High Mortality Among Patients With Severe COVID-19 and Do-not-intubate Orders Despite Use of Remdesivir and Dexamethasone

Abstract Background Moderate to severe respiratory distress among patients with coronavirus disease 2019 (COVID-19) is associated with a high mortality. Dexamethasone and remdesivir were introduced in the second wave of COVID-19 in Denmark. Methods This is a retrospective study of patients with COVID-19 and a supplemental oxygen requirement of ≥15 Liters per minute (L/min). The patients were divided in two groups corresponding to the first- and second wave of COVID-19 and analysed regarding need of ventilator support and mortality dependent on orders to Do Intubate (DI) or Do Not Intubate (DNI), respectively. Results The study included 178 patients. The mortality was 24% for patients with DI orders (n=115) and 81% for patients with DNI orders (n=63) increasing to 98% (n=46) for patients with DNI orders and very high flow oxygen requirements (≥30 L/min). Use of constant continuous positive airway pressure (cCPAP) increased from 71% in the first wave to 91% in the second wave (p<0.001) whereas the use of mechanical ventilation (MV) decreased from 54% to 28% (p=0.005). Conclusion The mortality was high for patients with DNI orders and respiratory distress with very high levels in supplemental oxygen in both the first and second wave of COVID-19 despite treatment with dexamethasone and remdesivir and improved prognosis for patients with DI orders. Hence careful evaluation on transition to palliative care must be considered for these patients. Study Registration The study was retrospectively registered and approved by the Danish Patient Safety Authority (record no. 31-1521-309) and the Regional Data Protection Center (record no. WZ20017637-2020-37).