Hypotension and Hypoxemic Respiratory Failure Precede Mortality in COVID-19

patient on ventilator in intensive care unit
Patient with aspiration pneumonia on a ventilator and intubated with a nasogastric tube in an intensive care unit (ICU).
Hypoxemic respiratory failure and hypotension were the most common precursors of mortality in critically ill patients with COVID-19 during the first 3 weeks of the outbreak in Seattle, Washington.

Hypoxemic respiratory failure and hypotension were the most common precursors of mortality in critically ill patients with coronavirus 2019 (COVID-19) during the first 3 weeks of the COVID-19 outbreak in Seattle, Washington, according to study results published in the New England Journal of Medicine.

According to researchers, the first reported cases of COVID-19 in the United States occurred in January 2020 in Washington State; however, reports describing patients with COVID-19 admitted to intensive care units (ICUs) in the United States are limited. The objective of this study was to identify and describe the demographic characteristics, comorbidities, imaging findings, and outcomes in critically ill patients with COVID-19 in Seattle and outlying suburbs.

The researchers identified 24 adults with confirmed COVID-19 who were admitted to 9 hospital ICUs in the Seattle area between February 24 and March 9, 2020. Data on demographics, symptoms at presentation, and lab and radiologic results were obtained during ICU admission. The researchers used the data available through March 23, 2020, for this study.

The mean (± standard deviation) age of patients was 64±18 years, 63% were men, and the mean duration of symptoms prior to ICU admission was 7±4 days. Shortness of breath and cough were the most common symptoms on admission to the ICU, each of which occurred in 88% of patients (n=21). Fever was present in 50% of patients (n=12), and chronic medical conditions were common in all 24 patients, with 58% having diabetes (n=14), 21% having chronic kidney disease (n=5), and 14% having asthma (n=3). 

Mechanical ventilation was administered to 75% of patients (n=18), and 71% (n=17) had hypotension and needed vasopressors. By March 23, half of the patients (n=12) had died, 17% (n=4) remained in the hospital, 13% (n=3) were receiving mechanical ventilation in the ICU, and 21% (n=5) had been discharged from the hospital. Death was more common in patients older than 65 years vs younger patients (62% vs 37%).

Limitations to this study included missing or incomplete data on clinical symptoms and laboratory testing, unknown outcomes for patients who remained in hospitals past March 23, small sample size, and exclusion of critically ill patients with established goals of care not consistent with ICU admission.

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The researchers concluded that the early experience of COVID-19 in the United States resembles that in other countries, and that patients at the highest risk for mortality from COVID-19 include those who require care in the ICU, those who are older, and those with comorbidities.


Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in critically ill patients in the Seattle region — case series [published online March 30, 2020]. N Engl J Med. doi:10.1056/NEJMoa2004500