Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources
Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources
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DOI：
10.1016/j.accpm.2020.05.008
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发表时间：
2020-06-01
影响因子：
5.5
通讯作者：
Veber, Benoit
中科院分区：
文献类型：
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作者：
Leclerc, Thomas;Donat, Nicolas;Veber, Benoit
背景：依靠能力增加和患者转移来应对大量持续流入的COVID-19危重患者是一种受有限人力和后勤资源限制的策略。理由：优先考虑重症监护的开始和继续，对于挽救最多的生命至关重要。它使稀缺资源能够优先分配给最有可能从中受益的人。只要它依靠客观和广泛共享的标准，从而防止武断的决定和保证公平，它就是完全合乎道德的。优先排序寻求公平分配治疗，最大限度地挽救生命，通过优先考虑暴露的医疗保健和类似的工作人员获得间接的生命效益，优先考虑那些最受惩罚的人，并将类似的优先排序方案应用于所有患者。优先级策略：优先级方案及其标准调整到资源稀缺水平：应变（A级）或饱和（B级）。优先级划分为开始或继续重症监护的四个优先级：p1 -高度优先，p2 -中等优先，p3 -不需要，p4 -不适当。优先方案考虑到患者的意愿、临床虚弱、已有的慢性疾病，以及急性疾病的严重程度和演变。一旦缺少决策要素，至少在48小时后，在疾病自然史的典型转折点（COVID-19的ICU第7至10天），以及每次资源稀缺程度发生变化时，必须重新评估初始优先级别。对于拒绝或撤销治疗，合议决策过程和患者和/或近亲的信息是至关重要的。观点：优先战略必将随着新知识和流行病学形势的变化而演变。(C) 2020法国麻醉与复苏协会（Sfar）。Elsevier Masson SAS出版。版权所有。
Background: Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources.Rationale: Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients.Prioritisation strategy: Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48 h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount.Perspective: Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation. (C) 2020 Societe francaise d'anesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.