key: cord-284616-jgtsl06q authors: Harkouk, Hakim; Jacob, Chantal; Fletcher, Dominique title: Urgent development of an anaesthesiology-based intensive care unit for critical COVID-19 infected patients date: 2020-05-04 journal: Anaesth Crit Care Pain Med DOI: 10.1016/j.accpm.2020.04.011 sha: doc_id: 284616 cord_uid: jgtsl06q nan The global COVID-19 pandemic requires anaesthesiologists to adapt themselves to this unprecedented situation 1 . Beyond this first adaptation, the major influx of patients imposes to rapidly manage critical patients outside the usual intensive care structures, in addition to required care of surgical patients. In France, the first cases are diagnosed on January 24 th , 2020. On March 14 th , all unessential institutions are shut down. Since March 17 th at noon, the population is confined at home with strict rules. On April 1 st , 6017 patients are hospitalised in intensive care units while national maximal admissions are estimated to be 5000 patients. We shortly describe the use of professional skills and existing structures in a French anaesthesia department to deal with this COVID-19 crisis. French anaesthesiologists have 5 years of training with mixed skills in anaesthesia (3 years) and resuscitation (2 years). Our 390 beds University Hospital is part of the Assistance Publique -Hôpitaux de Paris, the first hospitals group in Ile de France, a region that is severely affected by the COVID-19 pandemic. Our structures include 10 operating theatres and 14 beds of recovery room (RR), performing an average of 10.000 scheduled or urgent surgical interventions a year, in trauma, visceral and vascular surgeries. The medical team includes 14 anaesthesia consultants and 8 residents; the paramedic team includes 25 nurse anaesthetists and 13 RR nurses. The intensive care unit (ICU), managed by intensivists, has a capacity of 12 resuscitation beds and 14 continuous care beds. A regulatory team headed by an anaesthesiologist with the help of surgeons, usually meeting once a week, decides a new organisation evaluating rapidly both management of critical negative and positive COVID-19 patients and surgical activity; chronological details are listed in Table 1 The man-power includes 40 anaesthetist nurses and RR nurses and 10 anaesthesiologists (2 anaesthesiologists present 24 hours a day). All these professionals work in 12-hour shifts, 24 hours a day, 7 days a week. This radical reorganisation within 2 weeks of an operating theatre and a RR relies on the professional, structural and material resources of an anaesthesia department to create an ICU with 10 beds dedicated to critical COVID-19 infected patients while maintaining the management of selected scheduled and emergency surgery. Problems to overcome are numerous, covering both patient care, professional protection and urgency of management; we only discuss here three of them: 1. The isolation of COVID or non-COVID patients by restructuring the circulation areas, using the advantages of an operating theatre (clean and contaminated circuit, closed operating theatre under negative pressure) and identifying two separates care team selected both on professional skills and risk of viral exposition (age over 60 years old and/or comorbidities). All successive decisions were validated with hospital hygiene team; 2. Making the best of existing structures for patient care and professional protection: the RR allows easy centralised monitoring of patients but exposes to aerosolised virus, especially with high oxygen flow and requires enhanced protection for nursing professionals (FFP2 mask changed every 8 hours, dressing and take-off procedures, gown) but also an adaptation of the RR 1,2 . Negative pressure was installed on day 2 after admission of first critical patients and RR was equipped with 3 air extractors Plasmair© (Dalkia) which allow treating 7.500 m 3 of air per hour (i.e. 10 volumes per hour for a 750 m 3 RR) 3 ; 3. The medical and paramedical anaesthesia teams had to upgrade rapidly their skills to be able to use high and very high oxygen flow therapy, ventilation of the patient with severe adult respiratory distress syndrome and to be kept informed of additional therapeutic solutions specific to these patients in collaboration with intensivists. The target physician/patient ratio was set to 1/5 (2 anaesthesiologist 24 hours a day) and 1/2 for nurses in the acute phase and 1/2.5 in the steady phase. Page 4 of 7 J o u r n a l P r e -p r o o f 4 After 10 days of functioning as ICU for critical COVID-19 infected patients, 20 patients were admitted with 7 patients with mechanical ventilation. Patients start to be discharged from ICU and hospital (respectively 12 and 3) and 1 patient is deceased. We report our experience with mobilisation of an anaesthesia team and use of existing structures for urgent creation of an ICU managing critical COVID-19 patients in a pandemic which exceeds the usual resources of resuscitation structures. J o u r n a l P r e -p r o o f 6 Funding Statement: Support was provided solely from institutional and/or departmental sources Conflicts of Interest: the authors declare no competing interests Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript Service d'anesthésie, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris France; for ICU organisation and validation of the manuscript References COVID-19 Infection: Implications for Perioperative and Critical Care Physicians Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Supplemental treatment of air in airborne infection isolation rooms using high-throughput in-room air decontamination units