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Critically Ill Patients with Severe Acute Respiratory Syndrome

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Critically Ill Patients with Severe Acute Respiratory Syndrome CARING FOR THE CRITICALLY ILL PATIENT Critically Ill Patients With Severe Acute Respiratory Syndrome Robert A. Fowler, MD, MS Context Severe acute respiratory syndrome (SARS) is a newly recognized infectious Stephen E. Lapinsky, MB, BCh, MSc disease capable of causing severe respiratory failure. David Hallett, MSc Objective To determine the epidemiological features, course, and outcomes of pa- tients with SARS-related critical illness. Allan S. Detsky, MD, PhD Design, Setting, and Patients Retrospective case series of 38 adult patients with William J. Sibbald, MD SARS-related critical illness admitted to 13 intensive care units (ICUs) in the Toronto Arthur S. Slutsky, MD area between the onset of the outbreak and April 15, 2003. Data were collected daily during the first 7 days in the ICUs, and patients were followed up for 28 days. Thomas E. Stewart, MD Main Outcome Measures The primary outcome was mortality at 28 days after for the Toronto SARS Critical Care ICU admission. Secondary outcomes included rate of SARS-related critical illness, num- Group ber of tertiary care ICUs and staff placed under quarantine, and number of health care workers (HCWs) contracting SARS secondary to ICU-acquired transmission. EVERE ACUTE RESPIRATORY SYN- drome (SARS) is a newly rec- Results Of 196 patients with SARS, 38 (19%) became critically ill, 7 (18%) of whom ognized illness that has rapidly were HCWs. The median (interquartile range [IQR]) age of the 38 patients was 57.4 spread throughout Asia, North (39.0-69.6) years. The median (IQR) duration between initial symptoms and admis- sion to the ICU was 8 (5-10) days. Twenty-nine (76%) required mechanical ventila- SAmerica, and Europe. As of June 9, tion and 10 of these (34%) experienced barotrauma. Mortality at 28 days was 13 (34%) 2003, 8241 people in 30 countries have of 38 patients and for those requiring mechanical ventilation, mortality was 13 (45%) 1 developed SARS leading to 784 deaths. of 29. Six patients (16%) remained mechanically ventilated at 28 days. Two of these The morbidity and mortality associ- patients had died by 8 weeks’ follow-up. Patients who died were more often older, ated with SARS has led to interna- had preexisting diabetes mellitus, and on admission to hospital were more likely to tional concern. have bilateral radiographic infiltrates. Transmission of SARS in 6 study ICUs led to clo- The epidemiological findings and sure of 73 medical-surgical ICU beds. In 2 university ICUs, 164 HCWs were quaran- clinical presentation of SARS for the ini- tined and 16 (10%) developed SARS. tial cases in Canada and Hong Kong have Conclusions Critical illness was common among patients with SARS. Affected pa- been described.2-5 SARS produces an tients had primarily single-organ respiratory failure, and half of mechanically venti- acute respiratory illness with 23% to 32% lated patients died. The SARS outbreak greatly strained regional critical care resources. of patients becoming critically ill.4,6 The JAMA. 2003;290:367-373 www.jama.com burden of illness, clinical features, and sion from critically ill patients to HCWs. Author Affiliations: Interdepartmental Division of Criti- outcome may be different from acute cal Care Medicine (Drs Fowler, Lapinsky, Sibbald, Slut- lung injury due to other etiologies. In A better understanding of SARS- sky, and Stewart) and Departments of Medicine (Drs related critical illness will allow for im- Fowler, Lapinsky, Detsky, Sibbald, Slutsky, and addition, these outbreaks have caused Stewart), Health Policy, Management, and Evalua- a significant strain on the health care sys- proved resource planning and better pro- tion (Dr Detsky), and Anaesthesia (Dr Stewart), Uni- tem by the influx of patients and the hu- tection of HCWs and may suggest versity of Toronto; Sunnybrook and Women’s Col- effective interventions for the patients lege Health Sciences Centre (Drs Fowler and Sibbald); man resources issues related to quaran- Mount Sinai Hospital (Drs Lapinsky, Detsky, and Stew- tine and SARS infection in health care most seriously affected by SARS. art and Mr Hallett); St Michaels Hospital (Dr Slutsky); and University Health Network (Drs Detsky and workers (HCWs). METHODS Stewart), Toronto, Ontario. The objectives of this study were to Members of the Toronto SARS Critical Care group are Study Design listed at the end of this article. characterize the epidemiology, clinical Corresponding Author and Reprints: Stephen E. Lap- characteristics, and 28-day outcomes of We retrospectively studied consecu- insky, MB, BCh, MSc, Mount Sinai Hospital, Suite 1825, tive critically ill adult patients with sus- 600 University Ave, Toronto, Ontario, M5G1X5, critically ill patients with SARS, and to Canada (e-mail: [email protected]). evaluate the impact of SARS transmis- pected and probable SARS in the Caring for the Critically Ill Patient Section Editor: Toronto area who were admitted to in- Deborah J. Cook, MD, Consulting Editor, JAMA. tensive care units (ICUs) between the Advisory Board: David Bihari, MD; Christian Brun- See also pp 374 and 397. Buisson, MD; Timothy Evans, MD; John Heffner, MD; onset of the Toronto outbreak and April Norman Paradis, MD; Adrienne Randolph, MD. ©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, July 16, 2003—Vol 290, No. 3 367 Downloaded From: https://jamanetwork.com/ on 09/27/2021 CRITICALLY ILL PATIENTS WITH SARS 15, 2003 (FIGURE 1). We included 13 on chest radiograph. We defined criti- used only to compare noncritically ill hospitals (5 university, 8 community) cally ill patients as those admitted to the with critically ill SARS patients. Twenty- known to care for SARS patients. (A list ICU requiring mechanical ventilation, nine (76%) of the patients discussed in of the participating hospitals appears at inspired oxygen concentration on face this article were part of this earlier the end of this article.) Identification mask greater than or equal to 60%, or study,5 which did not address SARS- of all critically ill SARS patients in these inotropic medication. To evaluate the related critical illness. When occupa- institutions was achieved by collabo- proportion of patients with suspect or tional transmission of illness was re- ration with the Ontario Hospital Asso- probable SARS who became critically ported in any of the 5 university ICUs, ciation and the City of Toronto Depart- ill, we compared critically ill patients we identified the number of HCWs who ment of Public Health (which were with the total number of patients diag- were quarantined and who developed responsible for the mandatory report- nosed with probable or suspected SARS suspected or probable SARS. The num- ing of SARS), by communication among treated at any of the participating hos- ber of ICU bed closures resulting from an ad hoc Toronto SARS Critical Care pitals by April 15, 2003. SARS transmission or quarantine was group and by cross-reference with a da- tracked in all ICUs. tabase from a previous study that re- Data Collection ported the general characteristics of pa- Data collection forms were created with Patient Characteristics tients with SARS in 10 of our study input from a multidisciplinary group of The following information was col- hospitals.5 HCWs. Following approval from each lected for each patient: age, sex, occu- Suspected and probable SARS was hospital’s research ethics boards, ex- pation (HCW or non-HCW), time defined according to the definitions is- perienced research assistants ab- course of fever or respiratory symp- sued by the World Health Organiza- stracted data retrospectively from the toms, contact or travel to a SARS- tion as of April 20, 2003.7 Suspected medical records. Data were checked for affected area, medical comorbidities, SARS was defined by the presence of fe- errors by a second investigator through date of hospital and ICU admission and ver greater than 38°C, respiratory symp- manual and electronic inspection us- discharge, date of initiation of and lib- toms, and a history of travel to a geo- ing prespecified range limits. The au- eration from mechanical ventilation, graphic location associated with SARS thors of a recent report of SARS pa- and the Acute Physiology and Chronic transmission or close contact with a tients in Toronto provided a database Health Evaluation (APACHE) II and known SARS patient. Probable SARS re- of their general characteristics during sepsis-related organ failure assess- quired the addition of lung infiltrates a similar period.5 This database was ment (SOFA) scores.8,9 Figure 1. Epidemic Curve of All Probable and Suspected Cases of Severe Acute Respiratory Syndrome in Toronto by Source of Infection, Demonstrating the Study Period Data Collection Period Source of Infection 10 Health Care Setting Nonhealth Care Setting Travel Related 8 6 No. of Cases 4 2 0 February March April May Date of Disease Onset 368 JAMA, July 16, 2003—Vol 290, No. 3 (Reprinted) ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 CRITICALLY ILL PATIENTS WITH SARS For each of the first 7 days the pa- those closest to 08:00 hours were re- Table 1. Characteristics of Patients on tient was admitted to the ICU, physi- corded because this time corre- Admission to the Intensive Care Unit* ological markers of organ dysfunction, sponded with the majority of daily mea- Patients ventilatory, radiographic, and treatment- surements. Characteristics (N = 38) related variables were recorded. These Age, y 57.4 (39.0-69.6) Follow-up and Outcome Measures
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