharged from the ICU, and 405 (26% [95% CI, 23%-28%]) had died in the ICU. Older patients (n = 786; age ≥64 years) had higher mortality than younger patients (n = 795; age ≤63 years) (36% vs 15%; difference, 21% [95% CI, 17%-26%]; P < .001).

Conclusions and Relevance  In this case series of critically ill patients with laboratory-confirmed COVID-19 admitted to ICUs in Lombardy, Italy, the majority were older men, a large proportion required mechanical ventilation and high levels of PEEP, and ICU mortality was 26%.

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Article Information

Corresponding Author: Maurizio Cecconi, MD, Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Centre-IRCCS, Via Manzoni 56, 20089, Rozzano, Milan, Italy (maurizio.cecconi@hunimed.eu).

Accepted for Publication: March 28, 2020.

Published Online: April 6, 2020. doi:10.1001/jama.2020.5394

Author Contributions: Dr Zanella 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. Drs Grasselli and Zangrillo equally contributed to this work.

Concept and design: Cecconi, Grasselli, Zangrillo, Zanella, Foti, Ranieri, Storti, Pesenti.
Acquisition, analysis, or interpretation of data: Cecconi, Grasselli, Zanella, Antonelli, Cabrini, Castelli, Cereda, Colucello, Foti, Fumagalli, lotti, Latronico, Lorini, Merler, Natalini, Piatti, Ranieri, Scandroglio, Storti, Pesenti.
Drafting of the manuscript: Cecconi, Grasselli, Zanella, Castelli, Cereda, Fumagalli, Lorini, Piatti, Ranieri, Storti.
Critical revision of the manuscript for important intellectual content: Cecconi, Grasselli, Zangrillo, Zanella, Antonelli, Cabrini, Colucello, Foti, lotti, Latronico, Merler, Natalini, Ranieri, Scandroglio, Storti, Pesenti.
Statistical analysis: Zanella, Cereda.
Administrative, technical, or material support: Zangrillo, Lorini.
Supervision: Cecconi, Grasselli, Antonelli, Cabrini, Colucello, Foti, Latronico, Ranieri, Storti, Pesenti.

Conflict of Interest Disclosures: Dr Cecconi reported personal fees from Edwards Lifesciences, from Directed Systems, and from Cheetah Medical outside the submitted work. Dr Grasselli reported personal fees and nonfinancial support from Getinge and from Biotest, personal fees from Thermofisher, grants and personal fees from Fisher&Paykel, and personal fees from Draeger Medical outside the submitted work. Dr Iotti reported personal fees from Hamilton Medical, from Getinge Italia, from Eurosets, from Intersurgical, and from Burke & Burke outside the submitted work. Dr Pesenti reported personal fees from Maquet, from Novalung/Xenios, from Baxter, and from Boehringer Ingelheim outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported in part by institutional funding (Ricerca corrente 2020) of the Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

COVID-19 Lombardy ICU Network: Adriana Nailescu, MD, ASST Lodi-Ospedale Maggiore di Lodi, Lodi (Italy); Alberto Corona, MD, Ospedale di Valle Camonica Esine, ASST Vallecamonica, Brescia (Italy); Alberto Zangrillo, MD, IRCCS San Raffaele Scientific Institute, Milan, Italy and Vita-Salute San Raffaele University Milan, Italy; Alessandro Protti, MD, Humanitas Research Hospital, Milan, Italy; Andrea Albertin, MD, “San Giuseppe” Hospital, Multimedica Group, Milan (Italy); Andrea Forastieri Molinari, MD, ASST Lecco - Ospedale di Lecco, Lecco (Italy); Andrea Lombardo, MD, ASST Lariana - Ospedale Sant'Anna, Como (Italy); Angelo Pezzi, MD, ASST Nord Milano - Ospedale Edoardo Bassini, Cinisello Balsamo (Italy); Annalisa Benini, MD, ASST Monza - Ospedale San Gerardo, Monza (Italy); Anna Mara Scandroglio, MD, IRCCS San Raffaele Scientific Institute, Milan, Italy; Annalisa Malara, MD, ASST Lodi - Ospedale Maggiore di Lodi, Lodi (Italy); Antonio Castelli, MD, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan (Italy); Antonio Coluccello, MD, ASST Cremona - Ospedale di Cremona, Cremona (Italy); Antonio Micucci, MD, Hospital “Sant'Antonio Abate” of Cantù, ASST Lariana, Como; Antonio Pesenti, MD, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milano, Italy; Antonello Sala, MD, ASST Vimercate - Ospedale di Vimercate, Vimercate (Italy); Armando Alborghetti, MD, Policlinico San Pietro - Ponte San Pietro (Italy); Benvenuto Antonini, MD, ASST Garda - Ospedale di Manerbio, Manerbio (Italy); Carlo Capra, MD, ASST Laghi, Ospedale di Circolo e Fondazione Macchi; Carmine Troiano, MD, ASST Crema - Ospedale Maggiore di Crema, Crema (Italy); Claudio Roscitano, MD, Humanitas Gavazzeni, Bergamo (Italy); Danilo Radrizzani, MD, ASST Ovest Milanese - Ospedale Nuovo di Legnano, Legnano (Italy); Davide Chiumello, MD, ASST Santi Paolo e Carlo - Ospedale San Paolo, Milan (Italy); Davide Coppini, MD, ASST Garda - Ospedale Civile di “La Memoria”, Gavardo (Italy); Davide Guzzon, MD, ASST Lecco - Ospedale di Merate, Merate (Italy); Elena Costantini, MD, Humanitas Research Hospital, Milan; Elena Malpetti, MD, Fondazione Poliambulanza Istituto Ospedaliero, Brescia (Italy); Elena Zoia, Children's Hospital Vittore Buzzi, ASST FBF Sacco, Milan (Italy); Emanuele Catena, MD, ASST Fatebenefratelli - Ospedale Sacco, Milan (Italy); Emiliano Agosteo, MD, Clinica “San Carlo” Paderno Dugnano, Milano (Italy); Enrico Barbara, MD, Humanitas Mater Domini Hospital, Castellanza, Varese, Italy; Enrico Beretta, MD, ATS Montagna - Ospedale “Eugenio Morelli” di Sondalo, Sondalo (Italy); Enrico Boselli, MD, ASST Rhodense - Presidio ospedaliero Garbagnate Milanese (Italy); Enrico Storti, MD, ASST Lodi - Ospedale Maggiore di Lodi, odi (Italy); Fabiola Harizay, MD, ASST Cremona - Ospedale di Cremona, Cremona (Italy); Federica Della Mura, MD, ASST Melegnano - Ospedale di Vizzolo Predabissi, Melegnano (Italy); Ferdinando Luca Lorini, ASST Papa Giovanni XXIII, Bergamo, Italy; Francesco Donato Sigurtà, MD, Istituto di Cura “Città di Pavia”, Pavia (Italy); Francesco Marino, MD, Clinical Institute Betato Matteo, Vigevano, Pavia (Italy); Francesco Mojoli, Department of Intensive Medicine, I.R.C.C.S. San Matteo Hospital; Department of Clinical surgical, Pediatric and Diagnostic Sciences, University of Pavia, Italy; Frank Rasulo, MD, ASST Spedali Civili, Brescia (Italy); Giacomo Grasselli, MD, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milano, Italy; Giampaolo Casella, Grande Ospedale Metropolitano Niguarda, Milan, Italy; Gianluca De Filippi, MD, ASST Rhodense - Presidio ospedaliero Garbagnate Milanese (Italy); Gianpaolo Castelli, MD, ASST Mantova - Ospedale Carlo Poma, Mantova (Italy); Giorgio Aldegheri, MD, IRCCS Multimedica, Sesto San Giovanni (Italy); Giorgio Gallioli, MD, ASST Vimercate - Ospedale di Vimercate, Vimercate (Italy); Giorgio Iotti, MD, Fondazione IRCCS Policlinico San Matteo, Pavia (Italy); Giovanni Albano, MD, Humanitas Gavazzeni, Bergamo (Italy); Giovanni Landoni, MD, IRCCS Ospedale San Raffaele Scientific Institute, Milan (Italy); Giovanni Marino, MD, ASST Melegnano - Ospedale di Vizzolo Predabissi, Melegnano (Italy); Giovanni Vitale, MD, Policlinico San Marco, Zingonia (Italy); Giovanni Battista Perego, MD, Istituto Auxologico “San Luca”, Milano (Italy); Giulia Evasi, MD, ASST Lecco - Ospedale di Lecco, Lecco (Italy); Giuseppe Citerio, MD, Hospital of Desio, ASST Monza, Monza (Italy); Giuseppe Foti, MD, ASST Monza - Ospedale San Gerardo, Monza (Italy); Giuseppe Natalini, MD, Fondazione Poliambulanza Istituto Ospedaliero, Brescia (Italy); Giuseppe Sala, MD, Istutito Clinico Città Studi, Milano (Italy); Guido Merli, MD, ASST Crema - Ospedale Maggiore di Crema, Crema (Italy); Ilaria Sforzini, MD, ASST Pavia - Ospedale Civile di Voghera, Voghera (Italy); Leonardo Bianciardi, MD, Hospital of Pieve di Coriano, ASST Mantova, Mantova (Italy); Livio Carnevale, MD, ASST Pavia - Ospedale di Vigevano, Vigevano (Italy); Lorenzo Grazioli, MD, ASST Papa Giovanni XXIII, Bergamo (Italy); Luca Cabrini, MD, Ospedale di Circolo e Fondazione Macchi, Varese (Italy); Luca Guatteri, MD, Ospedale “Sacra Famiglia” Fatebenefratelli, Erba (Italy); Luca Salvi, Centro Cardiologico Monzino, Milan (Italy); Marco Dei Poli, MD, IRCCS Policlinico San Donato, Milan (Italy); Marco Galletti, MD, Ospedale Valduce, Como (Italy); Marco Gemma, MD, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco; Marco Ranucci, MD, IRCCS Policlinico San Donato, Milan (Italy); Mario Riccio, MD, Istituti Ospitalieri di Cremona - C.no Ospedale Oglio Po, Casalmaggiore (Italy); Massimo Borelli, MD, Ospedale Treviglio - Caravaggio, Treviglio (Italy); Massimo Zambon, MD, ASST Melegnano-Martesana, Presidio di Cernusco sul Naviglio (Italy); Matteo Subert, MD, Hospital of Melzo, ASST Melegnano Martesana, Milan (Italy); Maurizio Cecconi, MD, Humanitas Research Hospital, Milan (Italy); Maurizio Giovanni Mazzoni, MD, Humanitas Gavazzeni, Bergamo (Italy); Maurizio Raimondi, MD, ASST Pavia - Ospedale Civile di Voghera, Voghera (Italy); Mauro Panigada, MD, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy; Mirko Belliato, Department of Intensive Medicine, I.R.C.C.S. San Matteo Hospital; Department of Clinical surgical, Pediatric and Diagnostic Sciences, University of Pavia, Italy; Nicola Bronzini, MD, Clinical Institute “Sant’Anna”, Brescia; Nicola Latronico, MD, ASST Spedali Civili, Brescia (Italy); Nicola Petrucci, MD, ASST Garda - Ospedale di Desenzano d/G, Desenzano del Garda (Italy); Nicolangela Belgiorno, MD, Istituto Clinico San Rocco, Ome (Italy); Paola Tagliabue, MD, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy; Paolo Cortellazzi, MD, Ospedale Città di Sesto San Giovanni, ASST Nord Milano, Milan (Italy); Paolo Gnesin, MD, ASST Franciacorta - Presidio Ospedaliero Mellino Mellini, Chiari (Italy); Paolo Grosso, MD, Policlinico di Monza, Monza (Italy); Paolo Gritti, MD, ASST Papa Giovanni XXIII, Bergamo (Italy); Paolo Perazzo, MD, IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan (Italy); Paolo Severgnini, MD, ASST 7 Laghi, Ospedale di Circolo e Fondazione Macchi; Patrizia Ruggeri, MD, ASST Cremona - Ospedale di Cremona, Cremona (Italy); Pietro Sebastiano, MD, Istituto Clinico Città di Brescia - Istituti Ospedalieri Bresciani, Gruppo San Donato, Brescia (Italy); Remo Daniel Covello, ASST Valle Olona - Ospedale di Busto Arsizio, Busto Arsizio Italy; Raquel Fernandez-Olmos, MD, Fondazione Poliambulanza Istituto Ospedaliero, Brescia (Italy); Roberto Fumagalli, MD, ASST Grande Ospedale Metropolitano Niguarda, Milan (Italy); Roberto Keim, MD, ASST Bergamo est - Ospedale “Bolognini”, Seriate (Italy); Roberto Rona, MD, ASST Monza - Ospedale San Gerardo, Monza (Italy); Roberto Valsecchi, MD, General Hospital “Moriggia Pelascini” Gravedona, Como (Italy); Sergio Cattaneo, MD, ASST Spedali Civili, Brescia (Italy); Sergio Colombo, MD, IRCCS Ospedale San Raffaele Scientific Institute, Milan (Italy); Silvia Cirri, MD, Istituto Clinico Sant'Ambrogio, Milano (Italy); Stefano Bonazzi, MD, Hospital “M.O. A. Locatelli”, Piario, ASST Bergamo Est, Bergamo (Italy); Stefano Greco, MD, ASST Valle Olona - Ospedale di Saronno, Saronno (Italy); Stefano Muttini, MD, ASST Santi Paolo e Carlo - Ospedale San Carlo, Milan (Italy); Thomas Langer, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy and School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Valentina Alaimo, MD, ASST Mantova - Ospedale Carlo Poma, Mantova (Italy); Uberto Viola, MD, Ospedale “San Pellegrino”, Gruppo Mantova Salus, Mantova (Italy).

Additional Contributions: We thank Eleonora Carlesso, MS (Università degli Studi of Milan), for data management and statistical analysis, Serena Brusatori, MD (Università degli Studi of Milan) and Paolo Cadringher, MS (former Ospedale Maggiore Policlinico), for support in data management. We thank Chiara Paleari, MD (Università degli Studi of Milan), and Emanule Cattaneo, MD (Università degli Studi of Milan), and Giuliana Fusetti, MA (Ospedale Maggiore Policlinico), and Luigia Scudeller, MD (Ospedale Maggiore Policlinico) for help in preparing the documents for the ethics committee. We thank Marina Leonardelli (Ospedale Maggiore Policlinico) and Patrizia Minunno (Ospedale Maggiore Policlinico) for administrative support. We thank all the staff of the COVID-19 Lombardy ICU Network coordination: Anna Ribboni, retired MD, Lorenzo Chiaravalli, MD (former Ospedale San Gerardo, Monza), Barbara Marcora, retired MD, Barbara Antonelli, MD (Ospedale Maggiore Policlinico), Michele Battistin, MS (Ospedale Maggiore Policlinico), Lucio Caccamo, MD (Ospedale Maggiore Policlinico), Daniele Dondossola, MD (Ospedale Maggiore Policlinico), Luisa Napolitano, MD (Ospedale Maggiore Policlinico), Francesca Rossi, MD (Ospedale Maggiore Policlinico), Carlo Valsecchi, MD (Ospedale Maggiore Policlinico), and Arianna Zefilippo, MD (Ospedale Maggiore Policlinico), Daniela Codazzi, MD (DG Welfare Regione Lombardia), Caterina Accardo, MD (Università degli Studi of Milan), Chiara Anzanello, MD (Università degli Studi of Milan), Elena Cadone Ughi, MD (Università degli Studi of Milan), Davide Calabretta, MD (Università degli Studi of Milan), Sebastiano Colombo, MD (Università degli Studi of Milan), Marianna Di Feliciantonio, MD (Università degli Studi of Milan), Gaetano Florio, MD (Università degli Studi of Milan), Giorgio Giudici, MD (Università degli Studi of Milan), Amedeo Guzzardella, MD (Università degli Studi of Milan), Alessia Kersik, MD (Università degli Studi of Milan), Chiara Minaudo, MD (Università degli Studi of Milan), Matilde Moro (Università degli Studi of Milan), Carolina Negro, MD (Università degli Studi of Milan), Carolina Perali, MD (Università degli Studi of Milan), Martina Ratti, MD (Università degli Studi of Milan), Serena Todaro (Università degli Studi of Milan), Alberto Tredese, MD (Università degli Studi of Milan), Clarissa Uslenghi (Università degli Studi of Milan), Valentina Vago (Università degli Studi of Milan), and Bianca Della Santa, MD (Humanitas University, Milan), Arianna Pieroni, MD (Humanitas University, Milan), Francesca Terenzi, MD (Humanitas University, Milan). We thank Marco Salmoiraghi, MD (DG Welfare, Regione Lombardia) and Aida Andreassi, MD (DG Welfare, Regione Lombardia) and all the staff of the DG Welfare, Regione Lombardia for logistical and organizational support. We thank all the health care staff of the COVID-19 Lombardy ICU Network. These individuals were not compensated for their role in the study.

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