Lombardiet i Italien er som bekendt meget hårdt ramt af virus’en. Der har man nu ikke længere intensiv og respiratorpladser til de hårdest ramte og man er nødt til at prioritere, hvem der får behnadling og hvem der ikke får.
Hvad er det man risikerer:
COVID-19 (Novel Coronarovirus Disease 2019) kan forekomme i overensstemmelse med Verdenssundhedsorganisationens (WHO) anbefalinger [ii] i 6 forskellige stadier (Ukompliceret sygdom – Moderat lungebetændelse – Alvorlig lungebetændelse – ARDS – Sepsis – Septisk chok ), og den genoplivende anæstesiolog opfordres til at håndtere hurtigt forværrende hypoxemisk respirationssvigt. Cirka 80% af patienterne, der er til stede i de første to faser, 13,8% har svære former og 6,1% er kritiske.
Hvem er i størst risiko:
Personer med størst risiko for den nuværende alvorlige form og for dødelighed: alder> 60 år, systemisk arteriel hypertension, diabetes mellitus, hjerte-kar-sygdomme, kroniske luftvejssygdomme, tumorpatologi.1
Hvordan prioriterer de italienske læger:
The predictions of the Coronavirus epidemic (Covid-19) currently underway in some Italian regions they estimate an increase in cases of respiratory failure in the next few weeks in many centers acute (with the need for ICU admission) of such magnitude as to cause an enormous imbalance between the real clinical needs of the population and the actual availability of intensive resources.
It is a scenario where criteria for access to intensive care (and discharge) may be needed not only strictly clinical appropriateness and proportionality of care, but also inspired to a criterion as shared as possible of distributive justice and appropriate allocation of resources limited healthcare.
A scenario of this kind can be substantially approximated to the field of “disaster medicine”, for which ethical reflection has over time developed many concrete indications for doctors and nurses engaged in difficult choices.
As an extension of the principle of proportionality of care, allocation in a serious shortage of health resources must aim at guaranteeing intensive treatments to patients with greater chances of therapeutic success: it is therefore a matter of privileging the “greatest life expectancy “.
The need for intensive care must therefore be integrated with other elements of “clinical suitability” to intensive care, thus including: the type and severity of the disease, the presence of comorbidities, the impairment of other organs and systems and their reversibility.
This means not necessarily having to follow a criterion for access to intensive care like “first come, first served”. It is understandable that the carers, by culture and training, are not accustomed to reasoning with criteria of emergency triage, as the current situation has exceptional characteristics.
The availability of resources does not usually enter the decision-making process and the choices of the individual case, until resources become so scarce as to not allow to treat all patients who they could hypothetically benefit from a specific clinical treatment.
It is implied that the application of rationing criteria is justifiable only after that by all the subjects involved (in particular the “Crisis Units” and the governing bodies of hospital facilities) all possible efforts have been made to increase the availability of resources available (in the in particular, Intensive Care beds) and after any possibility of transfer of the patients to centers with greater availability of resources.
It is important that a change in access policies should be shared as much as possible among the operators involved. Patients and their family members affected by the application of the criteria should be notified of the extraordinary nature of the measures in place, due to a question of duty of transparency and maintenance trust in the public health service.
The purpose of the recommendations is also that:
(A) to relieve clinicians from a part of responsibility in choices, which can be emotionally burdensome, carried out in individual cases;
(B) to make the allocation criteria for healthcare resources explicit in a condition of their own extraordinary scarcity.
From the information available now, a substantial part of subjects diagnosed with infection from Covid-19 requires ventilatory support due to interstitial pneumonia characterized by severe hypoxemia. Interstitial disease is potentially reversible, but the acute phase can last many days.
Unlike more familiar ARDS cases, with the same hypoxemia, Covid-19 pneumonia appears to have slightly better lung compliance and respond better to recruitments, medium PEEP high, pronation cycles, inhaled nitric oxide. As for the most well-known paintings of habitual ARDS, these patients require protective ventilation, with low driving pressure.
All this implies that the intensity of care can be high, as well as the use of human resources
From the data for the first two weeks in Italy, about one tenth of infected patients require a intensive treatment with assisted ventilation, invasive or non-invasive.
Clinical ethics recommendations for admission
The Suspension of Intensive Care treatments in exceptional conditions where there is an imbalance between needs and available resources
1. Extraordinary admission and discharge criteria are flexible and can be adapted locally the availability of resources, the real possibility of transferring patients, the number of accesses in progress or expected. The criteria apply to all intensive patients, not only to patients infected with Covid-19 infection.
2. Allocation is a complex choice, also due to the fact that an extraordinary excessive increase in intensive beds would not guarantee adequate care for individual patients and would divert resources, attention and energies to the remaining patients admitted to Intensive Care. The increase is also to be considered predictable mortality from clinical conditions not related to the ongoing epidemic, due to the reduction elective surgical and outpatient activities and the scarcity of intensive resources.
3. It may be necessary to place an age limit on entry into ICU. It is not a question of making choices merely of value, but to reserve resources that could be very scarce for those who are primarily more likely to survive and secondarily to those who can have more years of life saved, with a view to maximizing of benefits for the most people. In a scenario of total saturation of intensive resources, deciding to keep a criterion of “First come, first served” would still be amounting to choosing not to treat any subsequent patients that would be excluded from Intensive Care.
4. The presence of comorbidities and functional status must be carefully evaluated, in addition to age. It is conceivable that a relatively short course in healthy people will potentially require a longer stay in ICU, and therefore more resource consuming on the health service. This would be worse in cases of elderly, frail or disabled patients with severe comorbidities. The specific and general clinical criteria present can be particularly useful for this purpose in the 2013 multi-company SIAARTI document on major end-stage organ failure (https://bit.ly/2Ifkphd). It is also appropriate to refer also to the SIAARTI document relating to the admission criteria in Intensive care (Minerva Anestesiol 2003; 69 (3): 101–118)
5. The possible presence of wishes previously expressed by the must be carefully considered through any Advanced Directives and, in particular, how shared care planning should take place with family and carers.
6. For patients for whom access to an intensive course is deemed “inappropriate”, the decision by however, setting a ceiling of care should be motivated, communicated and documented. The ceiling of care placed before mechanical ventilation must not preclude regular non-intensive care.
7. Any judgment of inappropriateness in accessing intensive care based solely on criteria of distributive justice (extreme imbalance between demand and availability) will find justification in this extraordinary situation.
8. In the decision-making process, if situations of particular difficulty and uncertainty arise, it can be useful to have a “second opinion” (possibly even by phone) from interlocutors of particular experience (for example, through a regional body or other health center).
9. The criteria for access to Intensive Care should be discussed and defined for each patient in the earliest most clearest way, ideally creating in time a list of patients who will be deemed candidates for Intensive Care when/if the patients deteriorate, provided that the availability at that moment allows for it. Any “do not intubate” instruction should be present in the medical record, ready to be used as a guide if clinical deterioration occurs precipitously and in the presence of caregivers who have not participated in the planning and who do not know the patient.
10. Palliative sedation in hypoxic patients with disease progression is considered necessary as an expression of good clinical practice, and must follow existing recommendations. Transfer should occur to a non-intensive care environment.
11. All accesses to intensive care must however be considered as an “ICU trial” and subjected therefore daily reassessment of appropriateness, care objectives and proportionality of cure. If it is considered that a patient, perhaps hospitalized with borderline criteria, does not respond to prolonged initial treatment or if the patients becomes more severely ill, transfer to palliative care — in an influx scenario with an exceptionally high number of patients – should not be postponed.
12. The decision to cease care should be discussed and shared as much as possible collegially by the caring team and – as far as possible – in dialogue with the patient (and family members), but it must be timely. It is foreseeable that the need to repeatedly make choices of this kind will render each ICU more capable in the decision-making process and better adaptable to the availability of resources.
13. ECMO support, as it is resource consuming compared to an ordinary ICU hospitalization, in conditions of extraordinary influx, it should be reserved for extremely selected cases and with relatively rapid weaning pre-planned. It should ideally be reserved for hub centers at high volumes, for which the patient in ECMO absorbs proportionately fewer resources than there are would absorb in a center with less expertise.
14. It is important to “network” through the aggregation and exchange of information between centers and individuals professionals. When working conditions allow, at the end of the emergency, it will be important to dedicate time and resources to moments of debriefing and monitoring of any burnout professional and moral distress of providers.
15. Relapses on family members hospitalized in IC Covid-19, especially in cases in which the patient dies at the end of a total visit restriction period. (translators note: not sure what this line means) Original: Devono essere considerate anche le ricadute sui familiari ricoverati nelle TI Covid-19, soprattutto nei casi in cui il paziente muoia al termine di un periodo di restrizione totale delle visite. Could mean: relax family visit restrictions when a patient dies in the visiting restriction period?