Epidemiology, outcomes, and utilization of intensive care unit resources for critically ill COVID-19 patients in Libya: A prospective multi-center cohort study

Abstract

Background: The coronavirus disease (COVID-19) pandemic has severely affected African countries, specifically the countries, such as Libya, that are in constant conflict. Clinical and laboratory information, including mortality and associated risk factors in relation to hospital settings and available resources, about critically ill patients with COVID-19 in Africa is not available. This study aimed to determine the mortality and morbidity of COVID-19 patients in intensive care units (ICU) following 60 days after ICU admission, and explore the factors that influence in-ICU mortality rate.

Methods: This is a multicenter prospective observational study among COVID-19 critical care patients in 11 ICUs in Libya from May 29th to December 30th 2020. Basic demographic data, clinical characteristics, laboratory values, admission Sequential Organ Failure Assessment (SOFA) score, quick SOFA, and clinical management were analyzed.

Result: We included 465 consecutive COVID-19 critically ill patients. The majority (67.1%) of the patients were older than 60 years, with a median (IQR) age of 69 (56.5-75); 240 (51.6%) were male. At 60 days of follow-up, 184 (39.6%) were discharged alive, while 281 (60.4%) died in the intensive care unit. The median (IQR) ICU length of stay was 7 days (4-10) and non-survivors had significantly shorter stay, 6 (3-10) days. The body mass index was 27.9 (24.1-31.6) kg/m2. At admission to the intensive care unit, quick SOFA median (IQR) score was 1 (1-2), whereas total SOFA score was 6 (4-7). In univariate analysis, the following parameters were significantly associated with increased/decreased hazard of mortality: increased age, BMI, white cell count, neutrophils, procalcitonin, cardiac troponin, C-reactive protein, ferritin, fibrinogen, prothrombin, and d-dimer levels were associated with higher risk of mortality. Decreased lymphocytes, and platelet count were associated with higher risk of mortality. Quick SOFA and total SOFA scores increase, emergency intubation, inotrope use, stress myocardiopathy, acute kidney injury, arrythmia, and seizure were associated with higher mortality.

Conclusion: Our study reported the highest mortality rate (60.4%) among critically ill patients with COVID-19 60 days post-ICU admission. Several factors were found to be predictive of mortality, which may help to identify patients at risk of mortality during the ongoing COVID-19 pandemic.

Fig 1. STROBE flow chart.

STROBE, Strengthening the Reporting of Observational Studies in Epidemiology.

Fig 2

(A) Distribution of mortality of critically ill patients with COVID-19 stratified according to age and sex. (B) Distribution of length of stay in critical care, in days, for COVID-19 patients stratified according to age and mortality.

Fig 3. Kaplan–Meier survival estimates during 60 days following ICU admission.

(A) Age grades (≤ 60, 60–70, > 70 years). (B) BMI (≤ 30, > 30). (C) Quick SOFA (0, 1, 2, 3). (D) Total SOFA Score.

Fig 4. Kaplan–Meier survival estimates during 60 days following ICU admission.

(A) Antibiotic (yes, no). (B) SOFA score category (≤ 9, 10–12, >12). (C) Type of intubation (no intubation, elective, emergency). (D) Inotrope use (yes, no). (E) DVT prophylaxis during first 12 hours.