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Intensive Care in MSF. F.Lallemant, V.Ioos, X.Lassale. Goals of Intensive Care Medicine. Pending or established organ failure Avoiding organ failure or Supporting organ function While the disease process is controlled. Principles of intensive care practice.
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Intensive Care in MSF F.Lallemant, V.Ioos, X.Lassale
Goals of Intensive Care Medicine • 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
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 • 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 : • 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