Critical care crisis and some recommendations during the COVID-19 epidemic in China
Identifieur interne : 000073 ( Pmc/Corpus ); précédent : 000072; suivant : 000074Critical care crisis and some recommendations during the COVID-19 epidemic in China
Auteurs : Jianfeng Xie ; Zhaohui Tong ; Xiangdong Guan ; Bin Du ; Haibo Qiu ; Arthur S. SlutskySource :
- Intensive Care Medicine [ 0342-4642 ] ; 2020.
Url:
DOI: 10.1007/s00134-020-05979-7
PubMed: 32123994
PubMed Central: 7080165
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Critical care crisis and some recommendations during the COVID-19 epidemic in China</title><author><name sortKey="Xie, Jianfeng" sort="Xie, Jianfeng" uniqKey="Xie J" first="Jianfeng" last="Xie">Jianfeng Xie</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.263826.b</institution-id><institution-id institution-id-type="ISNI">0000 0004 1761 0489</institution-id><institution>Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,</institution><institution>Southeast University,</institution></institution-wrap>Nanjing, 210009 Jiangsu China</nlm:aff></affiliation></author><author><name sortKey="Tong, Zhaohui" sort="Tong, Zhaohui" uniqKey="Tong Z" first="Zhaohui" last="Tong">Zhaohui Tong</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.24696.3f</institution-id><institution-id institution-id-type="ISNI">0000 0004 0369 153X</institution-id><institution>Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-yang Hospital,</institution><institution>Capital Medical University,</institution></institution-wrap>Beijing, 100020 China</nlm:aff></affiliation></author><author><name sortKey="Guan, Xiangdong" sort="Guan, Xiangdong" uniqKey="Guan X" first="Xiangdong" last="Guan">Xiangdong Guan</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.412615.5</institution-id><institution>Department of Critical Care Medicine,</institution><institution>The First Affiliated Hospital of Sun Yat-sen University,</institution></institution-wrap>Guangzhou, 510080 Guangdong China</nlm:aff></affiliation></author><author><name sortKey="Du, Bin" sort="Du, Bin" uniqKey="Du B" first="Bin" last="Du">Bin Du</name><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="GRID">grid.12527.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 0662 3178</institution-id><institution>Medical ICU, Peking Union Medical College Hospital,</institution><institution>Peking Union Medical College and Chinese Academy of Medical Sciences,</institution></institution-wrap>Beijing, 100730 China</nlm:aff></affiliation></author><author><name sortKey="Qiu, Haibo" sort="Qiu, Haibo" uniqKey="Qiu H" first="Haibo" last="Qiu">Haibo Qiu</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.263826.b</institution-id><institution-id institution-id-type="ISNI">0000 0004 1761 0489</institution-id><institution>Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,</institution><institution>Southeast University,</institution></institution-wrap>Nanjing, 210009 Jiangsu China</nlm:aff></affiliation></author><author><name sortKey="Slutsky, Arthur S" sort="Slutsky, Arthur S" uniqKey="Slutsky A" first="Arthur S." last="Slutsky">Arthur S. Slutsky</name><affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id><institution>Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael’s Hospital and Departments of Medicine, Surgery, and Biomedical Engineering,</institution><institution>University of Toronto,</institution></institution-wrap>Toronto, Canada</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32123994</idno><idno type="pmc">7080165</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080165</idno><idno type="RBID">PMC:7080165</idno><idno type="doi">10.1007/s00134-020-05979-7</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000073</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000073</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Critical care crisis and some recommendations during the COVID-19 epidemic in China</title><author><name sortKey="Xie, Jianfeng" sort="Xie, Jianfeng" uniqKey="Xie J" first="Jianfeng" last="Xie">Jianfeng Xie</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.263826.b</institution-id><institution-id institution-id-type="ISNI">0000 0004 1761 0489</institution-id><institution>Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,</institution><institution>Southeast University,</institution></institution-wrap>Nanjing, 210009 Jiangsu China</nlm:aff></affiliation></author><author><name sortKey="Tong, Zhaohui" sort="Tong, Zhaohui" uniqKey="Tong Z" first="Zhaohui" last="Tong">Zhaohui Tong</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.24696.3f</institution-id><institution-id institution-id-type="ISNI">0000 0004 0369 153X</institution-id><institution>Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-yang Hospital,</institution><institution>Capital Medical University,</institution></institution-wrap>Beijing, 100020 China</nlm:aff></affiliation></author><author><name sortKey="Guan, Xiangdong" sort="Guan, Xiangdong" uniqKey="Guan X" first="Xiangdong" last="Guan">Xiangdong Guan</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.412615.5</institution-id><institution>Department of Critical Care Medicine,</institution><institution>The First Affiliated Hospital of Sun Yat-sen University,</institution></institution-wrap>Guangzhou, 510080 Guangdong China</nlm:aff></affiliation></author><author><name sortKey="Du, Bin" sort="Du, Bin" uniqKey="Du B" first="Bin" last="Du">Bin Du</name><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="GRID">grid.12527.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 0662 3178</institution-id><institution>Medical ICU, Peking Union Medical College Hospital,</institution><institution>Peking Union Medical College and Chinese Academy of Medical Sciences,</institution></institution-wrap>Beijing, 100730 China</nlm:aff></affiliation></author><author><name sortKey="Qiu, Haibo" sort="Qiu, Haibo" uniqKey="Qiu H" first="Haibo" last="Qiu">Haibo Qiu</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.263826.b</institution-id><institution-id institution-id-type="ISNI">0000 0004 1761 0489</institution-id><institution>Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,</institution><institution>Southeast University,</institution></institution-wrap>Nanjing, 210009 Jiangsu China</nlm:aff></affiliation></author><author><name sortKey="Slutsky, Arthur S" sort="Slutsky, Arthur S" uniqKey="Slutsky A" first="Arthur S." last="Slutsky">Arthur S. Slutsky</name><affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id><institution>Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael’s Hospital and Departments of Medicine, Surgery, and Biomedical Engineering,</institution><institution>University of Toronto,</institution></institution-wrap>Toronto, Canada</nlm:aff></affiliation></author></analytic><series><title level="j">Intensive Care Medicine</title><idno type="ISSN">0342-4642</idno><idno type="eISSN">1432-1238</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Li, Q" uniqKey="Li Q">Q Li</name></author><author><name sortKey="Guan, X" uniqKey="Guan X">X Guan</name></author><author><name sortKey="Wu, P" uniqKey="Wu P">P Wu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Huang, C" uniqKey="Huang C">C Huang</name></author><author><name sortKey="Wang, Y" uniqKey="Wang Y">Y Wang</name></author><author><name sortKey="Li, X" uniqKey="Li X">X Li</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Shi, Cc" uniqKey="Shi C">CC Shi</name></author><author><name sortKey="Li, Jg" uniqKey="Li J">JG Li</name></author><author><name sortKey="Hu, B" uniqKey="Hu B">B Hu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chen, N" uniqKey="Chen N">N Chen</name></author><author><name sortKey="Zhou, M" uniqKey="Zhou M">M Zhou</name></author><author><name sortKey="Dong, X" uniqKey="Dong X">X Dong</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wang, D" uniqKey="Wang D">D Wang</name></author><author><name sortKey="Hu, B" uniqKey="Hu B">B Hu</name></author><author><name sortKey="Hu, C" uniqKey="Hu C">C Hu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Dom Nguez Cherit, G" uniqKey="Dom Nguez Cherit G">G Domı´nguez-Cherit</name></author><author><name sortKey="Lapinsky, Se" uniqKey="Lapinsky S">SE Lapinsky</name></author><author><name sortKey="Macias, Ae" uniqKey="Macias A">AE Macias</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kumar, A" uniqKey="Kumar A">A Kumar</name></author><author><name sortKey="Zarychanski, R" uniqKey="Zarychanski R">R Zarychanski</name></author><author><name sortKey="Pinto, R" uniqKey="Pinto R">R Pinto</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Drosten, C" uniqKey="Drosten C">C Drosten</name></author><author><name sortKey="Seilmaier, M" uniqKey="Seilmaier M">M Seilmaier</name></author><author><name sortKey="Corman, V" uniqKey="Corman V">V Corman</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lu, R" uniqKey="Lu R">R Lu</name></author><author><name sortKey="Zhao, X" uniqKey="Zhao X">X Zhao</name></author><author><name sortKey="Li, J" uniqKey="Li J">J Li</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wang, M" uniqKey="Wang M">M Wang</name></author><author><name sortKey="Cao, R" uniqKey="Cao R">R Cao</name></author><author><name sortKey="Zhang, L" uniqKey="Zhang L">L Zhang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Holshue, Ml" uniqKey="Holshue M">ML Holshue</name></author><author><name sortKey="Debolt, C" uniqKey="Debolt C">C DeBolt</name></author><author><name sortKey="Lindquist, S" uniqKey="Lindquist S">S Lindquist</name></author></analytic></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="brief-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Intensive Care Med</journal-id><journal-id journal-id-type="iso-abbrev">Intensive Care Med</journal-id><journal-title-group><journal-title>Intensive Care Medicine</journal-title></journal-title-group><issn pub-type="ppub">0342-4642</issn><issn pub-type="epub">1432-1238</issn><publisher><publisher-name>Springer Berlin Heidelberg</publisher-name><publisher-loc>Berlin/Heidelberg</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32123994</article-id><article-id pub-id-type="pmc">7080165</article-id><article-id pub-id-type="publisher-id">5979</article-id><article-id pub-id-type="doi">10.1007/s00134-020-05979-7</article-id><article-categories><subj-group subj-group-type="heading"><subject>What's New in Intensive Care</subject></subj-group></article-categories><title-group><article-title>Critical care crisis and some recommendations during the COVID-19 epidemic in China</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Xie</surname><given-names>Jianfeng</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Tong</surname><given-names>Zhaohui</given-names></name><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Guan</surname><given-names>Xiangdong</given-names></name><xref ref-type="aff" rid="Aff3">3</xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Du</surname><given-names>Bin</given-names></name><address><email>dubin98@gmail.com</email></address><xref ref-type="aff" rid="Aff4">4</xref></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">http://orcid.org/0000-0001-8589-4717</contrib-id><name><surname>Qiu</surname><given-names>Haibo</given-names></name><address><email>haiboq2000@163.com</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Slutsky</surname><given-names>Arthur S.</given-names></name><xref ref-type="aff" rid="Aff5">5</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="GRID">grid.263826.b</institution-id><institution-id institution-id-type="ISNI">0000 0004 1761 0489</institution-id><institution>Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,</institution><institution>Southeast University,</institution></institution-wrap>Nanjing, 210009 Jiangsu China</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="GRID">grid.24696.3f</institution-id><institution-id institution-id-type="ISNI">0000 0004 0369 153X</institution-id><institution>Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-yang Hospital,</institution><institution>Capital Medical University,</institution></institution-wrap>Beijing, 100020 China</aff><aff id="Aff3"><label>3</label><institution-wrap><institution-id institution-id-type="GRID">grid.412615.5</institution-id><institution>Department of Critical Care Medicine,</institution><institution>The First Affiliated Hospital of Sun Yat-sen University,</institution></institution-wrap>Guangzhou, 510080 Guangdong China</aff><aff id="Aff4"><label>4</label><institution-wrap><institution-id institution-id-type="GRID">grid.12527.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 0662 3178</institution-id><institution>Medical ICU, Peking Union Medical College Hospital,</institution><institution>Peking Union Medical College and Chinese Academy of Medical Sciences,</institution></institution-wrap>Beijing, 100730 China</aff><aff id="Aff5"><label>5</label><institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id><institution>Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael’s Hospital and Departments of Medicine, Surgery, and Biomedical Engineering,</institution><institution>University of Toronto,</institution></institution-wrap>Toronto, Canada</aff></contrib-group><pub-date pub-type="epub"><day>2</day><month>3</month><year>2020</year></pub-date><fpage>1</fpage><lpage>4</lpage><history><date date-type="received"><day>17</day><month>2</month><year>2020</year></date><date date-type="accepted"><day>19</day><month>2</month><year>2020</year></date></history><permissions><copyright-statement>© Springer-Verlag GmbH Germany, part of Springer Nature 2020</copyright-statement><license><license-p>This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.</license-p></license></permissions><funding-group><award-group><funding-source><institution-wrap><institution-id institution-id-type="FundRef">http://dx.doi.org/10.13039/501100013076</institution-id><institution>Ministry of Science and Technology of the People’s Republic of China</institution></institution-wrap></funding-source><award-id>2020YFC0841300</award-id><principal-award-recipient><name><surname>Du</surname><given-names>Bin</given-names></name></principal-award-recipient></award-group></funding-group></article-meta></front><body><p id="Par1">Since December 2019, a severe acute respiratory infection (SARI) caused by 2019 novel coronavirus (SARS-CoV-2), began to spread from Wuhan to all of China [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR2">2</xref>], and indeed the world. As of Feb 10, 2020, there are more than 40,000 confirmed cases and > 1000 deaths in China.
</p><sec id="Sec1"><title>Lack of critical care resource in face of COVID-19 epidemics</title><p id="Par2">Based on data reported by the National Health Commission of China, there have been about 2000 new confirmed cases and > 4000 suspected cases daily over the past week in Wuhan [<xref ref-type="bibr" rid="CR3">3</xref>]. About 15% of the patients have developed severe pneumonia, and about 6% need noninvasive or invasive ventilatory support. Currently, there are about 1000 patients who need ventilatory support and another 120 new patients daily who require noninvasive or invasive ventilation support in Wuhan city; however, there are only about 600 ICU beds [<xref ref-type="bibr" rid="CR4">4</xref>]. To address this shortfall, 70 ICU beds were created from general beds and the government quickly transformed three general hospitals to critical care hospitals with a total of about 2500 beds that specialize in patients with severe SARS-CoV-2 pneumonia (equipped with monitors and high-flow nasal cannula, noninvasive ventilator or invasive ventilators).</p><p id="Par3">An equally great (or potentially greater) problem is the shortage of trained personnel to treat these critically ill patients. Until the crisis, there were about 300 ICU physicians and 1000 ICU nurses in Wuhan city. By the end of January, more than 600 additional ICU doctors and 1500 ICU nurses were transferred to Wuhan from the rest of China. As well, an additional 3000 staff including infectious disease, respiratory, internal medicine physicians and nurses were transferred to Wuhan by the government.</p><p id="Par4">There are logistical issues which make care of the patients difficult. These include donning of personal protective equipment (e.g., gloves, gowns, respiratory and eye protection), lack of instruments and disposables, and shortages of supplemental oxygen. Many severe hypoxemic patients only receive high-flow nasal oxygen (HFNO) or noninvasive mechanical ventilation rather than invasive mechanical ventilation because of intubation delay or lack of mechanical ventilators (especially at early phase). Our preliminary data show that only about 25% of patients who died were intubated and received mechanical ventilation.</p><sec id="Sec2"><title>Recommendations</title><p id="Par5">It’s not possible at this stage to create new equipment or personnel. However, it would be very helpful to have mathematical models developed which predict the expected number of patients, and the necessary resources (equipment and personnel) required to treat these patients. This would aid in determining what resources might be moved to Wuhan to help local health care personnel.</p></sec></sec><sec id="Sec3"><title>Challenge of early recognition and treatment of critical SARI patients</title><p id="Par6">Several previous reports have described the characteristics of SARS-CoV-2 infected patients [<xref ref-type="bibr" rid="CR2">2</xref>, <xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR6">6</xref>]. Most patients are > 50 years of age; the mean age is much older than patients infected with H1N1 or with Middle East respiratory syndrome (MERS) [<xref ref-type="bibr" rid="CR7">7</xref>–<xref ref-type="bibr" rid="CR9">9</xref>]. About 30 to 50% of COVID-19 patients have chronic comorbidities. The duration from the initial symptom to respiratory failure in most patients is > 7 days, which is longer than H1N1 [<xref ref-type="bibr" rid="CR7">7</xref>, <xref ref-type="bibr" rid="CR8">8</xref>]. Additionally, many patients that go on to develop respiratory failure had hypoxemia but without signs of respiratory distress, especially in the elderly patients (“silent hypoxemia”). Moreover, only a very small proportion of patients have other organ dysfunction (e.g., shock, acute kidney injury) prior to developing respiratory failure. These characteristics suggest that traditional methods such as quick sequential organ failure assessment (qSOFA) score and the new early warning score (NEWS) may not help predict those patients who will go on to develop respiratory failure. Therefore, it is urgent to establish a prediction or early recognition model of patients likely to fail.</p><p id="Par7">Although the novel coronavirus was quickly isolated and sequenced [<xref ref-type="bibr" rid="CR10">10</xref>], there are no proven, effective drugs to treat COVID-19. Based on in vitro screening studies, several drugs were found to inhibit the virus [<xref ref-type="bibr" rid="CR11">11</xref>]. One case report demonstrated a surprising effect of remdesivir for SARS-CoV-2 infection [<xref ref-type="bibr" rid="CR12">12</xref>]; however, the clinical impact remains unclear. Encouragingly, several clinical trials are undergoing (ChiCTR2000029308, NCT04252664 and NCT04257656) to determine the effect of lopinavir/ritonavir or remdesivir. We have also tried Traditional Chinese Medicine such as Xuebijing, and several clinical trials are ongoing in this regard.</p><sec id="Sec4"><title>Recommendations</title><p id="Par8">Identifying a biomarker(s) that predicts severity and outcome in COVID-19 patients early in the presentation would be extremely helpful. Our data (unpublished) demonstrate that severe lymphopenia and high levels of C-reactive protein correlated with the severity of hypoxemia and predicted hospital mortality. In addition, the change of lymphocyte counts during the first 4 days after hospital admission was highly associated with mortality.</p></sec></sec><sec id="Sec5"><title>Crisis in management of SARI in the ICU</title><p id="Par9">The mortality rate of SARI is highest (4%) in Wuhan city, followed by other cities in Hubei province (1.4%) and other provinces (0.25%) [<xref ref-type="bibr" rid="CR3">3</xref>]. The higher morality in Wuhan may due to the limited resources, but we are uncertain whether patients are sicker in Wuhan than in other cities. Understanding the characteristics of the dead patients would help in triaging patients and allocating resources. We analyzed data of 135 patients who died before Jan 30, 2019, in Wuhan city. Older age and male were common in non-surviving patients. More than 70% patients had one or more comorbidities. Hypertension (48.2%) was the most common comorbidity in non-surviving patients, followed by diabetes (26.7%) and ischemic heart disease (17.0%), similar to data reported by others [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR6">6</xref>].</p><p id="Par10">Importantly, as stated above, of the patients who died only ~ 25% received invasive mechanical ventilation or ECMO. The median duration of HFNO and/or NIV was 6(4–8) days before intubation or death. The mortality of patients who received ECMO is high: of 28 patients who received ECMO up to the present, 14 died, 5 weaned successfully, and 9 are still on ECMO. Lack of ventilators, fear of becoming infected during the intubation procedure, and unclear need for intubation were the main reasons for delaying invasive ventilation.</p><p id="Par11">Compliance with lung protective ventilation strategy is also low in some centers, with some patients receiving tidal volumes > 8 ml/kg PBW and with high driving pressures. Sedation and paralysis strategies are also not standardized. Lack of intensivists may be a potential cause. Fortunately, we found a significant benefit of prone position in most severe ARDS patients.</p><sec id="Sec6"><title>Recommendations</title><p id="Par12">There should be a focus on high-risk patients, e.g., male, > 60 years old, and patients with comorbidities. Additionally, a standard protocol for SARS-CoV-2 infection recommended by World Health Organization should be widely implemented [<xref ref-type="bibr" rid="CR13">13</xref>]. It is crucial that our staff is trained to employ standard protocols for management, which may help implement evidence-based ventilatory and general ICU care in the face of an overwhelming workload. More importantly, in the context of a multidisciplinary team, intensivists should act as leaders, ensuring that severe patients receive standardized treatment (Fig. <xref rid="Fig1" ref-type="fig">1</xref>).
<fig id="Fig1"><label>Fig. 1</label><caption><p>Some recommendations to face the critical care crisis due to the COVID-19 epidemic</p></caption><graphic xlink:href="134_2020_5979_Fig1_HTML" id="MO1"></graphic></fig></p><p id="Par13">In summary, the COVID-19 epidemic has placed a huge burden on the Chinese health care system. This crisis has dramatically affected the delivery of critical care due to a lack of resources, lack of prediction models and of course the lack of effective pharmacotherapies. Front line critical care clinicians desperately require these tools.
</p></sec></sec></body><back><fn-group><fn><p><bold>Publisher's Note</bold></p><p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p></fn></fn-group><ack><title>Acknowledgements</title><p>This work was supported, in part, by the research Grant 2020YFC0841300 from Ministry of Science and Technology of the People’s Republic of China.
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