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 procedure records evaluated (62%) 132 deaths pre opper oppost 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 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