Prognostic significance of gastrointestinal dysfunction in critically ill patients with COVID-19

Lima, Ricardo Antônio Correia; Blaser, Annika Reintam; Ramalho, Júlia Falconiere Paredes; Lacerda, Barbara Cristina de Almeida Campos; Sadigurschi, Gabriela; Aarestrup, Paula Fonseca; Sales, Rafael Aguilar; Mansur Filho, João; Ferreira, Roberto Muniz

doi:10.62675/2965-2774.20240020-en

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Original Article • Crit. Care Sci. 36 • 2024 • https://doi.org/10.62675/2965-2774.20240020-en linkcopy

Prognostic significance of gastrointestinal dysfunction in critically ill patients with COVID-19

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective: To analyze in-hospital and 1-year morbidity and mortality associated with acute gastrointestinal dysfunction in critically ill patients with COVID-19 via a prespecified scoring system.

Methods: Between March and July 2020, consecutive hospitalized patients with COVID-19 from a single institution were retrospectively analyzed by medical chart review. Only those who remained in the intensive care unit for more than 24 hours were included. Gastrointestinal dysfunction was assessed according to a predefined 5-point progressive gastrointestinal injury scoring system, considering the first 7 days of hospitalization. Laboratory data, comorbidities, the need for mechanical ventilation, the duration of intensive care unit stay, and subsequent in-hospital and 1-year mortality rates were also recorded.

Results: Among 230 patients who were screened, 215 were included in the analysis. The median age was 68 years (54 - 82), and 57.7% were male. The total gastrointestinal dysfunction scores were 0 (79.1%), I (15.3%), II (4.7%), III (0.9%), and IV (0%). Any manifestation of gastrointestinal dysfunction was present in 20.9% of all patients and was associated with longer lengths of stay (20 days [11 - 33] versus 7 days [4 – 16]; p < 0.001] and higher C-reactive protein levels on admission (12.8mg/mL [6.4 - 18.4] versus 5.7mg/mL [3.2 - 13.4]; p < 0.001). The gastrointestinal dysfunction score was significantly associated with mortality (OR 2.8; 95%CI 1.7 - 4.8; p < 0.001) and the need for mechanical ventilation (OR 2.8; 95%CI 1.7 - 4.6; p < 0.001). Both in-hospital and 1-year death rates progressively increased as gastrointestinal dysfunction scores increased.

Conclusion: In the current series of intensive care unit patients with COVID-19, gastrointestinal dysfunction severity, as defined by a prespecified scoring system, was predictive of adverse in-hospital and 1-year outcomes.

Keywords:
COVID-19; Coronavirus infections; Gastrointestinal motility; Gastroparesis; Critical care; Prognosis; Hospital mortality; Hospitalization; Intensive care units

GID score	Definition
0	No symptoms or only 1 of the following factors with normal oral intake: absence of intestinal peristalsis, vomiting, gastric residual volume > 200mL, gastrointestinal paralysis or adynamic ileus, abdominal distension, nonsevere diarrhea, gastrointestinal bleeding without transfusion.
1	2 of the following: no oral intake, absence of intestinal peristalsis, vomiting, gastric residual volume > 200mL, gastrointestinal paralysis or adynamic ileus, abdominal distension, nonsevere diarrhea, gastrointestinal bleeding without transfusion.
2	≥ 3 symptoms of GID 1 or up to 2 of the following factors: severe diarrhea, gastrointestinal bleeding requiring transfusion.
3	≥ 3 of the following factors: prokinetic use, gastrointestinal paralysis or adynamic ileus, abdominal distension, severe diarrhea, gastrointestinal bleeding requiring transfusion.
4	1 of the following factors: gastrointestinal bleeding leading to hemorrhagic shock or mesenteric ischemia.

Variable	Total (n = 215)	GID score = 0 (n = 170)	GID score ≥ 1 (n = 45)	p value
Age (years)	68 (54 - 82)	67 (52 - 79)	71 (61 - 88)	0.002*
Male	124 (57.7)	101 (59.4)	23 (51.1)	0.32
BMI (kg/m²)	26.8 (23.9 - 30.1)	26.2 (23.8 - 29.5)	29 (25 - 31.6)	0.08
Hypertension	113 (52.6)	89 (52.4)	24 (53.3)	0.91
Diabetes	60 (27.9)	47 (27.7)	13 (28.9)	0.87
Cardiovascular disease	25 (11.6)	16 (9.4)	9 (20)	0.049*
Oxygen saturation %	93 (91 - 95)	94 (91 - 96)	92 (88 - 94)	< 0.001*
Noninvasive ventilation	78 (36.3)	47 (27.7)	31 (68.9)	< 0.001*
Hemoglobin (mg/dL)	13.4 (12 - 14.6)	13.4 (12.4 - 14.6)	13 (11.1 - 14.4)	0.14
Leukocyte count (cells/mm³)	5920 (4,590 - 8,300)	5755 (4,330 - 7,860)	7660 (5,350 - 10,480)	< 0.001*
C-reactive protein (mg/mL)	6.7 (3.3 - 14.1)	5.7 (3.2 - 13.4)	12.8 (6.4 - 18.4)	< 0.001*
D-dimer (ng/mL)	795 (465 - 1,446)	803 (459 - 1,446)	660 (473 - 1,366)	0.78

Variable	Univariate analysis OR (95%CI)	p value	Multivariate analysis OR (95%CI)	p value
Age	1.1 (1.0 - 1.1)	< 0.001*	1.0 (1.0 - 1.1)	0.002*
Coronary artery disease	1.7 (0.7 - 4.1)	0.23	0.8 (0.2 - 2.7)	0.73
GID Score	4.1 (2.3 - 7.2)	< 0.001*	3.3 (1.7 - 6.4)	< 0.001*
Oxygen saturation	0.9 (0.8 - 0.9)	0.002*	0.9 (0.8 - 1.0)	0.15
Systolic blood pressure	0.9 (0.9 - 1.0)	0.009*	0.9 (0.9 - 1.0)	0.009*
C-reactive protein	1.1 (1.1 - 1.2)	< 0.001*	1.1 (1.0 - 1.1)	0.014*
Leukocyte count	1.1 (1.0 - 1.1)	0.003*	1.0 (0.9 - 1.0)	0.87

Variable	Univariate analysis OR (95%CI)	p value	Multivariate analysis OR (95%CI)	p value
Age	1.1 (1.1 - 1.2)	< 0.001*	1.1 (1.1 - 1.2)	< 0.001*
Coronary artery disease	2.1 (0.9 - 5.4)	0.1	0.7 (0.2 - 2.1)	0.48
GID Score	2.7 (1.6 - 4.5)	< 0.001*	2.0 (1.1 - 4.0)	0.048*
Oxygen saturation	0.9 (0.8 - 0.9)	0.01*	0.9 (0.9 - 1.0)	0.08
Systolic blood pressure	0.9 (0.97 - 1.0)	0.1	0.9 (0.9 - 1.0)	0.14
C-reactive protein	1.1 (1.0 - 1.1)	0.03*	1.0 (0.9 - 1.1)	0.89

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Associação de Medicina Intensiva Brasileira - AMIB Rua Arminda, 93 - 7º andar - Vila Olímpia, CEP: 04545-100, Tel.: +55 (11) 5089-2642 - São Paulo - SP - Brazil
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[TFN1] GID - gastrointestinal dysfunction.

[2] Source: Adapted from Reintam Blaser A, Padar M, Mändul M, Elke G, Engel C, Fischer K, et al. Development of the gastrointestinal dysfunction score (GIDS) for critically ill patients - A prospective multicenter observational study (iSOFA study). Clin Nutr. 2021;40(8):4932-40.