LAUSR

Background On February 21, 2020, the first person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), the virus causing coronavirus disease 2019 (COVID-19), was identified in Italy. In the following days, despite the restrictive public health measures applied to avoid the spread of the infection [1], the number of cases sharply increased. As of March 8, 2020, Italy was the 2nd most affected country in the world. In one of the largest reports from China, 5% of COVID19 patients required admission to the intensive care unit (ICU) [2]. Since the beginning of the COVID-19 outbreak, the availability of ICU beds has been recognized as one of the major public health concerns in Italy, where a total of 5090 ICU beds (8.42/100,000 inhabitants) were reported in 2017 [3]. Despite further efforts have been done to contain the number of cases and extraordinary measures have been put in place, the dramatic increase of ICU admission abruptly overwhelmed the ICU capacity, mostly in Lombardy and in the nearby regions of Northern Italy. From the evidence available so far, a considerable proportion of subjects diagnosed with COVID-19 infection requires ventilatory support due to severe hypoxemia in the context of interstitial pneumonia. The interstitial lung disease is potentially reversible, but the acute course of the disease can last several days, and ventilatory support may be needed for weeks [4]. These clinical considerations imply that caring for patients with severe pneumonia from COVID-19 can be very demanding in terms of the number of devices and staff required. As of March 6, 2020, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) issued a series of recommendations [5] and relevant ethical considerations to better inform the clinicians involved in the care of critically-ill COVID-19 patients, in a setting where a disproportionate number of patients requiring life-sustaining treatments was rapidly saturating both the existing and the newly set-up ICU beds. The most relevant recommendations are summarized in Table 1.