Predictors of ICU Admission in Covid 19 Patients

sugar(RBS), Hb,total leucocytic count (TLC),procalcitonin(PCT), Na, kidney function, IL6, total bilirubin and ferritin. And significant negative correlation with albumin and O2 saturation on room temperature. MV showed significant positive correlation with smoking, age, RR, HR, SBP, DBP, RBS, Hb, TLC, PCT, Na, IL6 and ferritin. And significant negative correlation with albumin, K, total bilirubin and saturation on room temperature. Conclusion: Obesity, increase age, hypertension, diabetes, chest disease, cardiac disease, liver disease and renal disease, High LDH, RR, HR, Bps, DBP, RBS, TLC, CRP, PCT, Na, kidney function, IL6, total bilirubin, ferritin, D dimer and Psychological status are considered predictors of admission to ICU in COVID 19 patients.


Introduction
The severe acute respiratory syndrome corona virus 2 (SARS COV-2) that causes corona virus disease 2019 (COVID 19) poses multiple challenges to our health care.This virus originally identified in Wuhan, China and has forced several countries to take unprecedented public health measures as health professionals and policy makers try to shield those at highest risk [1].
The requirement of intensive care among COVID 19 hospitalized patients varies between countries from 5% to 32%.Many factors including age, sex, and comorbidities are associated with the severity of disease and ICU admission.According to these studies, severe disease is accompanied by acute kidney injury, acute respiratory distress syndrome (ARDS), myocarditis , cardiac and septic shock.Hence, ICU admission plays a crucial role in the care of COVID 19 patients and also is effective in decreasing the mortality rate [2].
The aim of the present study was to detect the predictors of ICU admission in COVID 19 patients.

PATIENTS AND METHODS
This was a retrospective study from patients' files involved 258 patients admitted to Shebin Elkom fever hospital who are diagnosed positive of covid 19 according to WHO criteria in the period between February and May2021.The studied patients were classified into the following groups according to the need of ICU admission Group I: include186 patient who need ICU care on admission or at some point during hospital stay, Group II: Included 72 patients who did not need ICU care.GI patients were reclassified into two subgroups according to the need of mechanical ventilation: GIa: Included 134 patient which undergo mechanical ventilation either invasive (123) IMV patients or not NIMV Group (11 patients), 52 patients admitted to ICU did not undergo mechanical ventilation.GI b Prognostic effects of variables on admission among patients who received intensive care unit (ICU) support and those who didn't require ICU care were studied.Adults more than18 years who are Covid 19 confirmed with any one item of serological or radiological evidence , real time PCR test positive for SARS-COV2 or radiological findings in the form of ground glass opacity or vascular were included in our study.Patients less than18 years old, Pregnant women and asymptomatic and normal x-ray finding subjects were excluded from our study.
All patients were subjected to full history taking: With special emphasis on constitutional and chest symptom.Full clinical examination (General examination, Local chest examination), Routine laboratory investigations, Complete blood count, Liver Function Tests including serum albumin, serum alkaline phosphatase (ALP), prothrombin concentration, prothrombin time and INR, blood urea and serum creatinine lipid profile inflammatory markers, electrolytes, and Imaging study.

Statistical analyses:
Data was statistically analyzed using SPSS (statistical package for social science) program version 13 for windows and for all the analysis a p value < 0.05 was considered statistically significant: Data are shown as mean, range, or value and 95% confidence interval (95% CI) and frequency and percent.Chi square test was done for qualitative variable analysis and p-value < 0.05 was considered p significant.Student t-test was done for normally distributed quantitative variables to measure mean and standard deviation and p-value < 0.05 was considered significant.Pearson correlation test was done to study correlation between one qualitative variable and one quantitative variable or two quantitative variables of not normally distributed data and p-value less than 0.05 was considered significant.All these tests were used as tests of significance at P<0.05: <0.05 non-significant, <0.01 Highly significant.

RESULTS
They were 145 males (56.2 %) and 113 females (43.8%) and their ages ranged between 30 and 82 years with mean value (61.57± 14.58 years).Sex had no effect on ICU admission (p>0.05).However, Obesity, age, hypertension, diabetes, chest disease, cardiac disease, liver disease and renal disease showed significant association with ICU admission (P 0.001, 0.006).However, autoimmune diseases had no association with admission to ICU (p >0.05) (table 1).RR(respiratory rate), HR(heart rate, SBP(systolic blood pressure) and DBP(diastolic pressure), showed significant increase in patients admitted to ICU when compared to patients not admitted to ICU (P= 0.001 each).However, saturation on room air showed significant decrease in patients admitted to ICU when compared to patients not admitted to ICU (P= 0.001) (table 2).Advanced CT and abnormal ABG were significantly associated with admission to ICU (P= 0.001).(table 3).
Significant difference between studied groups (IMN, NIMV and no MV groups ) regarding Hb, TLC, PCT, K, Il6, albumin, ferritin, D dimmer and saturation on room air.However, no significant difference was found regarding CRP, kidney function and total bilirubin (table 7).
There is a significant difference between studied groups (IMN, NIMV and no MV groups ) regarding mortality among studied patients (p=0.001) ( table 7)., Bps, BPD, showed significant increase in patients admitted to ICU when compared to patients not admitted to ICU (P= 0.001 each).However, saturation on room air showed significant decrease in patients admitted to ICU when compared to patients not admitted to ICU (P= 0.001).RR respiratory rate; HR heart rate; SPB systolic blood pressure; DPB diastolic blood pressure;

Discussion
The The present study revealed that High LDH was significantly associated with ICU admission.In line with our finding, high LDH was significantly associated with ICU admission.Elevated LDH indicates cell death and injury and is associated with a poor host immune response, resulting in a higher susceptibility to severe viral infections [17].Also, Hatami et al showed that Lactate dehydrogenase (LDH) level was also significantly higher among the ICU group [7].
The present study showed that worse CT and abnormal ABG were significantly associated with admission to ICU.Similarly, previous studies showed that increased rate of consolidations, along with increasing percentages of lung involvement in patients is associated with disease progression and could partially explain the observed association [18,19].

Also, Kanne et al showed that a higher proportion of cases who mandated ICU admission had worse CT signs of infection [19]
Numerous studies have illustrated the practical value of CT chest not just as a detector of disease severity but also as a diagnostic instrument in areas with limited resources [18].
Regarding vital signs we found that RR, HR, DPB, SBP, RBS showed significant increase in patients admitted to ICU when compared to patients not admitted to ICU.However, saturation on room air showed significant decrease in patients admitted to ICU when compared to patients not admitted to ICU.
In agreement with our study, Elsharawy et al.,(2021) demonstrated that ICU patients had significantly higher respiratory rates, body temperatures, and pulse rates.Furthermore, only two ICU admitted patients had bradycardia, while the majority had either normal or increased pulse rates.So pulse rate can be used as a rapid, simple, and bedside indicator of disease severity.Therefore, this finding highlights the importance of conducting ECG as a routine for COVID-19 infected patients [20].This increase in pulse rate can be attributed to many influences, including increased body temperature (as pulse increases 9.46 beats/min/°C in female patients and 7.24 beats/min/°C in male patients for every 1°C increase in body temperature), cardiac affection caused by COVID-19 infection, and associated inflammation.
The present study showed that CRP showed significant increase in patients admitted to ICU when compared to patients not admitted to ICU.CRP, in our study, was considerably higher in the ICU group and revealed an evident correlation with both oxygen saturation and severities, it could not be considered an independent forecaster of ICU admission since it was one of the crucial variables in univariate but not multivariate analysis, in contrast to previous studies [21,22].
The present study showed that TLC, PCT, Na, kidney function, IL6, total bilirubin, ferritin, D dimer showed significant increase in patients admitted to ICU when compared to patients not admitted to ICU.However, K level showed no significant difference between the two groups.
Previous studies showed that patients at high risk for ARDS development are those older than 65 years old, presenting high fever (T > 39ºC), neutrophilia, lymphocytopenia, elevated markers of hepatic and renal failure (aspartate aminotransferase, alanine aminotransferase, creatinine, and urea), elevated acute-phase proteins as markers of inflammation (highsensitivity C-reactive protein, procalcitonin, and serum ferritin), and elevated coagulation function-related indicators (prothrombin time, fibrinogen, and D-dimer) [23, 24].Huang et al in meta-analysis showed that an elevated serum CRP, PCT, D-dimer, and ferritin were associated with a poor outcome in COVID-19 [23].
The present study revealed that ICU admission not associated with presence of cancers.Contrarily, other study showed that suffering from cancer could increase the prevalence of ICU admission among COVID-19 infected patients [26] The present study showed that psychological status showed significant association with admission to ICU.Similarly, other study estimated that the risk for psychiatric sequelae is higher in COVID-19 patients and in those admitted to ICU using electronic health records data [28].
Our study revealed that ICU admission showed significant positive correlation with, Hb, TLC, PCT, Na, kidney function, IL6, total bilirubin and ferritin.And significant negative correlation with albumin and saturation on room temperature.
In line with our finding, previous studies showed that the level of serum ferritin had been posited as one of the predictors of poor outcome in COVID 19 sufferers.Higher levels of serum ferritin were associated with higher odds of ICU admission through both univariate and multivariate analyses in this work, which was comparable to earlier studies that found an association between raised ferritin count and fatality, but with a lower cut off value (300 ng/ml) vs (368 ng/ml) in our study [29].

Sadeghi et al., (2020)
showed that the admission O2 saturation, HCT, CRP levels at first admission and myalgia presentation could be considered as the valuable predictors of ICU admission [27].D-dimer elevation was associated with a hypercoagulable state, however, its specificity on the main cause of elevation may not be known as D-dimer elevations were associated with several unfavorable events including occlusion, sepsis, micro-thrombosis, and intravascular coagulation The present study revealed that there was significant difference between the IMN, NIV MV and no MV groups regarding sex, age, smoking and weight.men might be more susceptible to receive IMV and NIMV than women.Jackson  We found that there is a significant difference between studied groups (IMN, NIV, MV and no MV groups) regarding RR, HR, SBP, DBP and RBS.Seetharam et al showed that mechanically ventilated patients had a higher incidence of tachycardia (heart rate > 125), elevated respiratory rate > 24 cycles per minute, shortness of breath, and headaches.In addition, mechanically ventilated patients had a lower serum albumin (g/dl) ≤3 units, elevated serum creatinine, elevated serum CRP-HS, serum LDH, SGOT IU/L or AST IU/L, SGPT or ALT, and WBC count [33].
The present study showed that there is significant difference between studied groups (IMN , NIV MV and no MV groups ) regarding Hb, Tlc, PCT, K, Il6, albumin, ferritin, D dimmer and saturation on room air.However, no significant difference was found regarding CRP, kidney function and total bilirubin.
Our study showed that there is significant difference between studied groups (IMN, NIV MV and no MV groups) regarding associated oncology.Péron (2021) showed that the risk of intubation and mechanical ventilation was lower among cancer patients [35].
The current study showed that there is significant difference between studied groups (IMN, NIV MV and no MV groups) regarding psychological status.Similarly, Moreover, we found that there is a significant difference between studied groups (IMN , NIV MV and no MV groups ) regarding mortality among studied patients.
In line with our finding, studies of invasive mechanical ventilation to treat COVID-19 respiratory failure have shown a mortality rate greater than 85% [37].
Regarding the notable limitations of the present study, one can refer to limited generalizability of the results since it was a retrospective study based on a single institution.Moreover, relatively limited sample size; this could limit the generalizability of our results.

Conclusion
Obesity, increase age, Hypertension, diabetes, chest disease, cardiac disease, liver disease and renal disease, High LDH, RR, HR, Bps, DBP, RBS, TLC, CRP, PCT, Na, kidney function, IL6, total bilirubin, ferritin, D dimer and Psychological status are considered predictors of admission to ICU in COVID 19 patients.Also study showed that there is significant difference between studied groups ( IMN , NIV MV and no MV groups ) regarding Hb, TLC, PCT, K, Il6, albumin, ferritin, D dimmer and saturation on room air.However, no significant difference was found regarding CRP, kidney function and total bilirubin for the need for mechanical ventilation.
Ethical considerations All procedures were carried out in accordance with the ethical standards.Approval from the ethics committee of the Faculty of Medicine, Menoufia University was taken.

Highlights:
 The global spread of the SARS-CoV-2 virus imposes an enormous burden on medical health systems.

Table (
Relation between vital signs and ICU admission among studied group This table shows that sex,auto immune diseases had no effect on ICU admission (p>0.05).However, Obesity and increase age showed significant association with ICU admission (P=0.001each).AF; atrial fibrillation CKD chronic kidney diseases; CLD chronic liver diseases; COPD chronic obstructive pulmonary diseases; HTN hypertension; IHD ischemic heart diseases; SLE systemic lupus Table (2):

Table ( 3
): Relation between (CT,ABG and LDH ) and admission among studied groups PCT, Na, kidney function, IL6, total bilirubin, ferritin, D dimer showed significant increase in patients admitted to ICU when compared to patients not admitted to ICU (P= 0.001 each K level showed no significant difference between the two groups (p>0.05)CRPc-reactive protein, DPB diastolic blood pressure ; HR heart rate; PCT procalcitonin RR respiratory rate; SPB systolic blood pressure;; TLC total leucocytic count,Table (5): Correlation between ICU admission and mechanical ventilation with other parameters * P<0.05 significant ** P<0.01 Highly significant ICU admission showed significant positive correlation with smoking, age, RR, HR, Bps, Bpd, RBS, Hb, TLC, PCT, Na, kidney function, IL6, total bilirubin CRP c-reactive protein, DPB diastolic blood pressure ; HR heart rate; PCT procalcitonin RR respiratory rate; SPB systolic blood pressure;; TLC total leucocytic count, Table (6): Relation between ICU admission and mechanical ventilation in the study group

Table 7 :
relation between mortality and mechanical ventilation in the study group present study was retrospective study aimed to detect the predictors of ICU admission in COVID 19 patients.
et al reported that advanced age is one of the strongest predictors of the mortalityrelated to mechanical ventilation in COIVD19 patients [30].
Predictors of ICU admission in COVID 19 patients are needed.