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Abstract
INTRODUCTION
The number of people infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide is increasing dramatically [1], and reports from China, Iran, Italy and other areas hit hard by SARS-CoV-2 are chilling. The metropolitan area of Milan and its surrounding region of the Lombardy are one of the worst affected in Italy, and Europe at the moment. As of 29 March 2020, there have been 97 689 cases with 10 779 fatalities due to COronaVIrus Disease 2019 (COVID-19) in whole of Italy; of these, 41 007 (6360 fatalities) have occurred in Lombardy region [2]. In order to slow down viral transmission, local authorities and the Italian government have imposed strong containment measures by quarantining initial COVID-19 clusters and followed by a complete nationwide lock-down. The exponential increase in COVID-19-positive patients and the dramatically increasing need for intensive care unit (ICU) surge capacity for the management of critically ill patients has led the emergency task force of the Lombardy region to reallocate ICU resources [3]. In addition, elective surgery has been cancelled and beds dedicated to cardiac, neurosurgery and partially coronary care units reassigned to COVID-19-patients. For this reason, 16 of the 20 cardiac surgical units in the Lombardy region have discontinued their activities, with the remaining 4 units forming ‘the hub’ for the 16 other closed units (spokes). In this hub-and-spoke system, all urgent and emergency cases are sent to these 4 units, including those that cannot be delayed for more than 60 days. Moreover, beds for critically ill patients are also obtained from the reconversion of operation and recovery rooms (A. Parolari, personal communication).
At the same time, the progressively increasing numbers of patients with pneumonia who need ICU treatment have severely strained the ICU system in the Lombardy region and it has become clear that the current level of activity may not be sustainable for long, even with an increase in ICU resources. This has led SIAARTI, the scientific society of anaesthesia and intensive care of Italy, to issue guidelines on patient selection criteria for admission to the ICU, in case of an expected shortage of resources, such as ventilators or ICU beds [4], based on the Consensus Statement for the care of the critically ill during pandemics and disasters.
It is obvious that such a dramatic scenario poses many new questions and challenges, which are discussed in this paper.