Intensive Care in MSF

1. Intensive Care in MSF F.Lallemant, V.Ioos, X.Lassale

2. Goals of Intensive Care Medicine • Pending or established organ failure • Avoiding organ failure or • Supporting organ function • While the disease process is controlled

3. 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

4. Peri operative mortality MSFF jan-sept 2009 • 10 813 procedure records evaluated (62%) • 132 deaths

5. 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 ?…

6. Danger • 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)

7. 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 ?

8. 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 : • Human resources • Training objectives • Physical structure requirements • Equipments • Medical devices and drug (hospital kits)

9. 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.

10. 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

11. 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

12. 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…)

13. 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