• Giacomo Grasselli, Massimiliano Greco, Alberto Zanella, Giovanni Albano, Massimo Antonelli, Giacomo Bellani, Ezio Bonanomi, Luca Cabrini, Eleonora Carlesso, Gianpaolo Castelli, Sergio Cattaneo, Danilo Cereda, Sergio Colombo, Antonio Coluccello, Giuseppe Crescini, Forastieri Molinari Andrea A Department of Anesthesiology and Intensive Care, ASST Lecco-Ospedale di Lecco, Lecco, Italy., Giuseppe Foti, Roberto Fumagalli, Giorgio Antonio Iotti, Thomas Langer, Nicola Latronico, Ferdinando Luca Lorini, Francesco Mojoli, Giuseppe Natalini, Carla Maria Pessina, Vito Marco Ranieri, Roberto Rech, Luigia Scudeller, Antonio Rosano, Enrico Storti, B Taylor Thompson, Marcello Tirani, Pier Giorgio Villani, Antonio Pesenti, Maurizio Cecconi, and COVID-19 Lombardy ICU Network.
• Dipartimento di Anestesia, Rianimazione e Emergenza-Urgenza, Fondazione IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
• JAMA Intern Med. 2020 Oct 1; 180 (10): 1345-1355.

ImportanceMany patients with coronavirus disease 2019 (COVID-19) are critically ill and require care in the intensive care unit (ICU).ObjectiveTo evaluate the independent risk factors associated with mortality of patients with COVID-19 requiring treatment in ICUs in the Lombardy region of Italy.Design, Setting, And ParticipantsThis retrospective, observational cohort study included 3988 consecutive critically ill patients with laboratory-confirmed COVID-19 referred for ICU admission to the coordinating center (Fondazione IRCCS [Istituto di Ricovero e Cura a Carattere Scientifico] Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy) of the COVID-19 Lombardy ICU Network from February 20 to April 22, 2020. Infection with severe acute respiratory syndrome coronavirus 2 was confirmed by real-time reverse transcriptase-polymerase chain reaction assay of nasopharyngeal swabs. Follow-up was completed on May 30, 2020.ExposuresBaseline characteristics, comorbidities, long-term medications, and ventilatory support at ICU admission.Main Outcomes And MeasuresTime to death in days from ICU admission to hospital discharge. The independent risk factors associated with mortality were evaluated with a multivariable Cox proportional hazards regression.ResultsOf the 3988 patients included in this cohort study, the median age was 63 (interquartile range [IQR] 56-69) years; 3188 (79.9%; 95% CI, 78.7%-81.1%) were men, and 1998 of 3300 (60.5%; 95% CI, 58.9%-62.2%) had at least 1 comorbidity. At ICU admission, 2929 patients (87.3%; 95% CI, 86.1%-88.4%) required invasive mechanical ventilation (IMV). The median follow-up was 44 (95% CI, 40-47; IQR, 11-69; range, 0-100) days; median time from symptoms onset to ICU admission was 10 (95% CI, 9-10; IQR, 6-14) days; median length of ICU stay was 12 (95% CI, 12-13; IQR, 6-21) days; and median length of IMV was 10 (95% CI, 10-11; IQR, 6-17) days. Cumulative observation time was 164 305 patient-days. Hospital and ICU mortality rates were 12 (95% CI, 11-12) and 27 (95% CI, 26-29) per 1000 patients-days, respectively. In the subgroup of the first 1715 patients, as of May 30, 2020, 865 (50.4%) had been discharged from the ICU, 836 (48.7%) had died in the ICU, and 14 (0.8%) were still in the ICU; overall, 915 patients (53.4%) died in the hospital. Independent risk factors associated with mortality included older age (hazard ratio [HR], 1.75; 95% CI, 1.60-1.92), male sex (HR, 1.57; 95% CI, 1.31-1.88), high fraction of inspired oxygen (Fio2) (HR, 1.14; 95% CI, 1.10-1.19), high positive end-expiratory pressure (HR, 1.04; 95% CI, 1.01-1.06) or low Pao2:Fio2 ratio (HR, 0.80; 95% CI, 0.74-0.87) on ICU admission, and history of chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.28-2.19), hypercholesterolemia (HR, 1.25; 95% CI, 1.02-1.52), and type 2 diabetes (HR, 1.18; 95% CI, 1.01-1.39). No medication was independently associated with mortality (angiotensin-converting enzyme inhibitors HR, 1.17; 95% CI, 0.97-1.42; angiotensin receptor blockers HR, 1.05; 95% CI, 0.85-1.29).Conclusions And RelevanceIn this retrospective cohort study of critically ill patients admitted to ICUs in Lombardy, Italy, with laboratory-confirmed COVID-19, most patients required IMV. The mortality rate and absolute mortality were high.

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