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Der Anaesthesist Leitthema Anaesthesist https://doi.org/10.1007/s00101-020-00760-3 © Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2020 D. Thomas-Rüddel 1,2 · J. Winning 1 · P. Dickmann 1,2 · D. Ouart 1,2 · A. Kortgen 1 · U. Janssens 3 · M. Bauer 1,2 1 Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany 2 Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany 3 Dept. of Internal Medicine and Internal Intensive Care, St.-Antonius-Hospital Eschweiler, Eschweiler, Germany Coronavirus disease 2019 (COVID-19): update for anesthesiologists and intensivists March 2020 Introduction The novel coronavirus severe acute respiratory syndrome (SARS)-CoV-2 has also reached Germany. Currently, there is no reliable information about its future epidemiological course, the expected number of infected persons or patients who will need hospital treatment and especially the critically ill. Possible scenarios range from a manageable occurrence with a decline in spring to a major pandemia. The outbreak’s impact on public health not only depends on the clinical aspects but also on impairments in clinical pathways for other diseases. In the next weeks, every hospital needs to be prepared to face confirmed and suspected infections, bottlenecks in treatment and supplies as well as considerable staff shortages. For the last few weeks, healthcare systems worldwide have been facing a novel dis- ease. e characteristics, primary infec- tion of the respiratory tract, a relatively high risk of infection and potentially se- vere progression of the disease, make the SARS-CoV-2 virus and the resulting dis- ease coronavirus disease 2019 (COVID- This is the English full-text version of the article https://doi.org/10.1007/s00101-020-00758-x 19) a highly relevant topic, not only for intensive care medicine. In order to provide better care for COVID-19 patients and to plan precau- tionary measures, this article summarizes the knowledge about the disease as well as specific aspects and recommendations for this medical discipline. is article deliberately does not focus on epidemiological and virological top- ics or on preventive measures at the na- tional or societal level. Nonetheless, pos- sible impairments of clinical processes are mentioned even if hospitals might develop individual strategies for coping with them. Naturally, the level of information is subject to swiſt changes; new scien- tific articles are published on a daily basis. Even official recommendations from the Robert Koch Institute (RKI: https://www.rki.de/DE/Content/InfAZ/ N/Neuartiges_Coronavirus/ nCoV_node.html) and from the World Health Organization (WHO: https:// www.who.int/emergencies/diseases/ novel-coronavirus-2019) are being con- tinuously updated and should be referred to in their current version on the internet. For almost all topics, only observa- tional studies typically with low case numbers and short periods of observa- tion, case reports, expert opinions or experiences with related viral pathogens are available. Current estimates about infectiousness and mortality suggest medium values compared to other rel- evant viral infections, but variability is high (. Fig. 1). Despite epidemiologi- cal and clinical differences, experiences made during the SARS-epidemic in 2002/2003 are partly referred to due to the close relationship of the viruses. Progression of the disease and severity e infection by SARS-CoV-2 is char- acterized by a large variability of clin- ical symptoms, from asymptomatic in- fected persons to mild symptoms up to a small proportion of patients with fa- tal outcome. ere is no pathognomonic clinical picture; however, all publications and reports show similar frequency dis- tributions of symptoms (. Fig. 2). Almost all patients show fever/ elevated temperature in the course of the disease, although in a large cohort this was true for only 44% of patients at the time of hospital admission [9]. e second most common symptom is a mostly dry cough. Only every third to fourth patient also produces sputum and hemoptysis is reported only occasionally. “Classical” symptoms of the common cold, such as a sore throat and a blocked or runny nose occur in only around 5–10% of all recorded cases. Around 5–10% of patients present with primary gastrointestinal syndromes with diar- rhea, nausea and sometimes abdominal Der Anaesthesist

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Page 1: Coronavirusdisease2019 (COVID-19): updatefor ... · Fig.18 Mortalityrateandcontagiousnessofselectedviralinfectiousdiseasescomparedtolatest COVID-19estimates.COVID-19 coronavirusdisease2019

Der Anaesthesist

Leitthema

Anaesthesisthttps://doi.org/10.1007/s00101-020-00760-3

© Springer Medizin Verlag GmbH, ein Teil vonSpringer Nature 2020

D. Thomas-Rüddel1,2 · J. Winning1 · P. Dickmann1,2 · D. Ouart1,2 · A. Kortgen1 ·U. Janssens3 · M. Bauer1,2

1 Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany2 Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany3Dept. of Internal Medicine and Internal Intensive Care, St.-Antonius-Hospital Eschweiler, Eschweiler,Germany

Coronavirus disease 2019(COVID-19): update foranesthesiologists and intensivistsMarch 2020

Introduction

The novel coronavirus severe acuterespiratory syndrome (SARS)-CoV-2has also reached Germany. Currently,there is no reliable informationabout its future epidemiologicalcourse, the expected number ofinfected persons or patients whowill need hospital treatment andespecially the critically ill. Possiblescenarios range from amanageableoccurrence with a decline in springto a major pandemia. The outbreak’simpact on public health not onlydepends on the clinical aspectsbut also on impairments in clinicalpathways for other diseases. In thenext weeks, every hospital needs tobe prepared to face confirmed andsuspected infections, bottlenecksin treatment and supplies as well asconsiderable staff shortages.

For the last fewweeks, healthcare systemsworldwide have been facing a novel dis-ease. The characteristics, primary infec-tion of the respiratory tract, a relativelyhigh risk of infection and potentially se-vere progression of the disease, make theSARS-CoV-2 virus and the resulting dis-ease coronavirus disease 2019 (COVID-

This is the English full-text version of the articlehttps://doi.org/10.1007/s00101-020-00758-x

19) a highly relevant topic, not only forintensive care medicine.

In order to provide better care forCOVID-19 patients and to plan precau-tionarymeasures, thisarticlesummarizesthe knowledge about the disease as wellas specific aspects and recommendationsfor this medical discipline.

This article deliberately does not focuson epidemiological and virological top-ics or on preventive measures at the na-tional or societal level. Nonetheless, pos-sible impairments of clinical processesare mentioned even if hospitals mightdevelop individual strategies for copingwith them.

Naturally, the level of informationis subject to swift changes; new scien-tific articles are published on a dailybasis. Even official recommendationsfrom the Robert Koch Institute (RKI:https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/nCoV_node.html) and from the WorldHealth Organization (WHO: https://www.who.int/emergencies/diseases/novel-coronavirus-2019) are being con-tinuously updated and should be referredto in their current versionon the internet.

For almost all topics, only observa-tional studies typically with low casenumbers and short periods of observa-tion, case reports, expert opinions orexperiences with related viral pathogensare available. Current estimates aboutinfectiousness and mortality suggest

medium values compared to other rel-evant viral infections, but variability ishigh (. Fig. 1). Despite epidemiologi-cal and clinical differences, experiencesmade during the SARS-epidemic in2002/2003 are partly referred to due tothe close relationship of the viruses.

Progression of the disease andseverity

The infection by SARS-CoV-2 is char-acterized by a large variability of clin-ical symptoms, from asymptomatic in-fected persons to mild symptoms up toa small proportion of patients with fa-tal outcome. There is no pathognomonicclinical picture; however, all publicationsand reports show similar frequency dis-tributions of symptoms (. Fig. 2).

Almost all patients show fever/elevated temperature in the course ofthe disease, although in a large cohortthis was true for only 44% of patientsat the time of hospital admission [9].The second most common symptom isa mostly dry cough. Only every third tofourth patient also produces sputum andhemoptysis is reported only occasionally.“Classical” symptoms of the commoncold, such as a sore throat and a blockedor runny nose occur in only around5–10% of all recorded cases. Around5–10% of patients present with primarygastrointestinal syndromes with diar-rhea, nausea and sometimes abdominal

Der Anaesthesist

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pain and vomiting. Published cohortstudies naturally record mainly patientswho are more ill, hospitalized and tested.In studies describing patients with differ-ent degrees of severity, most symptomswere more frequent in seriously ill pa-tients so that the individual symptomsare probably less frequent in patientswith milder courses of the disease.

Severity of the disease

In the People’s Republic of China around80% of all recorded cases show thegeneral symptoms as described above,sometimes combined with mild pneu-monia and mild dyspnea. Around everyfifth patient develops a severe pneu-monia with dyspnea, tachypnea anddisturbed gas exchange. Approximatelyevery fourth of these patients, i.e. 5% ofall infected patients, is critically ill withsevere lung dysfunction, need for venti-lation, shock or extrapulmonary organfailure [12, 13]. There are no reliable dataregarding the additional group of symp-tom-free or weakly symptomatic casesthat have not been tested (. Fig. 3). Ifthis group is sufficiently large—as oftenassumed—increased testing of mildlysymptomatic patients will lead to a shiftof the frequencies described above infavor of the milder cases. On the otherhand, severely ill patients will be moreoften recorded in scenarios with limitedtesting, therefore presenting a largerproportion of severe cases. This phe-nomenon is probably responsible forthe high number of severe courses andfatal outcomes in relation to the totalnumber of confirmed cases in Italy (10%critically ill patients), the USA and Iran.

Chronological progression of thedisease

In contrast to many other severe infec-tiousdiseaseswithtimespansofonlyafewdays if not hours from onset of symp-toms to admission to the intensive careunit (ICU), COVID-19 shows a relativelyprotracted course with slow deteriora-tion of (primarily) lung function. Themedian incubation period from exposi-tion to onset of first symptoms is 4 days(interquartile range, IQR2–7days),max-

Zusammenfassung · Abstract

Anaesthesist https://doi.org/10.1007/s00101-020-00760-3© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2020

D. Thomas-Rüddel · J. Winning · P. Dickmann · D. Ouart · A. Kortgen · U. Janssens · M. Bauer

„Coronavirus disease 2019“ (COVID-19): update für Anästhesistenund Intensivmediziner März 2020

ZusammenfassungDie neu aufgetretene Atemwegserkrankung„coronavirus disease 2019“ (COVID-19)hat Deutschland erreicht. Die Erkrankungverläuft in den meisten Fällen leicht, aberder kleinere Anteil an schwer Erkranktenwird stationär und auch intensivmedizinischbehandelt werden. Im Gegensatz zuanderen akuten Infektionskrankheitenzeigen die schweren Verläufe eine langsameProgredienz von den ersten Symptomen biszur lebensbedrohlichen Verschlechterung.Die Diagnosestellung erfolgt mithilfe derPolymerase-Kettenreaktion (PCR) aus Probendes Respirationstrakts. Ein schweres „acute

respiratory distress syndrome“ (ARDS) istcharakteristisch für die kritischen Verläufe.Der Vermeidung nosokomialer Infektionen,insbesondere durch korrekte Anwendung derSchutzausrüstung, und der Aufrechterhaltungdes Krankenhausbetriebs kommen zentraleBedeutung zu. Auch in der Anästhesieund Notfallmedizin ist mit erheblichenHerausforderungen zu rechnen.

SchlüsselwörterAusbrüche von Infektionskrankheiten ·Infektionskontrolle · Notfallmedizin ·Anästhesiologie · Intensivmedizin

Coronavirus disease 2019 (COVID-19): update foranesthesiologists and intensivists March 2020

AbstractThe current outbreak of coronavirus disease(COVID-19) has reached Germany. Themajority of people infected present withmild disease, but there are severe casesthat need intensive care. Unlike other acuteinfectious diseases progressing to sepsis, thesevere courses of COVID19 seemingly showprolonged progression from onset of firstsymptoms to life-threatening deteriorationof (primarily) lung function. Diagnosis relieson PCR using specimens from the respiratorytract. Severe ARDS reflects the hallmark ofa critical course of the disease. Preventing

nosocomial infections (primarily by correctuse of personal protective equipment)and maintenance of hospitals’ operationalcapability are of utmost importance.Departments of Anaesthesia, Intensive Careand emergency medicine will envisage majorchallenges.

KeywordsInfectious disease outbreaks · Infection con-trol · Emergency medicine · Anesthesiology ·Intensive care

imum incubation period is assumed bythe RKI to be 14 days; however, thereare case reports showing longer incu-bation periods of up to 19 or 24 days.Amedian of 10 days from onset of symp-toms to admission to the ICU has beenreported, from the time of infection ittakes nearly 2 weeks (. Fig. 4). This isof considerable relevance for calculatingthe expected need of ICU beds basedon the current epidemiological situation.Faster and slower progression have beenreported as well, presumably dependingon the specific health care system. Criti-cal courses tend to have a faster progres-sion than milder cases.

Risk factors

High age, male gender, diabetes, respira-tory diseases, cancer, hypertension andarteriosclerotic diseases seem to be im-portant risk factors for severe coursesand mortality [5, 6, 8–13]. Age and pre-existing illness are known to be highlycorrelated; however, no regression analy-ses have been published that describe theindependent influence of these differentfactors. Whether gender differences aredue to lifestyle factors or biological dif-ferences is not yet clear. Severe courses inchildren and adolescents are extremelyrare, so far no cases of death have beendocumented for children under 10 years

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Fig. 18 Mortality rate and contagiousness of selected viral infectious diseases compared to latestCOVID-19 estimates.COVID-19 coronavirus disease 2019,MERSMiddle East respiratory syndrome,SARS severe acute respiratory syndrome, R0 basic reproduction number (data from [1–3])

Fig. 28 Frequency of typical symptoms in patients (synopsis from [4–11])

of age [13]. Contrary to the H1N1 in-fluenza epidemic, pregnant and postpar-tum women do not bear a higher risk[12], while so far no data are availablefor obesity.

Diagnostics

Confirmed infection currently dependson pathogen typing using polymerasechain reaction (PCR) diagnostics. Sero-logical tests are being developed but notyet available. In general, testing speci-mens from the upper and lower respi-ratory tract is recommended; feces canalso sometimes be used for detecting thepathogen. When obtaining specimensfrom the lower respiratory tract, suit-able measures for prevention of noso-comial transmission are obligatory forthe personnel, including wearing filter-ing face piece (FFP3) masks. The cur-rent flow diagram (. Infobox 1) of theRKI recommends this only for severelyill patients who need inpatient care. Inoutpatient settings, only obtaining spec-imens from the upper respiratory tractis recommended.

False negative results are describedwhere poor specimenquality, inadequatetransportation and also not yet existingviral shedding are discussed as possiblecauses; however, there are well docu-mented cases where in spite of initiallyobvious symptoms and chest computedtomography (CT)findings, several smeartests fromtheupperrespiratorytractwerenegative, while after 8 days, the resultswere positive [14]. This suggests thatthere are cases with an initially isolatedinfection of the lower respiratory tract.For this reason, it is thought that in criti-cally ill patients with suspected COVID-19, specimens should always be obtainedfrom the lower respiratory tract, in par-ticular if prior testing from the upperrespiratory tract was negative.

Whether patients or persons whowere potentially exposed should betested needs to be decided individu-ally, taking the current epidemiologicaldevelopment into account. Updatedrecommendations of the RKI, in partic-ular regarding the suspected COVID-19 symptoms that require testing, canbe found on the internet. As situation-

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Leitthema

Fig. 39 Frequencydistribution of thedegree of severity inthe People’s Repub-lic of China

Fig. 48 Medianchronological courseofsymptomsandinterquartile range(IQR)estimatedaccordingto [5–9, 11]. Hospital admission anddyspnea, acute respiratory distress syndrome (ARDS) anddeathon Intensive Care Unit (ICU) only in case of increasing severity

related adaptations of recommendationswere previously made each week and asfurther updates are expected, this articlerefrains from a detailed repetition andrecommends a case-related consulta-tion of the currently valid version ofthe flow chart (see . Infobox 1). Theauthors recommend including SARS-CoV-2 infection into the differential di-agnostic considerations when admittingpatients with respiratory insufficiency tothe ICU, and not to apply testing criteriatoo restrictively. The overall goal has tobe to detect as many as possible of thecases that have not been identified untilthey were admitted to the ICU, as hasbeen reported from earlier phases of the

pandemic e.g. in Spain, Italy and theUSA.

Laboratory findings and imaginginvestigations

Typical findings of imaging and clinicallaboratory results are shown in . Fig. 5.The CT diagnostics seem to be sensitive;however, due to the unspecific findings,neither imaging nor laboratory diagnos-tics seem to be suitable for diagnosis orexclusion diagnostics.

Infobox 1

Flowchart suspicion clarification andmeasures by the RKIhttps://doi.org/10.25646/6473RKI-information on COVID-19https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/nCoV.html

Transmission risks and hygienemeasures

Transmission route and hygienemeasures

Presentknowledge suggests transmissionvia respiratory droplets and direct con-tact with body fluids and excretions. Inaddition togeneral rules forbasichygieneand hand hygiene, the RKI recommendsaccommodation of in-patients in singlerooms, ideally with a vestibule or doubledoor system. Air-conditioning systemsneed to be turned off or adapted so thatno dissemination to other rooms or cor-ridors is possible as this would be thecase with air circulation systems or over-pressure ventilation. Preparatory plan-ning with hospital hygiene and facilitymanagement is recommended immedi-ately in preparation for more patients tobe admitted. Dailywiping disinfection ofareas that are close to patients is also rec-ommended: updated recommendationscan be found on the RKI webpage.

Nosocomial transmissions,infections of medical personnel

It has been reported that in the SARS epi-demic 20% of all infected persons weremedical personnel (in Canada and Sin-gapore even 40%), and that nosocomialinfections played a major role in theepidemiological course of events [16].For SARS-CoV-2 that situation is dif-ferent; most infections take place out-side hospital. Among other reasons, thisis due to the fact that contagiousnessandinfectiousnessofmildlysymptomaticpatients and probably also of asymp-tomatic infected persons are higher [17];however, forepidemiological reasonsandalso because the risk they present forstaff, including related fears and impair-ment to healthcare system functionality,

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Fig. 59 Typical changesin laboratory values andimaging findings (synopsisfrom [4–12, 15])

nosocomial infections are still importantand need to be minimized by suitablemeasures. According to official figures,in China 3.8% of all cases were medi-cal staff, corresponding to approximately2000 cases. In the Italian region of Lom-bardy, it was officially stated at the begin-ning of March that 10% of all physiciansandnurseswere tested positive for SARS-CoV-2 and were not available for patientcare. A case series with 138 patients inauniversityhospital inWuhanhas shownan infection rate of 29% of the medicalstaff, and the incidence of nosocomial in-fections among patients was 12% [6, 11].The majority of infections took place onthe general wards; only 2 cases were re-ported for ICU. A quarter of nosocomialcases in medical staff and fellow patientswere traced back to a single patient whowas admitted to the general surgery de-partmentbecauseofprimarilyabdominalsymptoms.

Personal protective equipment

The WHO and the RKI recommendslightly different measures for personalprotection equipment (. Table 1). Re-garding specific features of aerosol gen-erating procedures, further information

is given in the next section. Using eyeprotection (safety goggles or visor) inaddition to normal safety equipmenthas been proven to provide a significantreduction of nosocomial transmissionin the SARS epidemic [18] and is thussuggested in the care of COVID-19patients. Wearing medical headgeardoes not offer additional protection,but it might help reduce unintentionalhand-face contact and makes puttingon the protective equipment withoutcontamination easier. Make sure thatFFP2/3 masks sit tightly; bearded menmay require shaving. Figure 6 showsa complete protection equipment as anexample. Putting on the protection gearin a correct way, and in particular takingit off without contamination, requirestraining. Ideally, pictured instructionsare available in each double door systemchanging area. If available, a poweredair-purifying respirator (PAPR) can ofcourse be used, especially for activitiesor in areas with particularly high risks.

High-risk measures

Due to transmission by droplet infec-tion, transmission risks naturally in-crease with all measures that generate

aerosols. . Table 2 provides an overviewof risky measures and possible mini-mization strategies. In the context ofthe SARS epidemic, the following mea-sures were identified as most importantrisk situations: intubation, noninvasiveventilation, mask ventilation and ma-nipulation of oxygen masks [18, 19] aswell as resuscitation [20]. The risk forassistant personnel was at least as highas for the intubating person [19]. Itmust, however, be stated that at leastin Canada intubation standards withnebulization of topical anesthetics andwithoutmuscle relaxantswere apparentlyused [21]. Interestingly enough, apply-ing ECG electrodes was also associatedwith a high risk [18].

Emergency medicine aspects

Due to theabovementionedcourseofdis-ease that is initially relatively protracted,the large number of mild cases and thevery high alertness for SARS-CoV-2 in-fection in the general public, outpatientdiagnostics, treatmentandcareplayama-jor role. Telephone hotlines and specialdiagnostic centers for patients with fevershould be organized in close collabora-tion with hospitals, public health offices

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Table 1 Personal protection gear in treatment of SARS-CoV-2 patients

WHO recommendation RKI recommendation

Normal patient care Mouth-nose protection(MNP)Eye protectionMedical coatGloves

FFP2 maskMedical coatGloves

Measures with aerosol genera-tion, e.g. intubation or noninva-sive ventilation

In addition:FFP2 instead of MNPApron or waterproof coat

In addition:FFP2 instead of MNPApron or waterproof coatEye protection

FFP filtering face piece, RKI Robert Koch Institute,WHOWorld Health Organization

Table 2 Aerosol generatingmeasures and riskminimization

Aerosol generatingmeasures

Possible ways of risk minimization

Intubation [18, 22, 23] Only experienced staff

Early and well prepared

Avoid emergency intubation

Avoid intermediate ventilation, RSI

Sufficient depth of anesthesia and relaxation

Immediate wrapping of used spatula

Bronchoscopy Avoid awake bronchoscopy

Consider relaxation

Resuscitation [20] Do not neglect personal protection gear in emergencies

Swift airwaymanagement,minimizemask ventilation

Keep the team involved small

Suction Closed suction systems

NIV/HFNO [18] Highly restrictive indications

Specific staff instruction

Mouth-nose protection for patients with HFNO

Tracheotomy Only experienced staff

Keep the team on the patient small

Sufficient relaxation

Ventilator in standby between tracheal puncture and placement ofthe tracheal cannula

If justifiable, wait for negative PCR

Disconnection ofventilation

Clamp tube

HME filter

Extubation Reconsider standard procedure (suction, recruitmentmaneuvre)

Disconnect ventilator early enough

HFNO high-flow nasal oxygen, HME heat and moisture exchanger, NIV noninvasive ventilation,PCR polymerase chain reaction, RSI rapid sequence induction

and the Association of Statutory HealthInsurance Physicians. In addition, im-plementing permanent home visit teamsto do smear tests might be useful. Anindication for hospital admission onlyexists in cases of a severe clinical man-ifestation of COVID-19 or because ofother diseases, injuries or unclear symp-toms. Themere proof of SARS-CoV-2 or

mild symptoms does not qualify for hos-pital admission. Emergencymedical ser-vices, rescue service headquarters, pub-lic health offices, health insurance physi-cians and hospitals should closely co-ordinate regional approaches, solutions,structures and burden sharing.

Treatment of SARS-CoV-2 infectionsby emergency doctors or emergency

medical services should only be neces-sary in exceptional cases. Emergencydoctors should minimize contact withpatients or suspected cases. To thisend, headquarters need to be sensitizedand regularly trained according to upto date RKI information. Ideally, thisinformation is updated automatically onheadquarter computers. In situationsthat are not life-threatening, patientsshould be referred to outpatient health-care structures. In cases of real emer-gency operations, rescue services need tobe informed about the suspicion. Rescueservices need to have suitable personalprotection equipment ready for use.The emergency services staff/emergencydoctor is responsible for evaluating ifa patient’s clinical symptoms requirehospital admission or if further outpa-tient treatment needs to be arranged.If hospital admission is necessary, thepatient is driven to the nearest suitablehospital. Flooding large medical centerswith oligosymptomatic patients needs tobe avoided by all means. If possible, thepatient should wear mouth-nose pro-tection (MNP) during transportation.Additionally, windows or doors betweentreatment room and driver’s cabin of theambulance must be closed and ventila-tion systems in the treatment room shutoff. Consider presence of staff in thetreatment room carefully, depending onthe patient’s condition.

Due to its temporal dynamics, it ispossible that over the course of an epi-demic an increased number of patientswith deterioration of symptoms subse-quently needs to be admitted to hospital.Regarding logistics and consumption ofmaterials, deployment of specially dis-patched rescue services may be useful inthis case.

Considerations for anesthesia

For patients with confirmed SARS-CoV-2 infection and for suspected cases,there will be indications for surgery be-cause of complications in the courseof treatment or due to other reasonsthat might be unrelated to the infection.Ideally, it should be clarified in advancewhich operating rooms are suitable forthe procedure and how to modify the

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Fig. 68 Colleague in complete personal pro-tection gear

ventilation system settings. Patientswho are not yet intubated should wearmouth-nose protection until inductionand also immediately after end of anes-thesia. Because of the risk situationsat applying the monitoring, intubationand extubation as described, only expe-rienced staff in small teams wearing fullpersonal protection should be deployed[23]. Entering the operating suite viaholding areas and leaving via recoveryrooms must be avoided. By analogy toflu, bag valve masks and tubes shouldbe changed when using a respiratory gasfilter [24]. This instruction is based ona joint recommendation of the GermanSociety of Hospital Hygiene (DGKH)and the German Society of Anesthe-siology and Intensive Care (DGAI) in2010; however, this does not concernthe anesthesia circuit system or filter-based gas analysis far from the patient.

Fig. 79 Infor-mation sign forvisitors andpa-tients, distributionofmouth-noseprotection to symp-tomatic persons

Premedication clinics and recoveryrooms are functional areas where a highnumber of staff andpatientsmeet in closeproximity. Depending on the dynam-ics of the infection, it may be necessaryto change procedures here or even closewhole areas in order to avoid nosoco-mial chains of infection that are difficultto track. It seems reasonable to put upsigns for visitors, asking them to imme-diately get in touch with medical staffin case of symptoms of infection. Theywill then get mouth-nose protection andwill be asked to stay away from othervisitors, patients and staff in order to re-duce infection risks (e.g. . Fig. 7). Foroutpatient pain clinics, the situation is inprinciple similar.

It seems also reasonable to discussall procedures with all people involvedat an early stage for joint developmentof solutions that work in the respectivesetting.

Intensive care

Respiratory failure and ARDS

An absolute majority of all critically illCOVID-19 patients present with severerespiratory insufficiency [8, 10–12, 15].Sometimes clinical signs of dyspnea maybe missing even in cases of severe hy-poxia, especially in older patients [15].At least in the specific situation in Hubei,inChinamostsevereoxygenationfailureswith an oxygenation index <100mmHg[8, 12] were already present when pa-tients were admitted to ICU. Treatmentwithnoninvasiveventilationorhigh-flowoxygen, as has become established forprimary hypoxemic lung failure in thelast few years, is critically discussed forCOVID-19 treatment and many expertsreject this approach [12, 22, 25]. Suc-cess rates in critically ill COVID-19-pa-tients are limited, delayed intubation isassociated with poor outcome and thetreatment as well as a possibly neces-sary emergency intubation in cases oftreatment failure increase the risk for

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Leitthema

transmission to staff [8, 12, 15, 22]; how-ever, in situations with an imbalanced re-sources-needs ratio, this approach couldhelp bridge the time until decision-mak-ing and intubation, or it could also bea therapeutic option in cases of lack-ing ventilatory capacities. For ARDStherapy, the commonly known intensivecare principles apply, as e.g. documentedin the S3 guidelines invasive ventilation.Classical rescue therapies for severe oxy-genation failure, such as recruitment, re-laxation and prone positioning are pri-marily successful in most patients [12,15]. In the course of time some of thepatients develop severe hypercapnia ofunknown origin [12]. Barotrauma, of-ten observed in SARS, has been reportedonly in single cases; however, this mightresult from a trend towards more lung-protective ventilator settings comparedto 2003 [8].

Whether or not patients benefit fromextracorporeal membrane oxygenation(ECMO) therapy is not clear [15, 26].If one basically assumes prognosis im-provementwithECMOtherapy inARDSpatients, then this should also apply forCOVID-19 given the prominent pul-monary organ failure and the relativerarity of extrapulmonary organ failure.In a series of 28 cases, 14 had died,5 were weaned and 9 were still underECMO therapy at the time of manuscriptsubmission [15]. In the case of largernumbers of patients, a lack of ECMOtreatment facilities is to be expected.Good patient selection and timely startare likely crucial for successful imple-mentation.

In ICD-10-GM,COVID-19was giventhe coding U07.1! as pathogen-specificsecondary diagnosis code. Attentionshould be paid to correct coding.

Pharmacological therapy

Many antiviral and other agents arebeing used in patients, their applica-tion based on theoretical considerations,case studies and in vitro data aboutSARS and Middle East respiratory syn-drome (MERS). Several clinical trialsare being conducted. Most commonlyused seem to be remdesivir, lopinavir/ritonavir (Kaletra®), also in combination

with interferon beta 1b and chloro-quine [27–30]; however, the currentdata situation does not allow concretetreatment recommendations for any ofthese substances. The substances’ phar-macokinetic interaction potential is notwithout problems (http://www.covid19-druginteractions.org/). The WHO aswell as Chinese experts clearly adviseagainst use of steroids because prolongedvirus replication without clinical bene-fits was observed under steroid therapyin MERS [12, 25]. Delayed dramaticdeterioration after initial improvementunder protracted steroid application hasbeen reported anecdotally for COVID-19 [12]; however, there is no consensusregarding benefit or harm of short-termsteroid administration, and it is stillbeing used [11].

Bacterial superinfectionsare reported,but they seem to occur less frequentlythan in influenza pneumonia. Empiri-cal antibiotic therapy for community ornosocomiallyacquiredpneumonia is rec-ommended for all severely ill patients[25]. As known for influenza, Aspergillusco-infections can occur as well [4].

Extrapulmonary organ failure

Shock is relatively rarely observed; intotal, no more than up to one third ofcritically ill patients need catecholaminetreatment [5, 8, 9, 11, 12, 15, 31, 32];however, some patients die of refrac-tory heart failure after some time inthe course of disease, showing aspectsof cardiogenic shock [10, 12]. It is notclear whether this results from a directmyocardial damage by infection, stresscardiomyopathy or right heart failuredue to prolonged ARDS. Histological orechocardiographical findings have notbeen reported yet. Many patients sufferfrom kidney damage, around 20% needrenal replacement therapy in the courseof disease [8, 10–12]. As in all ICUpatients, in cases of newly occurringshock with multiorgan failure there isstrong suspicion of nosocomial infectionwith sepsis [8, 12].

Strategic considerations forreferrals

Referring suspected cases or patients, es-pecially if they are severely ill, to max-imum care hospitals may seem to bean attractive strategy and is well-estab-lished practice in Germany for patientswith severe, complex or rare medicalconditions; however, such an approachwould overburdenmaximumhealth careproviders and would bring their func-tionality, e.g. as transregional traumacenter, perinatal center, transplantationcenter and other highly specialized ar-eas of care, to a halt. For this reason,community hospitals should provide in-tensive care for patients with COVID-19. Referral seems to only be sensiblefor few, well-selected patients with med-ical indications, e.g. for ECMO therapy.

Prognosis and sequelae of thedisease

For COVID-19 patients treated on ICU,a mortality rate of 30–70% is expected[5, 8, 10, 11, 13, 15]. For older patientswith ARDS, this is an entirely expectableestimation that is comparable to other se-vere pulmonary infections. InHubei, theChinese province that was initially mostaffected andwheremost of the data comefrom, access to intensive care treatmentwas delayed and the quality of care wasprobably reduced due to the exceptionalsituation. Thus, in one case series trans-fer to ICU tookplace amedianof 1.5 daysafter onset of ARDS [5], in another caseseries some of the patients were treatedon newly established ICUs [8], other au-thors report that only 25% of deceasedpatients were intubated and invasivelyventilated at all [15]. In survivors, usualconsequences of long-term intensive caretreatment have to be expected. For sur-vivors of the SARS epidemic, a high rateofpulmonaryfibrosis is reported [33]. Asthere is also one case report with a newlyemerged fibrosis in a COVID-19 patient[34], COVID-19 survivors should be fol-lowed-up closely.

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Infobox Additional informationin English

https://www.esicm.org/resources/coronavirus-public-health-emergency/https://www.who.int/emergencies/diseases/novel-coronavirus-2019https://www.ecdc.europa.eu/en/novel-coronavirus-china

Impairment of clinical processes

Depending on the future progress of in-fection, and also on measures taken, sig-nificant impairmentsof clinicalprocessesare to be expected that do not directly re-sult from the inflow of COVID patients.Due to the following factors, consider-able staff shortages that are difficult toplan are very likely:4 Staff fall ill4 Staff need to care for ill relatives4 Staff need to care for their children

when schools and kindergartens areclosed

4 Staff need to care for relatives ifambulatory services stop working

4 Staff are in fear for their own health4 Mental overload

To meet these challenges, alternativestructures of care, especially for children,need to be established, and measures forconsequent avoidance of nosocomialinfections and transmission of diseases,e.g. in cafeterias and meetings, as well asoptimized communication and informa-tion should be implemented. Recruitingadditional staff, e.g. from the group ofmedical trainees and students, office staffand retired former colleagues should beconsidered at an early stage. Dependingon the situation, and in close cooperationwith local health authorities, quarantin-ing clinically asymptomatic medical staffafter SARS-CoV-2 contact needs to becarefully traded off against resultingstaff shortage in patient care. Regularinformation about current preparationsand adaption measures, the number ofinfected patients who actually need careas well as measures for protecting staff(protection gear, skill training and otheractivities) can help to ensure patient care

in situations with high workloads andstress.

Apart from this, an inventory of avail-able resources of rooms and consum-ables should be done at an early stage,and strategies should be developed toplan how to deal with possible short-ages of isolation rooms, personal protec-tion gear and also supply bottlenecks ofcrucial drugs. To this end, it is impor-tant to consider the hospital and health-care center regional characteristics, andto develop joint approaches with all pro-fessional groups involved about timelydetection and compensation for impair-ments and shortages in times of workintensification.

The checklist published by the Euro-pean Center for Disease Prevention andControl (ECDC) is helpful for prepa-ration (https://www.ecdc.europa.eu/en/publications-data/checklist-hospitals-preparing-reception-and-care-coronavirus-2019-covid-19).

Due to supply bottlenecks, staff needsto be economical with personal protec-tive gear, especially with FFP2/3 masks.Wearing these masks in situations thatdo not require their use needs to beprevented by better explanation. Fear-driven stockpiling by departments thatare not involved in the care of infectiouspatients and taking stock out of hospitalneeds to be prevented by measures inmaterials logistics and by storing thesematerials on the wards. The importanceof early-stage preparation in the above-mentioned areas was underlined by anappeal made by intensive care physiciansfrom heavily affected northern Italy totheir European colleagues (https://www.esicm.org/covid-19-update-from-our-colleagues-in-northern-italy/).

Summary for clinical practice

4 The COVID-19 epidemic confrontsthe disciplines with major challenges.

4 In most cases, the course of thedisease is mild, but around 5% ofpatients develop severe ARDS.

4 It is necessary to establish structuresfor providing outpatient care for asmany mild cases as possible.

4 Pathogen identification is doneby PCR, in critically ill patients

preferably from the lower respiratorytract.

4 NIV therapy or even high-flowoxygen must be assessed criticallydue to high risk of infection for staff.

4 If NIV is nonetheless applied, earlyintubation is needed in case of failure.

4 Unlike other severe infectious dis-eases, COVID-19 patients oftendeteriorate only with a certain delayin the course of disease.

4 Avoiding nosocomial COVID infec-tion is crucial, above all by consequentuse of personal protective gear.

4 Apart from challenges regardingpatient care, staff absences and lackof resources can cause considerableproblems in hospitals’ operationalprocesses.

4 Structures that provide the careof other medical conditions, e.g.trauma, myocardial infarction orbirths, need to be maintained at allcosts.

Corresponding address

Prof. Dr. M. BauerDept. of Anesthesiology and Intensive CareMedicine, Jena University HospitalAm Klinikum 1, 07747 Jena, [email protected]

Acknowledgements. The authors thank Dr. M. Leit-ner for creating the graphics, Dr. I. Salzmann for theprotection gear photograph and C. Weinmann forsupport with translating this article.

Compliance with ethicalguidelines

Conflict of interest. D. Thomas-Rüddel, J.Win-ning, P. Dickmann, D. Ouart, A. Kortgen, U. JanssensandM. Bauer declare that theyhave no competinginterests.

For this article no studieswith humanparticipantsor animalswere performedby anyof the authors. Allstudies performedwere in accordancewith the ethicalstandards indicated in each case.

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