Download Soins intensifs à MSF

Intensive Care in MSF
F.Lallemant, V.Ioos, X.Lassale
Goals
of Intensive Care Medicine
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Pending or established organ failure
Avoiding organ failure or
Supporting organ function
While the disease process is controlled
Principles of intensive care practice
• Insufficient organ support is deleterious
• Excessive organ support is deleterious
• Therapies need to be adapted from hour to
hour
• Continuity of care is required
Peri operative mortality MSFF jan-sept 2009
• 10 813 procedure records evaluated (62%)
• 132 deaths
pre op
per op
post op
15%
9%
76%
Target patient population
in MSF programs
• Reversibility of the disease process
• Increased complexity of surgeries performed in
MSF programs
• High severity of patients (violences, RTA, burns)
• Improving the outcome of multiple trauma patients
• Poisoning ? Tetanus ? Obstetrical emergencies ?
Cardiovascular emergencies ?…
Danger
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Paradoxical patient safety issues
Technology replaces clinical common sense
Invasive care associated morbidity
Antibiotic misuse with negative impact on
microbiological environment
« Most men die of their remedies, not of their
illnesses » (Molière)
Challenges for MSF
• In MSF field countries : frequently, no structured
intensive care training and certification
• Anesthesist human resources are rare and needed in
OT, anesthesiologists are not always trained in
intensive care.
• « ensuring continuity of care »
• … but, by who ?
• Junior doctors before their specialization ? Under
supervision of the anesthesiologist ?
Level of care
• Definitions have to take in account the
context of MSF missions and
« reasonnable » operational objectives
• Each level of care should be matched to :
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Human resources
Training objectives
Physical structure requirements
Equipments
Medical devices and drug (hospital kits)
Level 1
• Monitoring : non invasive blood pressure,
transcutaneous oxygen saturation and heart rate
(automated), respiratory rate and urine output
(clinical).
• Tests : Bedside measurement of haemoglobin and
glycaemia levels, hemogram, blood electrolytes and
renal function test. Portable chest X-Ray and
ultrasonography.
Level 1
• Supportive therapies :
– fluid challenge,
– blood transfusion,
– high flow oxygen therapy,
– continuous intravenous infusion of drugs (dopamine…)
with syringe pump excluding epinephrine and
norepinephrine,
– enteral nutrition through nasogastric tube and infusion
pump.
• Population of patients targeted :
– post-operative cases (including multiple trauma), burns
– medical patients (diabetic keto-acidosis, severe asthma,
severe pneumonia, severe dehydration…),
– obstetric emergencies
Level 2
• Continuous ECG monitoring
• Bedside measurement of blood gases and cardiac
enzymes, coagulation tests
• Supportive therapies : management of arrhythmias
(pharmacological, defibrillation), non invasive
ventilation
• Main population of patients targeted :
cardiovascular emergencies, acute respiratory
failure requiring non-invasive ventilation
Level 3
• Continuous invasive blood pressure sanglante
• Microbiology
• Supportive therapies : continuous infusion of
epinephrine and norepinephrine on central venous
catheter, invasive mechanical ventilation
• Main population of patients targeted: multiple
trauma, poisoning, infectious disease such as
tetanus and CNS infections (malaria, meningitis…)
2012 objectives
• Level 1 ICUs in surgicial hospitals in a first step
• Pilot experience in Drouillard Hospital, Haïti
• Training : if available human resources are only
junior doctors before their specialisation : how to
help them reach the minimum competency level to
ensure continuity of care ?
• BASIC