BACKGROUND:Awake intubation using a flexible bronchoscope is a well-established technique in the operating room but remains underutilized in the Emergency Department (ED), despite its potential benefits in managing anticipated difficult airways. CASE PRESENTATION:We describe three cases in which awake fiberoptic intubation was successfully performed in the ED setting. The first involved an elderly woman with caustic ingestion and progressive oropharyngeal edema. The second was a post-thyroidectomy patient presenting with massive cervicothoracic subcutaneous emphysema and suspected tracheal injury. The third case concerned a previously healthy woman with refractory angioedema and severe trismus. In all cases, conventional sedated intubation was deemed high-risk due to potential airway collapse or distortion. Awake intubation allowed for maintenance of spontaneous ventilation, real-time airway navigation, and safe endotracheal tube placement. All patients were successfully intubated and transferred to the Intensive Care Unit. CONCLUSION:These cases illustrate the feasibility and clinical utility of awake intubation with a flexible bronchoscope in emergency settings. When conventional techniques are contraindicated or unsafe, this approach may provide a life-saving alternative. Increased familiarity with fiberoptic-guided intubation could significantly expand the airway management toolkit of emergency physicians.

OBJECTIVES:We investigated donors with brain death on extracorporeal membrane oxygenation support, a clinically challenging situation due to hemodynamic instability frequently encountered in these donors, which may threaten organ function. MATERIALS AND METHODS:We described our experience with 15 utilized brain death donors on extracorporeal membrane oxygenation support, consecutively admit-ted in our intensive care unit (which is a referral center for extracorporeal membrane oxygenation) from 2018 to 2023. We investigated whether utilization rate for brain death donors on extracor-poreal membrane oxygenation was affected by the introduction of a monitoring hemodynamic schedule during the 6-hour observation period. RESULTS:The utilization rate was 78% in period 1 and 88% in period 2. No statistically significant differences were observed for age, sex, and the incidence of cardiovascular risk factors between period 1 and period 2. The cause of death was postanoxic encephalopathy in all but 1 donor, who was on venovenous extracorporeal membrane oxygenation for refractory respiratory failure and developed cerebral hemorrhage. Number of organs per donor was 2 in all the population with no significant differences between period 1 and period 2. In the overall population, 15 livers were transplanted, 11 kidneys, 1 heart, and 1 pancreas. In our population, left ventricular ejection fraction severe dysfunction was observed in all donors except in the donor on venovenous extracorporeal membrane oxygenation; the organ from this donor was deemed unsuitable for transplant. No significant differences were observed in hemodynamic data between the 2 subgroups. All donors were on 2 vasoactive drugs (norepinephrine and vasopressin) to maintain adequate perfusion (mean arterial pressure >60 mm Hg). Three donors were oligoanuric (due to postarrest acute renal failure). CONCLUISONS:In our series of 15 consecutive brain death donors on extracorporeal membrane oxygenation, a strict monitoring regimen during the 6-hour obser-vation period was associated with a higher utilization rate.

OBJECTIVES:Management of potential organ donors is crucial in the donation process, considering that hemodynamic instability is quite common. MATERIALS AND METHODS:In the this single-center retrospective observational study, we analyzed 87 utilized brain death donors consecutively admitted to our intensive care unit from January 1, 2019, to December 31, 2022. We assessed the achievement of donor management goals during the observation period, and we also evaluated whether the achieve-ment of donor goals differed between younger and older donors (arbitrary age cutoff of 65 years). RESULTS:In our series, mean age of donors was 67 ± 18 y, and organ-per-donor ratio was 2.3. The number of donor goals significantly increased during the 6-hour observation period (P < .001) and all donor goals were achieved in most donors (84/87) at the end of the observation period with no changes in the use and dose of vasoactive drugs. With respect to age, the number of donor goals was significantly higher in older donors at first evaluation, but goals significantly increased in both age subgroups of donors at the end of the 6-hour observation period. CONCLUSIONS:Our data strongly suggested that a strict hemodynamic monitoring schedule allows the achievement of donor goals both in older and in younger brain death donors. We confirmed our previous findings that hemodynamic management in brain death donors is influenced by age. A strict hemodynamic monitoring schedule of brain death donors is useful to consistently achieve donor goals.

Aims The role of immediate coronary angiography (CAG) with percutaneous coronary intervention (PCI) in patients who present with ST-segment elevation myocardial infarction (STEMI) and cardiac arrest is well recognized. However, the role of immediate angiography in patients after cardiac arrest without STEMI is less clear. We assessed whether urgent (<6 h) CAG and PCI (whenever needed) was associated with improved early survival in out-of-hospital cardiac arrest (OHCA). Methods In our single-centre, retrospective, observational study, we included all consecutive OHCA patients admitted to the A&E of the Careggi University Hospital between 1 June 2016 and 31 July 2020. One hundred and forty-four OHCA patients were submitted to CAG and constituted our study population. Results Among the 221 consecutive OHCA patients, 69 (31%) had refractory cardiac arrest treated with extracorporeal cardiopulmonary resuscitation (eCPR) in 37 (37/69, 56%) patients. The mortality rate was significantly higher in the no CAG subgroup (P < 0.00001). In the CAG subgroup, coronary artery disease was detected in the 70% (92 patients), among whom the left main coronary artery was involved in 10 patients (10.8%). At multivariable regression analysis (CAG subgroup, outcome ICU survival), witnessed cardiac arrest was independently associated with survival. Conclusion A high incidence of coronary artery disease was observed at CAG in the real–world of OHCA patients. Better planning of revascularization and treatment in patients studied with CAG may explain, at least in part, their lower mortality rate.

We assessed whether right ventricle (RV) alterations and their development may have clinical significance in critically-ill Coronavirus Disease (COVID) patients, as detected by serial echocardiograms during Intensive Care Unit (ICU) course. This observational single center study included 98 consecutive patients with COVID-related acute respiratory distress syndrome (ARDS). Three subgroups were considered: RV Dysfunction (Dys) on admission (10/98, 10%), developed RV Dys (17/98, 17%), and no RV Dys (71/98, 73%). Overall mortality at 3 months was 46.9%. The first subgroup was characterized by the highest need for Extracorporeal Membrane Oxygenation (ECMO) support (P < .001) and a systemic inflammatory activation (as indicated by increased D-dimer), the second one by the lowest PaO2/FiO2 (P/F). At multivariate regression analysis, age and Sequential Organ Failure Assessment score were independent predictors for mortality. Different RV echo patterns were observed in critically ill patients presenting with COVID-related ARDS during ICU stay. RV Dys on admission was characterized by a high inflammatory activation while patients who developed RV Dys during ICU stay showed lowest P/F. Both these two subgroups identify patients with a severe COVID disease which in a high percentage of cases was unresponsive to standard treatment and required the use of ECMO.

Objectives: The study authors hypothesized that in patients with SARS-CoV-2, COVID-19-related refractory respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support echocardiographic findings (just before ECMO implantation) would be different from those observed in patients with refractory respiratory failure from different etiologies.Design: A single-center observational study.Setting: At an intensive care unit (ICU).Participants: A total of 61 consecutive patients with refractory COVID-19-related respiratory failure (COVID-19 series) and 74 patients with refractory acute respiratory disease syndrome from other etiologies (no COVID-19 series), all needing ECMO support.Interventions: Echocardiogram pre-ECMO.Measurements and Main Results: Right ventricle dilatation and dysfunction were defined in the presence of the RV end-diastolic area and/or left ventricle end-diastolic area (LVEDA >0.6 and tricuspid annular plane systolic excursion [TAPSE] <15 mm. Patients in the COVID-19 series showed a higher body mass index (p < 0.001) and a lower Sequential Organ Failure Assessment score (p = 0.002). In-ICU mortality rates were comparable between the 2 subgroups. Echocardiograms performed in all patients before ECMO implantation revealed an incidence of RV dilata-tion that was higher in patients in the COVID-19 series (p < 0.001), and they also showed higher values of systolic pulmonary artery pressure (sPAP) (p < 0.001) and lower TAPSE and/or sPAP (p < 0.001). The multivariate logistic regression analysis showed that COVID-19-related respiratory failure was not associated with early mortality. The presence of RV dilatation and the uncoupling of RV function and pulmonary cir-culation were associated independently with COVID-19 respiratory failure.Conclusions: The presence of RV dilatation and an altered coupling between RVe function and pulmonary vasculature (as indicated by TAPSE and/or sPAP) are associated strictly with COVID-19-related refractory respiratory failure needing ECMO support.& COPY; 2023 Elsevier Inc. All rights reserved.

BACKGROUND The prognostic role of right ventricle dilatation and dysfunction (RVDD) has not been elucidated in patients with coronavirus disease (COVID)-related respiratory failure refractory to standard treatment needing extracorporeal membrane oxygenation (ECMO) support. AIM To assess whether pre veno-venous (VV) ECMO RVDD were related to in-intensive care unit (ICU) mortality. METHODS We enrolled 61 patients with COVID-related acute respiratory distress syndrome refractory to conventional treatment submitted to VV ECMO and consecutively admitted to our ICU (an ECMO referral center) from 31(th) March 2020 to 31(th) August 2021. An echocardiographic exam was performed immediately before VV ECMO implantation. RESULTS Males were prevalent (73.8%) and patients with a body mass index > 30 kg/m(2) were the majority (46/61, 75%). The overall in-ICU mortality rate was 54.1% (33/61). RVDD was detectable in more than half of the population (34/61, 55.7%) and associated with higher simplified organ functional assessment (SOFA) values (P = 0.029) and a longer mechanical ventilation duration prior to ECMO support (P = 0.046). Renal replacement therapy was more frequently needed in RVDD patients (P = 0.002). A higher in-ICU mortality (P = 0.024) was observed in RVDD patients. No echo variables were independent predictors of in-ICU death. CONCLUSION In patients with COVID-related respiratory failure on ECMO support, RVDD (dilatation and dysfunction) is a common finding and identifies a subset of patients characterized by a more severe disease (as indicated by higher SOFA values and need of renal replacement therapy) and by a higher in-ICU mortality. RVDD (also when considered separately) did not result independently associated with in-ICU mortality in these patients.

BACKGROUND:In brain death donors (BDDs), donor management is the key in the complex donation process. Donor management goals, which are standards of care or clinical parameters, have been considered an acceptable barometer of successful donor management.AIM:To test the hypothesis that aetiology of brain death could influence haemody namic management in BDDs.METHODS:Haemodynamic data (blood pressure, heart rate, central venous pressure, lactate, urine output, and vasoactive drugs) of BDDs were recorded on intensive care unit (ICU) admission and during the 6-h observation period (Time 1 at the beginning; Time 2 at the end).RESULTS:The study population was divided into three groups according to the aetiology of brain death: Stroke (n = 71), traumatic brain injury (n = 48), and postanoxic encephalopathy (n = 19). On ICU admission, BDDs with postanoxic encephalopathy showed the lowest values of systolic and diastolic blood pressure associated with higher values of heart rate and lactate and a higher need of norepinephrine and other vasoactive drugs. At the beginning of the 6-h period (Time 1), BDDs with postanoxic encephalopathy showed higher values of heart rate, lactate, and central venous pressure together with a higher need of other vasoactive drugs.CONCLUSION:According to our data, haemodynamic management of BDDs is affected by the aetiology of brain death. BDDs with postanoxic encephalopathy have higher requirements for norepinephrine and other vasoactive drugs.

Background: Emergency surgery is associated with high mortality and morbidity and identifying the patients at highest risk of death represents a major challenge for intensivists. Obesity is a common comorbidity with increasing prevalence in the last 20 years. While conflicting results were reported on the association between obesity and mortality in elective surgery, very few data are available on this relationship in emergency surgery.

Objectives: Venovenous extracorporeal membrane oxygenation (ECMO) support may be considered in experienced centers for patients with acute respiratory distress syndrome (ARDS) due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection refractory to conventional treatment. In ECMO patients, echocardiography has emerged as a clinical tool for implantation and clinical management; but to date, little data are available on COVID-related ARDS patients requiring ECMO. The authors assessed the incidence of right ventricular dilatation and dysfunction (RvDys) in patients with COVID-related ARDS requiring ECMO. Design: Single-center investigation. Setting: Intensive care unit (ICU). Participants: A total of 35 patients with COVID-related ARDS requiring ECMO, consecutively admitted to the ICU (March 1, 2020, to February 28, 2021). Interventions: Serial echocardiographic examinations. RvDys was defined as RV end-diastolic area/LV end-diastolic area >0.6 and tricuspid annular plane excursion <15 mm. Measurements and Main Results: The incidence of RvDys was 15/35 (42%). RvDys patients underwent ECMO support after a longer period of mechanical ventilation (p = 0.006) and exhibited a higher mortality rate (p = 0.024) than those without RvDys. In nonsurvivors, RvDys was observed in all patients (n = nine) who died with unfavorable progression of COVID-related ARDS. In survivors, weaned from ECMO, a significant reduction in systolic pulmonary arterial pressures was detectable. Conclusions: According to the authors' data, in COVID-related ARDS requiring ECMO support, RvDys is common, associated with increased ICU mortality. Overall, the data underscored the clinical role of echocardiography in COVID-related ARDS supported by venovenous ECMO, because serial echocardiographic assessments (especially focused on RV changes) are able to reflect pulmonary COVID disease severity. (C) 2021 Elsevier Inc. All rights reserved.

Study objectives: To assess whether echocardiography, systematically performed, could help in risk stratifying patients with acute respiratory distress syndrome (ARDS) due to SARS-CoV2 (COVID) infection for non invasive ventilation (NIV) failure. Design: Observational single center investigation. Setting: Intensive care unit. Interventions: Echocardiography. Outcome measures: NIV failure. Main results: Seventy-five patients were included in our study. In respect to patients who did not need mechanical ventilation (NIV success), those in the NIV failure subgroup (31 patients, 41 %) were older, with more comorbidities and showed a higher SOFA score and LOS. Higher values of NTpro BNP, CRP and D-dimer were observed in the NIV failure subgroup who exhibited a higher ICU mortality rate. At echocardiographic examination, the NIV failure subgroup showed higher values of RV/LV ratio, systolic pulmonary arterial pressure (sPAP) and lower values of tricuspid annular plane systolic excursion (TAPSE)/SPAP, and PaO2/FiO2. At logistic regression analysis TAPSE/sPAP resulted an independent predictor of NIV failure. At receiving operating characteristic curve analysis, the TAPSE/SPAP cut-off of 0.575 mm/mm Hg showed a sensitivity of 97 % and a specificity of 48 %. Conclusions: Our results documented a marked uncoupling of right ventricular function from the pulmonary circulation (as indicated by TAPSE/sPAP) in COVID-related ARDS treated with non invasive ventilation and the measurement of this parameter, performed on ICU admission, provides independent prognostic relevance for NIV failure.

Lung ultrasound (LU) is a useful tool for monitoring lung involvement in novel coronavirus (COVID) disease, while information on echocardiographic findings in COVID disease is to date scarce and heterogeneous. We hypothesized that lung and cardiac ultrasound examinations, serially and simultaneously performed, could monitor disease severity in COVID-related ARDS. We enrolled 47 consecutive patients with COVID-related ARDS (1st March–31st May 2020). Lung and cardiac ultrasounds were performed on admission, at discharged and when clinically needed. Most patients were mechanically ventilated (75%) and veno-venous extracorporeal membrane oxygenation was needed in ten patients (21.2%). The in-ICU mortality rate was 27%%. On admission, not survivors showed a higher LUS score (p = 0.006) and a higher incidence of consolidations (p = 0.003), lower values of LVEF (p = 0.027) and a higher RV/LV ratio (0.008). At discharge, a significant reduction in the incidence of subpleural consolidations (p < 0.001) and, thus, in LUS score (p < 0.001) and an increase in patter A findings (p < 0.001) together with reduced systolic pulmonary arterial pressures were detectable. In not survivors at final examination, an increased in LUS score (p < 0.001), and in RV/LV ratio (p < 0.001) associated with a reduction in TAPSE (p = 0.013) were observed. A significant correlation was observed between LUS and systolic pulmonary arterial pressure (p = 0.04). LUS and RV/LV resulted independent predictors of in-ICU death. In COVID-related ARDS, the combined lung and cardiac ultrasound proved to be an useful clinical tool in monitoring disease progression and in identifying parameters (LU score and RV/LV ratio) able to risk stratifying these patients.

Lazzeri, Chiara; Bonizzoli, Manuela; Batacchi, Stefano; Socci, Filippo; Peris, Adriano Author Information

Backgrounds: The still high poor outcome of ARDS may be more consequence of circulatory failure than hypoxemia per se. For patients with circulatory failure and ARDS, hemodynamic instability is directly related to ARDS following pulmonary circulation dysfunction and its consequence - right ventricular (RV) dysfunction. Objectives: We hypothesize that in the era of protective ventilation, echocardiographic abnormalities did not parallel ARDS severity, defined by the degree of hypoxemia. Methods: We included 63 consecutively identified mechanically ventilated ARDS patients (1st January 2015 to 31th December 2016). All had echocardiography performed routinely within the first 12 h after ICU admission. Results: The analysis included 110 exams. Twenty-eight patients had severe ARDS (28/63, 44.4%), 27 had moderate ARDS (27/63, 42.1%) and 8 mild ARDS (8/63, 12.7%).There was no difference in echocardiographic findings between mild-moderate and severe ARDS. At Pearson's linear regression analysis, TAPSE was directly correlated with LVEF (r = 0.22, p = 0.021) and inversely with sPAP (r = -0.37, p < 0.001). Systolic pulmonary arterial pressure (sPAP) showed a direct correlation with pCO(2) (r = 0.30, p = 0.002) and an inverse one with pH (r = -0.35, p < 0.001) and TAPSE (r =-0.35, p < 0.001). Conclusions: Among patients with ARDS, the severity of disease (as indicated by pO2) does not translate into specific cardiac abnormalities, detected by echocardiography. However, RV function (as indicated by TAPSE) is inversely related to pCO(2) and to sPAP (which therefore may be underestimated in presence ofRV dysfunction). Our data strongly suggest that in mechanically ventilated ARDS, the interpretation of echo findings should consider also pCO(2) values. (C) 2020 Elsevier Inc. All rights reserved.

In patients with the novel coronavirus (COVID-19) infection, the echocardiographic assessment of the right ventricle (RV) represents a pivotal element in the understanding of current disease status and in monitoring disease progression. The present manuscript is aimed at specifically describing the echocardiographic assessment of the right ventricle, mainly focusing on the most useful parameters and the time of examination. The RV direct involvement happens quite often due to preferential lung tropism of COVID-19 infection, which is responsible for an interstitial pneumonia characterized also by pulmonary hypoxic vasoconstriction (and thus an RV afterload increase), often evolving in acute respiratory distress syndrome (ARDS). The indirect RV involvement may be due to the systemic inflammatory activation, caused by COVID-19, which may affect the overall cardiovascular system mainly by inducing an increase in troponin values and in the sympathetic tone and altering the volemic status (mainly by affecting renal function). Echocardiographic parameters, specifically focused on RV (dimensions and function) and pulmonary circulation (systolic pulmonary arterial pressures, RV wall thickness), are to be measured in a COVID-19 patient with respiratory failure and ARDS. They have been selected on the basis of their feasibility (that is easy to be measured, even in short time) and usefulness for clinical monitoring. It is advisable to measure the same parameters in the single patient (based also on the availability of valid acoustic windows) which are identified in the first examination and repeated in the following ones, to guarantee a reliable monitoring. Information gained from a clinically-guided echocardiographic assessment holds a clinical utility in the single patients when integrated with biohumoral data (indicating systemic activation), blood gas analysis (reflecting COVID-19-induced lung damage) and data on ongoing therapies (in primis ventilatory settings).

Severe Acute Respiratory Syndrome Coronavirus 2 World Health Organization Oropharyngeal Emergency and Reception Department Emergency Department Operating Theater Personal Protection Equipment Bronchoalveolar Lavage The spread of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), declared a pandemic by the World Health Organization (WHO),1Coronavirus disease.https://www.who.int/emergencies/diseases/novel-coronavirus-2019Date: 2019Date accessed: April 26, 2020Google Scholar triggered a global response to preparedness in health systems worldwide. It was March 2020 when the Italian Government implemented extraordinary measures to limit viral transmission such as restricting the movement of citizens, promoting physical distancing and banning social activities, unless strictly required. Hence, the Italian national health system suggested a reorganization in order to optimize already existing resources and implement them to overcome the crisis caused by the pandemic. Careggi University Hospital, high specialty hospital and HUB for Trauma in Tuscany, reorganized all activities and adopted several measures in order to optimize the health response to the pandemic, including:-the suspension of the elective non-oncological general surgical activity in order to guarantee priority access for surgical cancer patients and ensure a redistribution of hospitalization areas into COVID-19 pathways and Non-COVID-19 pathways;-the remodelling of non-urgent outpatient activities, guaranteeing reservations only for post-surgical evaluations or surgical visits deemed urgent, non-deferrable, or reserved for oncological patients. In this regard, the possibility of carrying out a remote digital examination, via a dedicated platform which records all activities, has been envisaged;-the execution of the oropharyngeal (OP) swab 48 hours before the elective hospitalization for patients with neoplastic pathologies who need scheduled surgery, or for patients who need to perform invasive procedures;-limitation of access for carers and visitors, except for procedures involving minors where the presence of at least one parent is required;-the body temperature measurement with body-temperature scanners, providing a surgical mask for those without it and the disinfection of hands with hydroalcoholic gel for anyone entering the hospital, including employees;-the postponement of all internal and open training events within the hospital;-the suspension of meetings that require the presence of multiple professionals, replacing them with video conferences or rescheduling them after the pandemic-banning the presence in the hospital of volunteers or trainees for educational/training purposes;-the communication of news regarding the state of health of patients to designated family members performed by telephone, daily, or in case of changes in the clinical status (need for surgery, outcome of surgery, post-operative course, etc.). Over 100 years have already elapsed since the foundation of the Careggi University Hospital, and despite the continuous restorations and the hospital building dynamics that led to a complete redistribution of care activities over the years, one thing has not changed, the fact that it was, and still is, a pavilion hospital. The same spirit that inspired the construction of the hospital with pavilions, today is evidence of the efficacy precisely as it enables a more effective response to the pandemic. The only limit is the increase in access points, which are present in all individual pavilions and not the presence of one single access point. In this regard, in each pavilion there is a check point where an operator measures body temperature, provides the masks and invites the disinfection of hands with an hydroalcoholic gel. Our pavilion, the DEA (Emergency and Reception Department) pavilion, which includes the activities related to the emergency and urgency as a whole, has been remodelled in order to allow an adequate response to the pandemic in progress such as enhancing the number of beds in the intensive care unit, the increasing of sub-intensive care units and the remodulation of the DEA into differentiated COVID-19 and Non-COVID-19 wards. At the beginning of the introduction of social distancing measures and the beginning of lockdown, we noticed a reduction in the inflow of surgical patients in urgency, which lasted approximately 15 days. Subsequently, there was a gradual resumption of surgical activity in urgency until reaching the previous standard activity. Conversely, the emergency surgical activity related to traumatic pathology has undergone to a sharp reduction due to the lockdown measures imposed by the government with the limitation of people's movement. Our hospital follows standardized procedures in order to homogenize behaviors, precisely in the management of emergencies. In the event of surgery, COVID-19 confirmed patients are transferred from a dedicated area of the Emergency Department (ED) to a dedicated COVID-19 Operating Theater (OT) by a specific transfer pathway. The entire OT team is equipped with full Personal Protection Equipment (PPE); numerically surgeons, nurses, anaesthetists are limited to the minimum required staff to perform surgery. Moreover, changes of personnel are limited until the end of the procedure in order to involve the least number of operators. A filter area is provided at the entrance to the COVID-19 Operating Theater where all the necessary PPE are available. All the clinical and essential patient's documentation is consulted and updated outside the OT after removing the PPE and performing the disinfection of hands. The doors of the OT are kept closed during operation and any supply of material to the OT is carried out by personnel with PPE, present outside the dedicated OT. In addition, all the recommendations reported by SAGES2SAGES and EAES recommendations regarding surgical response to COVID-19 crisis - SAGES.https://www.sages.org/recommendations-surgical-response-covid-19/Date accessed: April 26, 2020Google Scholar and the American College of Surgeons3COVID-19: considerations for optimum surgeon protection before, during, and after operation.https://www.facs.org/covid-19/clinical-guidance/surgeon-protectionDate accessed: April 26, 2020Google Scholar regarding the use of electrocautery, ultrasonic scalpels and the risk of transmission by aerosol during laparoscopy were provided. In our experience, all cases were treated via exploratory laparotomy. In COVID-19 confirmed patients, it is important to consider the time that elapses between the disposition for urgent surgical intervention and the preparation of the OT and the protection of all OT staff. In addition, the use of complete PPE makes the surgery non-comfortable due to perspiration or fogging of the goggles and the implementation of the recommendations that reduce energy devices to a minimum make the intervention technically challenging. According to the precautionary principle, every patient undergoing emergency surgery not already tested for COVID-19, must be considered as potentially infected, an issue that entails putting into practice of all precautions. This principle of safety for all healthcare professionals obviously translates into implementing all the provisions used in confirmed COVID-19 patients for surgical interventions that are not postponable and that require the immediate availability of the operating room (such as trauma, shock, bleeding, suicide attempts, peritonitis, etc). Still on the same precautionary principle, patients with negative swab for COVID-19 but suspected pulmonary radiological picture for COVID-19 should be treated in any case as COVID-19 positive patients and, very often, waiting for a second swab or for a BAL examination is not always possible. Patients with potential surgical disease, not COVID-19-like, but not yet tested for COVID-19 should be considered as potentially infected until the outcome of the swab. Obviously it would be preferable to perform the surgery knowing that the swab is negative in order to serenely perform surgery using all the surgical energy devices, the laparoscopic approach and not wearing complete and uncomfortable PPE. Of course, this entails some specific issues, especially regarding surgical indications and the decision-making process. For less significant surgical pathologies, such as appendicitis, cholecystitis, diverticulitis (excluding the forms associated with general peritonitis) and potential surgical intervention that can be deferred by a few hours (waiting for the swab) it must be considered that the time that elapses between the execution of the swab and the response of the swab must not change the treatment strategy. In fact, in order keep stress factors mitigated within the team, many surgeons may be tempted to abandon the surgical strategy in favour of conservative treatments. The risk of undertaking a conservative treatment, with the consequent discharge of the patient and re-admission after a few days for the same pathology for a worsening of symptoms (and subsequent new swab at entry), is high and must be taken into consideration. In our opinion, the surgical response should be the same as before the COVID-19 era. Patients with a negative swab for COVID-19 who require surgery undertake the "clean" pathway with dedicated operating rooms and the possibility of hospitalization in the Covid-free surgical ward. The problem may be the time between the patient admission, performing the swab, the surgical consultation, the outcome of the swab and the activation of the OT. In our hospital a pathway for a rapid evaluation of the swab in this type of patients have been undertaken in order to optimize timing, reduce waiting time, and improve the surgical response. These COVID-19 related problems have been addressed by surgeons all over the world and specific pathways have also been described4Al-Balas M. Al-Balas H.I. Al-Balas H. Surgery during the COVID-19 pandemic: a comprehensive overview and perioperative care.Am J Surg. 2020; https://doi.org/10.1016/j.amjsurg.2020.04.018Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar; yet, it should be considered that the hospital administration and the heads of departments must adjust their policies to international guidelines, national government measures, local data and resources.5Diaz A. Sarac B.A. Schoenbrunner A.R. Janis J.E. Pawlik T.M. Elective surgery in the time of COVID-19.Am J Surg. 2020; https://doi.org/10.1016/j.amjsurg.2020.04.014Abstract Full Text Full Text PDF Scopus (195) Google Scholar In conclusion, the pandemic has also increased surgical stress. In fact, as suggested by Diaz et al. surgeons have witnessed one of the most dramatic changes in their practices with rapidly decreasing numbers of elective surgeries.5Diaz A. Sarac B.A. Schoenbrunner A.R. Janis J.E. Pawlik T.M. Elective surgery in the time of COVID-19.Am J Surg. 2020; https://doi.org/10.1016/j.amjsurg.2020.04.014Abstract Full Text Full Text PDF Scopus (195) Google Scholar In our opinion, the interruption of the elective non-oncological surgery procedures may cause stress due to the discomfort that the postponement will cause to the patient, as well as the rescheduling which the surgeon will have to organize at the earliest convenience. Furthermore, also the relations between the doctor and the patient and between the doctor and the patient's family members may be impaired due to the different approach which a telephone contact represents, instead of the face-to-face contact. If we consider also the apparent reduction/absence of polytrauma due to social distancing measures imposed by the government, a minor human contact in patient handover (even if digital platforms are provided) and the difficulties in the technical management of surgical COVID-19 patients in emergency settings, this pandemic era is further tempering the spirit of surgeons. Moreover, it should be considered that, when the government containment measures will be discontinued, after two months of lockdown, we might assist to a "0–100" increase in polytraumas, and that the resumption of normal surgical activity and the increase in traumatic pathology will require additional resources to support surgery in emergency and trauma settings. Authors assert that the work described has not been published previously, that it is not under consideration for publication elsewhere and that its publication is approved by all authors involved. The authors state that no funding has been received for this article.

The cardiac involvement in Coronavirus disease (COVID-19) is still under evaluation, especially in severe COVID-19-related Acute Respiratory Distress Syndrome (ARDS). The cardiac involvement was assessed by serial troponin levels and echocardiograms in 28 consecutive patients with COVID-19 ARDS consecutively admitted to our Intensive Care Unit from March 1 to March 31. Twenty-eight COVID-19 patients (aged 61.7 +/- 10 years, males 79%). The majority was mechanically ventilated (86%) and 4 patients (14%) required veno-venous extracorporeal membrane oxygenation. As of March 31, the Intensive Care Unit mortality rate was 7%, whereas 7 patients were discharged (25%) with a length of stay of 8.2 +/- 5 days. At echocardiographic assessment on admission, acute core pulmonale was detected in 2 patients who required extracorporeal membrane oxygenation support. Increased systolic arterial pressure was detected in all patients. Increased Troponin T levels were detectable in 11 patients (39%) on admission. At linear regression analysis, troponin T showed a direct relationship with C-reactive Protein (R square: 0.082, F: 5.95, p = 0.017). In conclusions, in COVID-19-related ARDS, increased in Tn levels was common but not associated with alterations in wall motion kinesis, thus suggesting that troponin T elevation is likely to be multifactorial, mainly linked to disease severely (as inferred by the relation between Tn and C-reactive Protein). The increase in systolic pulmonary arterial pressures observed in all patients may be related to hypoxic vasoconstriction. Further studies are needed to confirm our findings in larger cohorts. (C) 2020 Elsevier Inc. All rights reserved.