The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

Abstract

Summary Novel coronavirus 2019 is a single‐stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non‐technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.

Elective, Non-urgent Procedures and Aesthetic Surgery in the Wake of SARS–COVID-19: Considerations Regarding Safety, Feasibility and Impact on Clinical Management

“…In case of general anesthesia, the patient should be preoxygenated with 100% oxygen over 5 min using a completely sealed facial mask. Manual bag ventilation should be avoided in these cases [45,66,[69][70][71].…”

“…Ideally trans-oral endotracheal intubation (EI) with video laryngoscope should be used. Once the correct positioning of the tracheal tube is established, it must be sealed immediately by cuff inflation [41,43,45,51,53,54,66,69,70,[72][73][74][75][76][77].…”

“…The use of extremely reduced or superhigh fresh-gas flow is contraindicated due to the risk of contamination in the anesthesia machine and the operating room. The exhalation gases must be connected to active scavenging elimination system [45,69,70,73,76,77].…”

To Do or Not to Do?—A Review of Cancer Surgery Triage Guidelines in COVID-19 Pandemic

“…Aerosol generating procedures during administration of general anaesthesia include bag and mask ventilation, endotracheal intubation and open airway suctioning. It is preferable to use regional anaesthesia wherever feasible, with added advantage of less effect on pulmonary function as compared to general anaesthesia [31][32][33][34][35][36]. Considering the significant risk of COVID transmission related to anaesthesia, it is prudent to defer the non-emergent surgical interventions.…”

Procedural precautions and personal protective equipment during head and neck instrumentation in the COVID‐19 era

“…Some groups, cultivating their experience from treatment of either SARS-CoV1 or SARS-CoV2 patients, have advocated for enhanced PPE during highrisk airway procedures, such as tracheostomy, including full face-shields or helmets with full face coverage and double gloves, or concomitant N95 and PAPR use. 18,19 Other important considerations include (a) possibility of performing open tracheostomy in a negative-pressure room in the intensive care unit, to minimize unnecessary ventilatory circuit manipulation for patient transport; (b) complete muscular paralysis, when permitted (ie, not awake tracheostomy), during the procedure to minimize coughing with an open airway; (c) minimization of electrocautery to mitigate the potential transmission of aerosolized virions through smoke, 20 and (d) use of a closed tracheal suction system with a viral filter. Although percutaneous tracheostomy can be considered as an alternative to intraoperative open tracheostomy, there may be similar, if not more significant, risk of aerosolization given the need for bronchoscopy and serial instrumentation of the airway for dilation.…”