LAUSR

To the Editor, The COVID-19 outbreak is currently spreading throughout northern Italy and is forcing a rapid change of clinical priorities and organizational logistics. In this dramatic scenario, angio-suites and operatory rooms only admit urgent procedures and the interventional radiology (IR) service is mostly dedicated to assisting the emergency department in dealing with SARS-CoV-2-positive patients. We share a case of pleural drainage in one COVID-19 patient and provide the IR community with some practical recommendations regarding the management of this particular category of patients. A 63-year-old woman with metastatic ovarian cancer and recurrent malignant pleural effusion came to our institutional ER with fever (39 C) and dyspnea at rest. Being our institute located in a severely involved area of the COVID19 outbreak, clinical symptoms were compatible with COVID-19 infection. Laboratory parameters included hemoglobin 10.7, white blood cells 3.98, C-reactive protein 43.5, arterial pH 7.5, pO2 53 mmHg, pCO2 31 mmHg and blood lactate concentration 1 mmol/L. Although the patient underwent a right pleurodesis 6 months ago, chest X-ray showed bilateral pleural effusion (loculated on the right side) as well as interstitial thickening (Fig. 1A), a common imaging feature in COVID-19. She underwent a naso-/ oropharyngeal swab which turned positive for SARS-CoV2 nucleic acid after being processed through a real-time reverse transcriptase polymerase chain reaction (Novel Coronavirus PCR Fluorescence Diagnostic Kit, BioGerm Medical Biotechnology). She started as an inpatient with 1 week of non-invasive assisted ventilation that reduced fever, clinical symptoms and normalized inflammatory laboratory values such as C-reactive protein. Still, respiratory function and blood oxygen levels remained poor despite an increase in FiO2 from 60 to 70%. Consequently, percutaneous drainage was requested with the aim of improving ventilation and blood oxygen saturation. The procedure was performed at the bedside in an isolated ward dedicated to COVID-19 patients. The operator wore an FFp2 mask, double gloves, protective glasses and a surgical gown (Fig. 2). After local anesthesia, two 8F multi-hole drainages were inserted bilaterally using dedicated US equipment in the isolated ward as image guidance. The procedure lasted approximately 1 h and was well tolerated. Around 1800 mL was drained in the next 5 h from both sides. All disposable equipment and devices were then immediately discarded in specific containers. Post-procedural chest X-rays showed a marked increase in the ventilated parenchyma. Along with clinical symptoms, also laboratory markers rapidly improved and blood saturation levels reached the normal range (SpO2 98%). The patient switched from assisted ventilation to a simple face mask (2 L/min O2) and maintained normal peripheral capillary oxygen saturation. At the time of writing, she is alive and close to hospital discharge. The current COVID-19 outbreak is causing a massive overcrowding of admitted patients for symptomatic pneumonia. Patient presentation ranges from mild symptoms to & Nicolò Gennaro [email protected]