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Innocent bystanders: effects of the COVID-19 pandemic on non-COVID-19 critical illness outcomes
  1. James A Russell
  1. Division of Critical Care Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to Dr James A Russell, Division of Critical Care Medicine, The University of British Columbia, Vancouver, Canada; Jim.Russell{at}

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The COVID-19 pandemic massively impacted healthcare directly and indirectly causing staggering collateral damage on innocent bystander patients with critical illness and non-COVID-19 community-acquired pneumonia (CAP). We consider in more detail non-COVID-19 CAP because it is one of the most common causes of Intensive Care Unit (ICU) admission and mortality.

It is propitious that McLarty et al evaluated effects of the COVID-19 pandemic on critical illness mortality.1 In 1.7 million non-COVID-19 admissions in 15 countries, ICU mortality increased slightly but significantly between 2019 (9.3%) and 2020 (10.4%), especially in low-income and middle-income countries. One evaluated mechanism of altered mortality was burden of COVID-19/ICU bed, but that did not correlate with altered critical illness mortality. Strengths of their study are the large international sample size and evaluation of COVID-19 burden per bed within sites. Limitations are findings of association without proof of causation, lack of several prepandemic years to evaluate prepandemic year-to-year oscillations in ICU mortality, that the main results could be the play of chance, that the small—1%—absolute difference in mortality was significant mainly because of the very large sample size, and unintended site and country selection bias and variable data quality of registries could affect outcomes.

McLarty et al’s study suggested direct associations between COVID-19 ICU admission burden and non-COVID-19 ICU mortality in low-income and middle-income countries.1 Discerning the causes of altered COVID-19 mortality is nearly impossible in cohort studies because there are inevitably many confounders, for example, societal interventions (eg, lockdowns), healthcare and ICU system differences (funding, nurse/patient ratios), patient mix changes between study periods and the effects of COVID-19 surges on non-COVID-19 outcomes.

Taking non-COVID-19 CAP as a paradigm example of the impact of the pandemic on non-COVID-19 conditions that often require ICU admission, in our single-centre study of 5219 non-COVID-19 CAP ward …

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  • Contributors Conception and design: JAR. Interpretation: JAR. Drafting the manuscript for important intellectual content: JAR.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests JAR reports patents owned by the University of British Columbia (UBC) that are related to (1) the use of PCSK9 inhibitor(s) in sepsis, (2) the use of vasopressin in septic shock and (3) a patent owned by Ferring for use of selepressin in septic shock. JARl is an inventor on these patents. JAR was a founder, Director and shareholder in Cyon Therapeutics (now closed) and is a shareholder in Molecular You Corp. JAR is Senior Research Advisor of the British Columbia, Canada Post COVID—Interdisciplinary Clinical Care Network (PC-ICCN). JAR is no longer actively consulting for any industry. JAR reports receiving consulting fees in the last 3 years from: (1) JAR was a funded member of the Data and Safety Monitoring Board (DSMB) of an NIH-sponsored trial of plasma in COVID-19 (PASS-IT-ON) (2020-2021). 2. PAR Pharma (sells prepared bags of vasopressin). JAR has received grants for COVID-19 and for pneumonia research: four from the Canadian Institutes of Health Research (CIHR) and three from the St. Paul’s Foundation (SPF). JAR was a non-funded Science Advisor and member, Government of Canada COVID-19 Therapeutics Task Force (June 2020–2021).

  • Provenance and peer review Commissioned; internally peer reviewed.

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