Usefulness of NEWS 2 score in monitoring patients with cytokine storm of COVID-19 pneumonia

Dr. K. Saisoundharya, Dr. G. Dominic Rodriguez*, Dr. Ivan A Jones, Dr. Stephy George

Department of General Medicine, Kauvery Hospital, Trichy

Abstract

There is a need for uniform assessment of inpatients with critical illness to assess progress and to guide decisions. NEWS 2 score is a simple validated score which we used to monitor patients during the cytokine storm phase of COVID-19 pneumonia.

Background

NEWS 2 is a standardized clinical scoring system developed to improve the detection of deterioration in acutely ill patients. It is based on the aggregate scoring of six physiological parameters: respiratory rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion and body temperature. In addition, two points are added for patients requiring supplemental oxygen treatment. A NEWS 2 score of 5 or 6 is considered a key threshold that may indicate clinical deterioration and should prompt an urgent response by a clinician or team with competence in the assessment and treatment of acutely ill patients. A prospective cohort study by Myrstad et al [1] stated that NEWS 2 on admission predicts severe disease and in hospital mortality in COVID 19 patients1.

Aim

The primary aim is to study the utility of NEWS2 score as a clinical predictor of outcome post Tocilizumab administration.

Objective

The objective is to study the trends of NEWS2 score before Tocilizumab, 2 days, 1 week, 2 weeks and 28 days post-Tocilizumab between the survived patients and the patients who succumbed to death and to analyse if there is any significant difference between the two groups.

Materials

Study area: COVID Intensive care unit, Kauvery Medical Centre, a tertiary care hospital, Trichy. Study population: Patients admitted with COVID-19 who were treated with Tocilizumab from June to December 2020 were included in this study. Sample size: 60 Study design: Retrospective observational study Study duration: January 2021 to December 2021

Inclusion criteria:

1) Hospitalized patients with COVID-19 pneumonia diagnosed by positive RT-PCR and evidence of ground glass opacities/consolidation in CT chest.

2) Severe COVID are defined as patients with SpO2 less than 90 and respiratory rate more than 30.

3) Cytokine storm is defined as a syndrome clinically characterized by (a) acute rapid deterioration in clinical status over a period of 24 to 48 h which usually occurs on the 6th to 10th day of illness with (b) rapid increase in respiratory rate and oxygen requirements accompanied by laboratory evidence of hyperinflammatory syndrome which includes increased levels of one or more of the following

Ferritin
CRP
LDH
D-dimer

Exclusion criteria

Severe allergic reactions to Tocilizumab or other monoclonal antibodies
Active TB infection
Suspected active bacterial or fungal infection
Treatment with immunosuppressive or immune-modulatory therapy within the past 3 months
Pregnant and lactating mothers.
Absolute Neutrophil Count < 500
Platelet count < 50000
AST/ALT > 5 times the upper limit of normal
History of diverticulitis or bowel perforation

Table 1. The NEWS scoring system

The NEWS 2 scoring system reproduced from the Royal college of Physicians (National Early Warning Score 2 (NEWS 2): Standardizing the assessment of acute illness severity in NHS. Updated report of a working party London. RCP, 2017.

Results

Table 2. Analysis of mean NEWS 2 score before Tocilizumab, 2 Days, 1 week, 2 week, 28 days post-Tocilizumab administration in the survivor and non survivor groups.

NEWS 2 BEFORE TOCILIZUMAB
GROUP	N	Mean	Std. Deviation	P - Value
Survivor group	37	6.16	1.482	χ2= 0.021 SIG
Non survivor group	23	7.22	1.757	χ2= 0.021 SIG

2 DAYS AFTER TOCILIZUMAB
GROUP	N	Mean	Std. Deviation	P - Value
Survivor group	37	5.43	1.537	χ2= 0.000 SIG
Non survivor group	20	7.10	1.518	χ2= 0.000 SIG

1WEEK AFTER TOCILIZUMAB
GROUP	N	Mean	Std. Deviation	P - Value
Survivor group	36	4.28	1.466	χ2= 0.000 SIG
Non survivor group	15	7.33	2.059	χ2= 0.000 SIG

2WEEKS AFTER TOCILIZUMAB
GROUP	N	Mean	Std. Deviation	P - Value
Survivor group	21	3.29	1.189	χ2= 0.000 SIG
Non-survivor group	10	6.90	0.994	χ2= 0.000 SIG

28 DAYS AFTER TOCILIZUMAB
GROUP	N	Mean	Std. Deviation	P - Value
Survivor group	6	3.00	0.632	χ2= 0.056 SIG
Non-survivor group	3	10.33	3.215	χ2= 0.056 SIG

In our study population (60), 37 patients survived post-Tocilizumab administration and 23 patients succumbed to death post-Tocilizumab. We studied the NEWS 2 score before Tocilizumab, 2 days, 1 week; 2 weeks and 28 days post-Tocilizumab in the survivor group and the non-survivor group. A NEWS 2 score of 5 or 6 and above denotes significant clinical deterioration.

We compared the mean NEWS 2 score before Tocilizumab between the survivor group and the non-survivor group and found that the NEWS 2 score prior to Tocilizumab was significantly higher in the non-survivor group when compared to the survivor group (p-value = 0.021).

When comparing the mean NEWS 2 score 2 days post-Tocilizumab administration we found that the NEWS 2 score was significantly high in the non-survivor group compared to the survivor group (p-value = 0.00)

When comparing the mean NEWS 2 score 1-week post-Tocilizumab between the survivor group and the non-survivor group we found that NEWS 2 score was persistently high in the non-survivor group compared to the survivor group (p-value = 0.00).

When comparing the mean NEWS 2 score 2 weeks post-Tocilizumab between the survivor group and the non-survivor group, we found that the NEWS 2 score was persistently high in the non-survivor group compared to the survivor group (p-value = 0.000).

When comparing the mean NEWS 2 score 28 days post-Tocilizumab between the survivor group and the non-survivor group, we found that the NEWS 2 score was persistently high in the non-survivor group compared to the survivor group (p-value = 0.056).

Fig 1. Line diagram showing the trends of NEWS2 score before Tocilizumab, 2 days, 1 week, 2 weeks and 28 days post-Tocilizumab administration in the survived group and the non-survivor group.

The above graph shows the trends in the NEWS 2 score before Tocilizumab and 2 days, 1 week, 2 week and 28 days post-Tocilizumab administration in the group which survived post-Tocilizumab administration and the group which succumbed to death

Discussion

Among the study population (60 people), the clinical outcome in terms of survival and mortality were studied. Among 60 people who received Tocilizumab, 61.7% of people (37) people survived and 38.3% of people (23) died. When analysing the NEWS 2 score we found that the mean baseline value prior to Tocilizumab administration was higher in the non-survivor group compared to the survivor group and it was statistically significant. Similarly, the NEWS 2 score compared by the end of 2 days, 1 week, 2 weeks and 28 days between the survived group and the non-survived group of patients was also statistically significant with a higher NEWS 2 score persisting in the non-survived group compared to the survived group. This is the most important observation from our study since we found that a simple clinical score without the need for expensive investigations could predict the outcome in patients with COVID-19 who received Tocilizumab.

Conclusion

Tocilizumab has been found to be effective in a subset of patients with cytokine storm especially when identified and administered early along with steroids. NEWS 2 score was able to predict a higher risk of mortality before administration and also on follow-up on the 2nd day, 1 week, 2 weeks and 28 days post-Tocilizumab administration. A persistent high NEWS2 score was associated with mortality.

The limitation of our study was that it was a retrospective study. The sample size was small, and only a single dose of Tocilizumab was used. Moreover, we didn’t have a control group for effective comparison.

Refercence

Myrstad M, et al. NEWS2 on admission predicts severe disease and in-hospital mortality from COVID-19: a prospective cohort study. Scand. J. Trauma, Resusc. Emerg. Med. 2020;28:66.

Dr. G. Dominic Rodriguez

General Physician

Dr. Ivan A. Jones

Critical Care specialist

Usefulness of NEWS 2 score in monitoring patients with cytokine storm of COVID-19 pneumonia