Minerva Anestesiologica 2020 November;86(11):1234-45

DOI: 10.23736/S0375-9393.20.14762-X

language: English

Management of critically ill patients with COVID-19: suggestions and instructions from the coordination of intensive care units of Lombardy

Giuseppe FOTI ^{1, 2}, Alberto GIANNINI ³, Nicola BOTTINO ⁴, Gian Paolo CASTELLI ⁵, Maurizio CECCONI ^{6, 7}, Giacomo GRASSELLI ^{4, 8}, Luca GUATTERI ⁹, Nicola LATRONICO ^{3, 10, 11}, Thomas LANGER ^{2, 12}, Giacomo MONTI ¹³, Stefano MUTTINI ¹⁴, Antonio PESENTI ^{4, 8}, Danilo RADRIZZANI ¹⁵, Marco RANUCCI ¹⁶, Vincenzo RUSSOTTO ^{1, 2} ✉, Roberto FUMAGALLI ^{2, 12}, COVID-19 Lombardy ICU Network

¹ Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy; ² School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; ³ Unit of Pediatric Anesthesiology and Intensive Care, Children’s Hospital, ASST Spedali Civili Hospital, Brescia, Italy; ⁴ Department of Anesthesiology, Reanimation and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; ⁵ Department of Anesthesiology and Intensive Care, ASST Mantua, Carlo Poma Hospital, Mantua, Italy; ⁶ Department of Anesthesiology and Intensive Care Medicine, IRCCS Humanitas Clinic, Rozzano, Milan, Italy; ⁷ Humanitas University, Pieve Emanuele, Milan, Italy; ⁸ Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; ⁹ Department of Anesthesiology and Intensive Care, Sacra Famiglia Fatebenefratelli Hospital, Erba, Como, Italy; ¹⁰ Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy; ¹¹ Department of Anesthesiology, Critical Care and Emergency, ASST Spedali Civili, Brescia, Italy; ¹² Department of Anesthesiology and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; ¹³ Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Hospital, Milan, Italy; ¹⁴ Department of Anesthesiology and Intensive Care, ASST Santi Paolo e Carlo, San Carlo Hospital, Milan, Italy; ¹⁵ Department of Anesthesiology and Intensive Care, ASST Ovest Milanese, Hospital of Legnano, Legnano, Milan, Italy; ¹⁶ Department of Anesthesiology and Intensive Care, IRCCS San Donato Hospital, Milan, Italy

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With 63,098 confirmed cases on 17 April 2020 and 11,384 deaths, Lombardy has been the most affected region in Italy by coronavirus disease 2019 (COVID-19). To cope with this emergency, the COVID-19 Lombardy intensive care units (ICU) network was created. The network identified the need of defining a list of clinical recommendations to standardize treatment of patients with COVID-19 admitted to Intensive Care Unit (ICU). Three core topics were identified: 1) rational use of intensive care resources; 2) ventilation strategies; 3) non-ventilatory interventions. Identification of patients who may benefit from ICU treatment is challenging. Clinicians should consider baseline performance and frailty status and they should adopt disease-specific staging tools. Continuous positive airway pressure, mainly delivered through a helmet as elective method, should be considered as initial treatment for all patients with respiratory failure associated with COVID-19. In case of persisting dyspnea and/or desaturation despite 4-6 hours of noninvasive ventilation, endotracheal intubation and invasive mechanical ventilation should be considered. In the early phase, muscle relaxant use and volume-controlled ventilation is recommended. Prone position should be performed in patients with PaO2/FiO2≤100 mmHg. For patients admitted to ICU with COVID-19 interstitial pneumonia, we do not recommend empiric antibiotic therapy for community-acquired pneumonia. Consultation of an infectious disease specialist is suggested before start of any antiviral therapy. In conclusion, the COVID-19 Lombardy ICU Network identified a list of best practice statements supported by the available evidence and clinical experience or identified as panel members expert opinions for the management of critically ill patients with COVID-19.

KEY WORDS: COVID-19; Respiratory distress syndrome, adult; Pandemics

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Publication History

Issue published online: November 23, 2020
Manuscript accepted: September 15, 2020
Manuscript revised: July 27, 2020
Manuscript received: May 4, 2020

Cite this article as

Foti G, Giannini A, Bottino N, Castelli GP, Cecconi M, Grasselli G, et al. Management of critically ill patients with COVID-19: suggestions and instructions from the coordination of intensive care units of Lombardy. Minerva Anestesiol 2020;86:1234-45. DOI: 10.23736/S0375-9393.20.14762-X

COVID-19 Lombardy ICU Network

Emiliano AGOSTEO (San Carlo Clinical Institute, Milan, Italy); Valentina ALAIMO (ASST Mantua, Carlo Poma Hospital, Mantua, Italy); Giovanni ALBANO (Humanitas Gavazzeni Hospital, Bergamo, Italy); Andrea ALBERTIN (San Giuseppe Hospital, Milan, Italy); Armando ALBORGHETTI (Policlinico San Pietro, Ponte San Pietro, Bergamo, Italy); Giorgio ALDEGHERI (IRCCS Multimedica, Sesto San Giovanni, Milan, Italy); Benvenuto ANTONINI (ASST Garda, Hospital of Manerbio, Manerbio. Brescia, Italy); Enrico BARBARA (Humanitas Mater Domini Hospital, Castellanza, Varese, Italy); Nicolangela BELGIORNO (San Rocco Institute, Ome, Brescia, Italy); Mirko BELLIATO (Department of Clinical Surgery, Pediatric and Diagnostic Sciences, University of Pavia, Pavia, Italy); Annalisa BENINI (ASST Monza, San Gerardo Hospital, Monza, Italy); Enrico BERETTA (ATS Montagna, Eugenio Morelli Hospital, Sondalo, Sondrio, Italy); Leonardo BIANCIARDI (ASST Mantua, Hospital of Pieve di Coriano, Mantua, Italy); Stefano BONAZZI (ASST Bergamo Est, A. Locatelli Hospital, Bergamo, Italy); Massimo BORELLI (Treviglio-Caravaggio Hospital, Treviglio, Bergamo, Italy); Enrico BOSELLI (ASST Rhodense, Hospital of Garbagnate Milanese, Milan, Italy); Nicola BRONZINI (Sant’Anna Institute, Brescia, Italy); Luca CABRINI (ASST Laghi, Circolo e Fondazione Macchi Hospital, Varese, Italy); Carlo CAPRA (ASST Laghi, Circolo e Fondazione Macchi Hospital, Varese, Italy); Livio CARNEVALE (ASST Pavia, Hospital of Vigevano, Vigevano, Italy); Giampaolo CASELLA (ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy); Antonio CASTELLI (ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy); Gianpaolo CASTELLI (ASST Mantua, Carlo Poma Hospital, Mantua, Italy); Emanuele CATENA (ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy); Sergio CATTANEO (ASST Spedali Civili, Brescia, Italy); Maurizio CECCONI (Humanitas University, Pieve Emanuele, Milan, Italy); Davide CHIUMELLO (ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy); Silvia CIRRI (Sant’Ambrogio Institute, Milan, Italy); Giuseppe CITERIO (ASST Monza, Desio Hospital, Monza, Italy); Sergio COLOMBO (IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy); Antonio COLUCCELLO (ASST Cremona, Hospital of Cremona, Cremona, Italy); Davide COPPINI (ASST Garda, La Memoria Hospital, Gavardo, Italy); Alberto CORONA (ASST Vallecamonica, Hospital of Valle Camonica Esine, Brescia, Italy); Paolo CORTELLAZZI (ASST Nord Milan, Sesto San Giovanni Hospital, Milan, Italy); Elena COSTANTINI (Humanitas University, Pieve Emanuele, Milan, Italy); Remo D. COVELLO (ASST Valle Olona, Hospital of Busto Arsizio, Busto Arsizio, Varese, Italy); Gianluca DE FILIPPI (ASST Rhodense, Hospital of Garbagnate Milanese, Garbagnate Milanese, Milan, Italy); Marco DEI POLI (IRCCS San Donato Hospital, Milan, Italy); Federica DELLA MURA (ASST Melegnano, Vizzolo Predabissi Hospital, Melegnano, Milan, Italy); Giulia EVASI (ASST Lecco, Lecco Hospital, Lecco, Italy); Raquel FERNANDEZ-OLMOS (Fondazione Poliambulanza Hospital, Brescia, Italy); Andrea FORASTIERI MOLINARI (ASST Lecco, Hospital of Lecco, Lecco, Italy); Giuseppe FOTI (Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy); Roberto FUMAGALLI (ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy); Marco GALLETTI (Valduce Hospital, Como, Italy); Giorgio GALLIOLI (ASST Vimercate, Hospital of Vimercate, Vimercate, Monza-Brianza, Italy); Marco GEMMA (ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy); Paolo GNESIN (ASST Franciacorta, Mellino Mellini Hospital, Chiari, Brescia, Italy); Giacomo GRASSELLI (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy); Lorenzo GRAZIOLI (ASST Papa Giovanni XXIII, Bergamo, Italy); Stefano GRECO (ASST Valle Olona, Hospital of Saronno, Saronno, Varese, Italy); Paolo GRITTI (ASST Papa Giovanni XXIII, Bergamo, Italy); Paolo GROSSO (Monza Polyclinic, Monza, Italy); Luca GUATTERI (Sacra Famiglia Fatebenefratelli Hospital, Erba, Como, Italy); Davide GUZZON (ASST Lecco, Hospital of Merate, Merate, Lecco, Italy); Fabiola HARIZAY (ASST Cremona, Hospital of Cremona, Cremona, Italy); Giorgio IOTTI (IRCCS San Matteo Polyclinic, Pavia, Italy); Roberto KEIM (ASST Bergamo Est, Bolognini Hospital, Seriate, Bergamo, Italy); Giovanni LANDONI (IRCCS Ospedale San Raffaele Scientific Institute, Milan, Italy); Thomas LANGER (ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy); Nicola LATRONICO (ASST Spedali Civili, Brescia, Italy); Andrea LOMBARDO (ASST Lariana, Sant’Anna Hospital, Como, Italy); Ferdinando L. LORINI (ASST Papa Giovanni XXIII, Bergamo, Italy); Annalisa MALARA (ASST Lodi, Maggiore Hospital, Lodi, Italy); Elena MALPETTI (Fondazione Poliambulanza Hospital, Brescia, Italy); Francesco MARINO (Beato Matteo Institute, Vigevano, Pavia, Italy); Giovanni MARINO (ASST Melegnano, Vizzolo Predabissi Hospital, Melegnano, Milan, Italy); Maurizio G. MAZZONI (Humanitas Gavazzeni Hospital, Bergamo, Italy); Guido MERLI (ASST Crema, Maggiore Hospital, Crema, Cremona, Italy); Antonio MICUCCI (ASST Lariana, Sant’Antonio Abate Hospital, Como, Italy); Francesco MOJOLI (Department of Clinical Surgical, Pediatric and Diagnostic Sciences, University of Pavia, Pavia, Italy); Stefano MUTTINI (ASST Santi Paolo e Carlo, San Carlo Hospital, Milan, Italy); Adriana NAILESCU (ASST Lodi, Maggiore Hospital, Lodi, Italy); Giuseppe NATALINI (Fondazione Poliambulanza Hospital, Brescia, Italy); Mauro PANIGADA (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy); Paolo PERAZZO (IRCCS Galeazzi Orthopedic Institute, Milan, Italy); Giovanni B. PEREGO (San Luca Institute, Milan, Italy); Antonio PESENTI (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy); Nicola PETRUCCI (ASST Garda, Hospital of Desenzano del Garda, Desenzano del Garda, Brescia, Italy); Angelo PEZZI (ASST Nord Milan, Edoardo Bassini Hospital, Cinisello Balsamo, Milan, Italy); Alessandro PROTTI (Humanitas University, Pieve Emanuele, Milan, Italy); Danilo RADRIZZANI (ASST Ovest Milanese, Hospital of Legnano, Legnano, Milan, Italy); Maurizio RAIMONDI (ASST Pavia, Hospital of Voghera, Voghera, Pavia, Italy); Marco RANUCCI (IRCCS San Donato Hospital, Milan, Italy); Frank RASULO (ASST Spedali Civili, Brescia, Italy); Mario RICCIO (Oglio Po Hospital, Casalmaggiore, Cremona, Italy); Roberto RONA (ASST Monza, San Gerardo Hospital, Monza-Brianza, Italy); Claudio ROSCITANO (Humanitas Gavazzeni Hospital, Bergamo, Italy); Patrizia RUGGERI (ASST Cremona, Hospital of Cremona, Cremona, Italy); Antonello SALA (ASST Vimercate, Hospital of Vimercate, Vimercate, Monza-Brianza, Italy); Giuseppe SALA (Città Studi Institute, Milan, Italy); Luca SALVI (IRCCS Centro Cardiologico Monzino, Milan, Italy); Anna M. SCANDROGLIO (IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy); Pietro SEBASTIANO (Città di Brescia Institute, San Donato Group, Brescia, Italy); Paolo SEVERGNINI (ASST Sette Laghi, Circolo e Fondazione Macchi Hospital, Varese, Italy); Ilaria SFORZINI (ASST Pavia, Hospital of Voghera, Voghera, Italy); Francesco D. SIGURT (Città di Pavia Institute, Pavia, Italy); Enrico STORTI (ASST Lodi, Maggiore Hospital, Lodi, Italy); Matteo SUBERT (ASST Melegnano Martesana, Melzo Hospital, Milan, Italy); Paola TAGLIABUE (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy); Carmine TROIANO (ASST Crema, Maggiore Hospital, Crema, Cremona, Italy); Roberto VALSECCHI (Moriggia Pelascini General Hospital, Gravedona, Como, Italy); Uberto VIOLA (San Pellegrino Hospital, Mantua Salus Group, Mantua, Italy); Giovanni VITALE (San Marco Polyclinic, Zingonia, Bergamo, Italy); Massimo ZAMBON (ASST Melegnano-Martesana, Hospital of Cernusco sul Naviglio, Milan, Italy); Alberto ZANGRILLO (IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy); Elena ZOIA (ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy)

Corresponding author e-mail

vincenzo.russotto@unimib.it

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