21st October 2020
UK COVID Deaths – Daily 191 / Total 44,158
UK COVID Deaths with COVID-19 on the death certificate - Total 58,164 (up to 9 Oct)
James Cook Hospital – Total COVID deaths – 276
All COVID cases within South Tees Hospitals Trust – 50
James Cook Critical Care COVID cases – 8 (2 ventilated)
We are seeing more and more patients admitted both to the hospital and to Critical Care. Our COVID ICU is now full and we are using the isolation rooms on the High Dependency Unit. We are starting to run out of beds and will have to expand soon. During the last few weeks I have been working on the regular ICU and have not had much chance to catch up with our COVID patients next door.
We currently have eight patients on the ICU with COVID-19, two of whom are ventilated. We are admitting more patients for CPAP to the ICU than we were before. This is partly because this is our usual practice. It was only during the first surge that we were forced to provide a CPAP service on the wards in order to keep the ICU beds free for ventilated patients. One of the other reasons we have fewer ventilated patients at the moment is that they are sadly much less likely to survive and we have had a number of deaths.
The COVID ICU patients are, barring one older exception, in their 50’s and 60’s. They all have underlying health problems although, to be honest, some of these are relatively minor. They have nearly all presented with classic COVID-19 symptoms and have gone on to become breathless and develop respiratory failure. All of them have tried CPAP in an effort to avoid ventilation. This has, so far, worked for most of them.
One of our ventilated patients has been with us for nearly two months now and their ICU stay has been similar to that of a lot of ICU patients with COVID pneumonitis. They have spent most of this time sedated and unconscious. Their respiratory failure has remained a significant, ongoing problem and has been complicated by recurrent infections and pneumothoraces (a pneumothorax occurs when air enters the lining of the lung, causing the lung to collapse. They are caused by lung damage as a result of the infection and the need for ventilation). A recent improvement in ventilator pressures and oxygen requirement meant that our patient was able to undergo a tracheostomy and there is hope that we can begin to reduce the sedative drugs and allow them to gradually wake up. This is an important step in the right direction. It would be unusual for a non-COVID ICU patient not to have undergone a tracheostomy before now but the lung damage caused by the virus can persist for many weeks and we have seen many such patients spend a significant portion of their ICU stay asleep and ventilated with an oral breathing tube.
The latest report from ICNARC (Intensive Care National Audit & Research Centre) has been split into two parts. The first part deals with all COVID-19 Critical Care admissions in the UK up until 31st August, the so-called first wave of patients. The latter part of the report deals with the second wave of ICU patients that have been admitted after 1st September. This will allow us to scrutinise any differences between the cases we are currently seeing and those we treated earlier in the year.
There have been 1233 patients admitted to UK Critical Care Units with confirmed COVID-19 between 1 September and 16th October. The median age of these patients is 60 which is slightly younger than the median age of 62 years seen during the first wave. The male to female distribution appears the same, with 70% of the patients being male and 30% female. The patients are otherwise pretty similar except our current patients are perhaps a little less overweight than before.
We have only just started collecting data for this second wave of patients and so it’s way too early to draw any conclusions. However, it is interesting to note that the rest of the country’s ICUs are also seeing fewer ventilated patients. Only 27% of the current ICU patients required ventilation within the first 24 hours, compared to 58% during the first wave. If we look at the numbers of current patients who have ended up ventilated at any point during their ICU stay, this figure is 29% whereas previously it was 72%. The incidence of kidney failure requiring dialysis, the best marker of illness severity is 8% amongst second wave patients compared to 27% of first wave patients.
Trying to analyse survival at this stage is fraught with inaccuracy. We only know outcome data for 643 of these 1233 second wave patients, We cannot yet compare this with the outcome data we have for the 10,837 first wave patients. Any current survival rate will be biased towards patients who have short stays in the ICU; those who get better quickly or die quickly. It does not paint anything like a full picture.
However, even so, there is a suggestion of a significant improvement in survival amongst these second wave patients. This leads us to ask why this might be the case. Is it the fact that we are still seeing younger patients than before? Or that we may not be admitting the very old and frail as we know, first-hand, that ventilation will not help them recover? Is it the fact that ICU teams are trying to utilise CPAP in order avoid intubation and ventilation? Is it the effect of dexamethasone, the only treatment so far that has been proven to reduce mortality in COVID-19? Or is it the experience that we all gained looking after the deluge of horribly sick COVID patients that we saw back in March and April?
We don’t know. But with winter approaching and the days becoming darker, a little brightness is always welcome.