One Italian ICU Stressed to Breaking Point by COVID-19

Therese Borden

March 13, 2020

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The outbreak of COVID-19 in the Lombardy region of Italy has severely stressed the medical system and the current level of activity may not be sustainable for long, according to Maurizio Cecconi, MD, of the department of anesthesia and intensive care, Humanitas Research Hospital, Milan. Dr. Cecconi spoke via JAMA Live Stream interview with Howard Bauchner, MD, the Editor in Chief of JAMA.

A summary of comments by Dr. Cecconi and two colleagues was simultaneously published in JAMA (2020 Mar 13. doi: 10.1001/jama.2020.4031).

Dr. Cecconi discussed the progress and medical response to the swiftly expanding outbreak that began on Feb. 20. A man in his 30s was admitted to the Codogno Hospital, Lodi, Lombardy, Italy, in respiratory distress. He tested positive for a new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). In less than 24 hours, the hospital had 36 cases of COVID-19.

In a slide provided by the Italian National Health Service, the number of cases in Italy stands at 13,882 with 803 associated deaths.

ICU resources have been severely stressed. Before the outbreak, Lombardy had 720 ICU beds (about 5% of total beds). Within 48 hours of the first case, ICU cohorts were formed in 15 hub hospitals totaling 130 COVID-19 ICU beds. By March 7, the total number of dedicated cohorted COVID-19 ICU beds was 482.

Dr Maurizio Cecconi. JAMA Network

"The proportion of ICU admissions represents 12% of the total positive cases, and 16% of all hospitalized patients," compared with about 5% of ICU admissions reported from China. The difference may be attributable to different criteria for ICU admissions in Italy, compared with China, according to Dr. Cecconi and colleagues.

Dr. Cecconi mentioned that there were relatively few cases in children, and they had relatively mild disease. The death rate among patients remained under 1% up to age 59. For patients aged 60-69 years, the rate was 2.7%; for patients aged 70-79 years, the rate was 9.6%; for those aged 80-89, the rate was much higher at 16.6%.

Modeled forecasts of the potential number of cases in Lombardy are daunting. "The linear model forecasts that approximately 869 ICU admissions could occur by March 20, 2020, whereas the exponential model growth projects that approximately 14,542 ICU admissions could occur by then. Even though these projections are hypothetical and involve various assumptions, any substantial increase in the number of critically ill patients would rapidly exceed total ICU capacity, without even considering other critical admissions, such as for trauma, stroke, and other emergencies," wrote Dr. Cecconi and his colleagues in JAMA. He said, "We could be on our knees very soon," referring to the potential dramatic increase in cases.

Dr. Cecconi had some recommendations for other countries in which a major outbreak has not yet occurred. He recommended going beyond expanding ICU and isolation capacity and focus on training staff with simulation for treating these highly contagious patients. His medical center has worked hard to protect staff but 1,116 health care workers have tested positive for the virus. Conditions for staff are very difficult in full protective gear, and Dr. Cecconi commended the heroic work by these doctors and nurses.

In addition, Dr. Cecconi is focused on supportive care for patients and does not recommend using untried approaches on these patients that could cause harm. "Everyone wants to find a specific drug for these patients, but I say there is not particular drug at the moment." He stressed that, despite the crisis, doctors should focus on evidence-based treatment and tried-and-true supportive care.

Disclosures by Dr. Cecconi are available on the JAMA website.

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