key: cord-300510-fhpkdqr0
authors: Mojoli, Francesco; Mongodi, Silvia; Orlando, Anita; Arisi, Eric; Pozzi, Marco; Civardi, Luca; Tavazzi, Guido; Baldanti, Fausto; Bruno, Raffaele; Iotti, Giorgio Antonio
title: Our recommendations for acute management of COVID-19
date: 2020-05-08
journal: Crit Care
DOI: 10.1186/s13054-020-02930-6
sha: 
doc_id: 300510
cord_uid: fhpkdqr0

nan

disease, with cough, fever and flu-like syndrome, evolving to dyspnoea after 2-10 days and presenting with bilateral chest infiltrates. Blood gas analysis initially shows moderate hypoxaemia, metabolic acidosis with/without respiratory compensation, normal lactates and increased anion gap; ketoacids are found in urinary sticks. Blood samples show high C-reactive protein, normal procalcitonin, increased lactate dehydrogenase, creatine phosphokinase, amylases, lipases and hyperglycaemia. A nasal swab for 2019 novel coronavirus is routinely performed in any upper/lower airways disease [2] [4] . For this same purpose, add a highefficiency particulate air filter before the positive end-expiratory pressure valve or, better, connect the valve to wall gas aspiration [6] [7] [8] . 7. Perform early intubation if poor response to continuous positive airway pressure in terms of oxygenation: do not trust patients' relatively good respiratory mechanics and feeling of improved dyspnoea, since these patients may have relatively normal lung compliance and the only clinical sign of fatigue may be high respiratory rate. Connect ventilator expiratory valve to wall gas aspiration to limit droplets' spread. 8. Once intubated, perform a closed system bronchoalveolar lavage to confirm diagnosis: minimize the use of fiberbronchoscopes to limit airways' opening; we connect a bronchoalveolar lavage test tube to the closed aspiration system-mandatory in these patients-for deep bronchial sampling. Thereafter, repeat the sampling every 7 days for viral charge assessment and bacterial over-infection detection [4] . 9. After intubation, evaluate basic lung mechanics: it usually shows a respiratory system compliance of 0.5-1 ml/cmH 2 O per kilogramme of predicted body weight with high recruitability at pressure-volume curve and normal resistances. These patients usually show good response to high positive end-expiratory pressure levels; calibrated oesophageal pressure may help its setting [9] . Consider neuromuscular blocking agents if deep sedation does not control the patient's trigger and ventilation is not protective; perform daily a trial of neuromuscular blocking agents stop.

it is accurate in interstitial diseases and may show pathological signs before chest X-ray. A basic assessment helps deciding the ventilatory strategy: if diffuse loss of aeration, keep high positive endexpiratory pressure levels; if posterior consolidations, consider pronation. Lung ultrasound may also help in limiting traditional imaging, avoiding patients' transportation to radiology department. It also allows a daily monitoring of clinical evolution, response to treatment and possible complications (pneumothorax, over-infections) [10] [11] [12] .

11. Avoid positive fluid balance: perform fluid challenges and stop fluid resuscitation if no haemodynamic response; use vasoactive drugs instead to optimize tissue perfusion [4] . We accept moderate elevation of creatinine without urinary output impairment to improve the lung status. 12. Fever is a frequent issue, reaching values as high as 40°C; we decided to treat it only if > 39°C, if oxygenation is acceptable. Spontaneous defervescence can be the first sign of clinical improvement. 13. As soon as possible according to gas exchanges (PaO 2 /FiO 2 > 150 with FiO2 < 50%) and lung ultrasound score (≤ 12), start assisted ventilation with a sigh while maintaining moderate to high positive end-expiratory pressure to prevent derecruitment. Regularly check patient's respiratory drive (P0.1), tidal volume and plateau pressure to keep ventilation safe. Dexmedetomidine may help in the weaning phase. 14. In patients having received prolonged sedation, we frequently observed prolonged awakening with altered respiratory drive and difficult patientventilator interaction; if no prompt awakening is observed, perform early tracheostomy to accelerate the weaning and discharge from ICU. The number of patients requiring intensive care rapidly increases; therefore, rapid discharge is mandatory. 15. Hyperinflammatory status increases the risk of thrombosis and pulmonary embolism; check for thrombotic complications systematically, mainly in correspondence of central lines [13, 14] . 16. Communication with families is difficult since patients' relatives are frequently in quarantine and access to the hospital is limited; moreover, while wearing personal protective equipment, physicians' possibility to answer to relatives' phone call is limited. Consider identifying each day one person in charge of phone calls to daily update relatives on clinical conditions [15] .

We hope sharing our experience while facing the Italian outbreak of 2019 novel coronavirus may help other Units eventually facing the same threat in the future.

Abbreviations SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; ICU: Intensive care unit

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We thank all the healthcare professionals involved in the management of such epidemics, in particular nurses and physicians of Intensive Care Unit at S. Matteo Hospital.

Authors' contributions All the authors actively contributed to the conception, redaction and final revision before submission of the manuscript. The authors read and approved the final manuscript.

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