Risk factors associated with mortality in critically ill patients with SARS-CoV-2 pneumonia in a tertiary hospital in Ecuador
Authors
-
Fausto Guerero-Toapanta
Universidad de Las Américas, UDLA
https://orcid.org/0000-0002-5839-8539
- Jorge Hurtado-Tapia Hospital de Especialidades Carlos Andrade Marín . Ecuador
- Abel Godoy-Miketta Hospital de Especialidades Carlos Andrade Marín . Ecuador
- Yeimi Herrera-Parra Hospital de Especialidades Carlos Andrade Marín . Ecuador
-
Freddy Maldonado-Cando
Hospital de Especialidades Carlos Andrade Marín . Ecuador
https://orcid.org/0000-0001-8335-7969
- Gabriel García-Montalvo Hospital de Especialidades Carlos Andrade Marín . Ecuador
- José Vinueza-Rivadeneira Hospital de Especialidades Carlos Andrade Marín . Ecuador
-
Juan López-Altamirano
Hospital de Especialidades Carlos Andrade Marín . Ecuador
https://orcid.org/0000-0003-4936-6022
- Edison Ramos-Tituaña Hospital de Especialidades Carlos Andrade Marín . Ecuador
- Cecilia Cruz-Betancourt Hospital de Especialidades Carlos Andrade Marín . Ecuador
DOI:
https://doi.org/10.70099/BJ/2026.03.01.11Keywords:
Pneumonia, Viral Pneumonia, SARS-CoV-2, COVID-19, Sepsis, Adult Respiratory Distress Syndrome, Critical Care, Mechanical VentilationAbstract
Life-threatening pediatric dermatologic emergencies—including Stevens–Johnson syndrome/toxic epidermal necrolysis, necrotizing soft tissue infections, and severe drug-induced cutaneous reactions—carry substantial risk of multi-organ failure (MOF) and death in the pediatric intensive care unit (PICU). Early risk stratification is difficult because commonly used prognostic tools depend on laboratory or organ-based parameters that may not be immediately available. We aimed to identify readily observable cutaneous predictors of early systemic deterioration and to develop and internally validate a simple bedside Pediatric Cutaneous Risk Score (pCRS) to predict MOF and PICU mortality in critically ill children with dermatologic emergencies.
We conducted a retrospective, multicenter cohort study across two tertiary PICUs (January 2018–December 2023) that included 50 consecutive patients aged 0–18 years. The primary outcome was MOF, defined as PELOD-2 ≥11 within 48 hours; the secondary outcome was PICU mortality. Multivariable logistic regression (model limited to three pre-specified predictors) identified three independent cutaneous predictors: body surface area involvement >30% (OR 5.6; 95% CI 2.1–14.9), purpura (OR 4.2; 95% CI 1.6–10.9), and mucosal involvement at ≥2 sites (OR 3.8; 95% CI 1.2–12.1). Each predictor was assigned 1 point (pCRS 0–3), with stepwise mortality increasing from 0% (0 points) to 75% (3 points). The pCRS showed excellent discrimination for mortality (AUC 0.87; optimism-corrected AUC 0.85 after 1,000 bootstrap resamples). This rapid, reproducible score may support early bedside triage and resource allocation in PICU, pending external validation.
References
1. Salluh JI, Burghi G, Haniffa R. Intensive care for COVID-19 in low-and middle-income countries: research opportunities and challenges. Intensive Care Med. 2021;47(2):226–9. DOI: https://doi.org/10.1007/s00134-020-06285-y
2. Ferrando C, Mellado-Artigas R, Gea A, Arruti E, Aldecoa C, Bordell A, et al. Características, evolución clínica y factores asociados a la mortalidad en UCI de los pacientes críticos infectados por SARS-CoV-2 en España: estudio prospectivo, de cohorte y multicéntrico. Rev Esp Anestesiol Reanim. 2020;67(8):425–37. DOI: https://doi.org/10.1016/j.redar.2020.07.003
3. Ioannou GN, Locke E, Green P, Berry K, O'Hare AM, Shah JA, et al. Risk factors for hospitalization, mechanical ventilation, or death among 10 131 US veterans with SARS-CoV-2 infection. JAMA Netw Open. 2020;3(9): e2022310–e2022310. DOI:10.1001/jamanetworkopen.2020.22310
4. Xu J, Yang X, Yang L, Zou X, Wang Y, Wu Y, et al. Clinical course and predictors of 60-day mortality in 239 critically ill patients with COVID-19: a multicenter retrospective study from Wuhan, China. Crit Care. 2020;24(1):1–11. DOI: https://doi.org/10.1186/s13054-020-03098-9
5. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 2020 Mar;395(10229):1054–62. DOI: https://doi.org/10.1016/S0140673620305663
6. Vélez-Paez JL, Montalvo MP, Jara FE, Aguayo-Moscoso S, Tercero-Martínez W, Saltos LS, et al. Predicting mortality in critically ill patients with COVID-19 in the ICU from a secondary-level hospital in Ecuador. Rev Bionatura Internet. 2022; DOI: https://www.revistabionatura.com/files/2022.07.01.1.pdf
7. Vélez Páez JL. Predicción de la mortalidad con marcadores inmunológicos-inflamatorios y hematológicos en pacientes críticos con COVID-19 que habitan en elevada altitud. 2022. DOI: https://hdl.handle.net/20.500.12866/11954
8. Llangarí Lliguín CE. Índice neutrófilo/linfocito como predictor temprano de mortalidad por COVID-19, Hospital General Riobamba Instituto Ecuatoriano de Seguridad Social enero – junio 2021. 2024 Feb; DOI: http://dspace.espoch.edu.ec/handle/123456789/20485
9. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. Jama. 2020;323(13):1239–42. DOI:10.1001/jama.2020.2648
10. Ganesh B, Rajakumar T, Malathi M, Manikandan N, Nagaraj J, Santhakumar A, et al. Epidemiology and pathobiology of SARS-CoV-2 (COVID-19) in comparison with SARS, MERS: An updated overview of current knowledge and future perspectives. Clin Epidemiol Glob Health. 2021 Jun; 10:100694. DOI: https://doi.org/10.1016/j.cegh.2020.100694
11. Kumar A, Arora A, Sharma P, Anikhindi SA, Bansal N, Singla V, et al. Is diabetes mellitus associated with mortality and severity of COVID-19? A meta-analysis. Diabetes Metab Syndr Clin Res Rev. 2020;14(4):535–45. DOI: https://doi.org/10.1016/j.dsx.2020.04.044
12. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The lancet. 2020;395(10229):1054–62. DOI: https://doi.org/10.1016/S01406736(20)305663
13. Wang Z, Wang Z. Identification of risk factors for in-hospital death of COVID-19 pneumonia–lessions from the early outbreak. BMC Infect Dis. 2021;21(1):1–10. DOI: https://doi.org/10.1186/s12879-021-05814-4
14. Kuswardhani RT, Henrina J, Pranata R, Lim MA, Lawrensia S, Suastika K. Charlson comorbidity index and a composite of poor outcomes in COVID-19 patients: A systematic review and meta-analysis. Diabetes Metab Syndr Clin Res Rev. 2020;14(6):2103–9. DOI: https://doi.org/10.1016/j.dsx.2020.10.022
15. Shanbhag V, Arjun N, Chaudhuri S, Pandey AK. Utility of Age-adjusted Charlson Comorbidity Index as a Predictor of Need for Invasive Mechanical Ventilation, Length of Hospital Stay, and Survival in COVID-19 Patients. Indian J Crit Care Med. 2021 Sep;25(9):987–91. DOI: 10.5005/jp-journals-10071-23946
16. Schmidt M, Hajage D, Demoule A, Pham T, Combes A, Dres M, et al. Clinical characteristics and day-90 outcomes of 4244 critically ill adults with COVID-19: a prospective cohort study. Intensive Care Med. 2021 January 1;47(1):60–73. DOI: https://doi.org/10.1007/s00134-020-06294-x
17. Tzotzos SJ, Fischer B, Fischer H, Zeitlinger M. Incidence of ARDS and outcomes in hospitalized patients with COVID-19: a global literature survey. Crit Care. 2020 Aug 2;24(1):516. DOI: https://doi.org/10.1186/s13054-020-03240-7
18. Li X, Liu C, Mao Z, Xiao M, Wang L, Qi S, et al. Predictive values of neutrophil-to-lymphocyte ratio on disease severity and mortality in COVID-19 patients: a systematic review and meta-analysis. Crit Care. 2020;24(1):1–10. Available from: https://doi.org/10.1186/s13054-020-03374-8
19. King AH, Mehkri O, Rajendram P, Wang X, Vachharajani V, Duggal A. A High Neutrophil-Lymphocyte Ratio Is Associated With Increased Morbidity and Mortality in Patients With Coronavirus Disease 2019. Crit Care Explor. 2021 May;3(5): e0444. DOI: 10.1097/CCE. 0000000000000444
20. Lin GL, McGinley JP, Drysdale SB, Pollard AJ. Epidemiology and immune pathogenesis of viral sepsis. Front Immunol. 2018; 9:2147. DOI: https://doi.org/10.3389/fimmu.2018.02147
21. Li H, Liu L, Zhang D, Xu J, Dai H, Tang N, et al. SARS-CoV-2 and viral sepsis: observations and hypotheses. The Lancet. 2020;395(10235):1517–20. DOI: https://doi.org/10.1016/S0140-6736(20)30920-X
22. Force ADT, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson N, Caldwell E, et al. Acute respiratory distress syndrome. Jama. 2012;307(23):2526–33. DOI:10.1001/jama.2012.5669
23. Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. COVID-19 Does Not Lead to a "Typical" Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2020 May 15;201(10):1299–300. DOI: https://doi.org/10.1164/rccm.202003-0817LE
24. Álvarez-Lerma F, Marín-Corral J, Vilà C, Masclans JR, Loeches IM, Barbadillo S, et al. Characteristics of patients with hospital-acquired influenza A (H1N1) pdm09 virus admitted to the intensive care unit. J Hosp Infect. 2017 Feb;95(2):200–6. DOI: https://doi.org/10.1016/j.jhin.2016.12.017
25. Guérin C, Beuret P, Constantin JM, Bellani G, Garcia-Olivares P, Roca O, et al. A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study. Intensive Care Med. 2018 Jan;44(1):22–37. DOI: http://doi.org/10.1007/s00134-017-4996-5
26. RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19. N Engl J Med. 2021 February 24;384(8):693–704. DOI: 10.1056/NEJMoa2021436
27. Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I, et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009;64(Suppl 3): iii1–55. DOI: https://doi.org/10.1136/thx.2009.121434
28. Armstrong RA, Kane AD, Kursumovic E, Oglesby FC, Cook TM. Mortality in patients admitted to intensive care with COVID-19: an updated systematic review and meta-analysis of observational studies. Anaesthesia. 2021;76(4):537–48. DOI: https://doi.org/10.1111/anae.15425
29. Henríquez A, Accini J, Baquero H, Molina F, Rey A, Ángel VE, et al. Clinical features and prognostic factors of adults with COVID-19 admitted to intensive care units in Colombia: A multicentre retrospective study during the first wave of the pandemic. Acta Colomb Cuid Intensivo. 2022 Apr 1;22(2):95–9. DOI: https://doi.org/10.1016/j.acci.2021.02.001
30. Estenssoro E, Loudet CI, Ríos FG, Edul VSK, Plotnikow G, Andrian M, et al. Clinical characteristics and outcomes of invasively ventilated patients with COVID-19 in Argentina (SATICOVID): a prospective, multicentre cohort study. Lancet Respir Med . 2021 September 1;9(9):989–98. DOI: 10.1016/S2213-2600(21)00229-0
Published
How to Cite
Issue
Section
Categories
License
Copyright (c) 2026 FAUSTO GUERRERO-TOAPANTA, Jorge Hurtado-Tapia, Abel Godoy-Miketta, Yeimi Herrera-Parra, Freddy Maldonado-Cando, Gabriel García-Montalvo, José Vinueza-Rivadeneira, Juan López-Altamirano, Edison Ramos-Tituaña, Cecilia Cruz-Betancourt (Author)
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with BioNatura Journal agree to the following terms: Authors retain copyright and grant the BioNatura Institutional Publishing Consortium (BIPC) right of first publication with the work simultaneously licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). This allows others to share the work with an acknowledgment of the work's authorship and initial publication in this journal.This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
