Retour d'expérience sur la cellule régionale d'appui à la régulation des lits de réanimation Covidréa pendant la crise Covid-19

La disponibilité des lits de réanimation a été un enjeu majeur de la gestion de la crise Covid-19, imposant aux acteurs régionaux de construire une réponse coordonnée et novatrice pour apporter une réponse en termes de recherche de place. Dans la région Île-de-France, la mise en place du dispositif a été constituée par deux mesures : la refonte du répertoire opérationnel des ressources (ROR) et la création d'une cellule d'appui régionale (Covidréa) comportant des cellules médicale et administrative. Les opérateurs de la cellule médicale étaient des chirurgiens volontaires sous la supervision d'un médecin urgentiste, chargés des actions de recherche et de régulation des demandes. La cellule administrative a vérifié la pertinence des informations du ROR sur un rythme pluriquotidien. La mobilisation des acteurs locaux (anesthésistes et réanimateurs) a permis d'obtenir des données actualisées du ROR quasiment en temps réel. La crise sanitaire Covid-19 a mis en lumière les faiblesses des systèmes d'information, particulièrement la connaissance de la disponibilité en lits de réanimation en temps réel. Une démarche collective pour construire de nouveaux outils de pilotage adaptés au quotidien, dans le cadre des tensions hivernales (bronchiolite, grippe) ou saisonnières (canicule), et la gestion des situations sanitaires exceptionnelles est impérative. Il est nécessaire d'intégrer cette fonction dans la mission des Samu départementaux en temps ordinaire et des Samu zonaux en temps de crise, en particulier dans la logique de construction du futur service d'accès aux soins (SAS).Alternate : The availability of intensive care unit (ICU) beds was a major stake in the management of the COVID-19 crisis, requiring the regional actors to build a coordinated and innovative response in terms of finding a bed. In the Ilede- France region, the implementation of the system was made up of two measures: the overhaul of the operational resource directory (ROR) and the creation of a regional support unit (COVID-ICU) including medical and administrative units. The operators of the medical cell were volunteer surgeons under the supervision of an emergency physician, in charge of research and demand medical regulation actions. The administrative unit verified the relevance of the information from the ROR on a multi-daily basis. The mobilization of local actors (anesthesiologists and intensivists) made it possible to obtain updated information almost in real time. The COVID-19 health crisis highlighted the weaknesses of the information systems, particularly the knowledge of the availability of ICU beds in real time. A collective approach to build new management tools adapted to daily life, in the context of winter (bronchiolitis, flu) or seasonal (heat wave) tensions, and the management of exceptional health situations is mandatory. It is necessary to integrate this function into the mission of the departmental Samu in ordinary times and the zonal Samu in times of crisis, especially in the logic of building the future French access to care service (SAS).

Covid-19 : les transferts internationaux de patients de réanimation, une solution pour les départements frontaliers

La crise sanitaire de la Covid-19 a imposé une adaptabilité jamais réalisée de notre système de santé. Les services de réanimation et les structures de médecine d'urgence ont dû innover et développer des stratégies novatrices pour garantir des soins de qualité à tous les patients relevant de réanimation. La région Grand-Est, et plus particulièrement les départements de Moselle, du Bas-Rhin et du Haut-Rhin, a été particulièrement touchée. Parmi les 349 patients transférés hors de la région, 164 l'ont été vers des pays européens (Allemagne, Autriche, Luxembourg et Suisse) entre le 14 mars et le 4 avril 2020. Ces transferts internationaux, organisés par l'Agence régionale de santé et les Samu-Centre 15, ont essentiellement fait appel à des moyens aériens des hôpitaux, de l'armée et de la protection civile. L'accompagnement des patients, soigneusement sélectionnés, était assuré par un binôme médecin‒ infirmier spécialisés. Le choix de cette stratégie a permis d'éviter la saturation des services de réanimation et d'avoir à faire un choix entre les patients pouvant ou non bénéficier de soins aigus. L'adaptabilité des professionnels de santé et une organisation au plus près du terrain ont permis de réaliser ces transferts dans de bonnes conditions. Cet épisode témoigne de l'importance de laisser la gestion des crises sanitaires aux professionnels de la santé. Cet article présente l'organisation mise en place en région Grand-Est pour préparer et réaliser ces transferts internationaux.Alternate : The COVID-19 health crisis has imposed an unprecedented adaptability of our health system. Intensive care units and emergency departments had to innovate and develop new strategies to guarantee quality care for patients needing intensive care. The "Grand-Est” region and particularly the counties of Moselle, Bas-Rhin and Haut-Rhin, were strongly impacted. Among the 349 patients transferred out of region, 164 were transferred to European countries (Austria, Germany, Luxembourg, and Switzerland) between March 14 and April 4, 2020. These international transfers, organized by the regional health agency and the emergency medical call centers, mainly use flying ambulances belonging to hospitals, army, and civil protection. The support of these patients was provided by a specialized physiciannurse team. The choice of this strategy made it possible to avoid saturation of intensive care units and to make a choice between patients admitted or not in intensive care. Adaptability of health care providers and an organization as close as possible to the field allowed these transfers to be carried out under good conditions. This episode demonstrates the importance of leaving the management of health crisis to health professionals. This article presents the organization set up to prepare and carry out these international transfers.

[Traumatic motherhood in Covid-19 times]. / Maternités traumatiques en temps de Covid-19.

In the context of maternal vital emergency due to Covid-19, dire situations of birth questioned the health practitioners of a neonatal intensive care unit. How can mothers take care of their baby when their own life has been threatened ? The analysis of two clinical cases underlines the importance of talking for these mothers who have been through disastrous experiences, which could lead to a post-traumatic stress disorder. Restoring a connection to outside reality thanks to psychological care in the acute post-trauma period helps these mothers take care of their child.

Utilisation des curares en réanimation

Résumé L’usage des curares en réanimation répond essentiellement a deux objectifs : améliorer les conditions d’intubation et faciliter la ventilation des patients en SDRA. Les conditions de l’intubation qui sont souvent celles de l’urgence imposent l’administration d’un curare d’action rapide : succinylcholine ou rocuronium. Le cisatracurium est le curare de référence pour la curarisation continue. La curarisation diminue les pressions intra-thoraciques et améliore les échanges gazeux mais pas la survie des patients ayant un ARDS. La relation entre neuromyopathie de réanimation et curarisation reste discutée. Summary The use of muscle relaxants in intensive care patients aims facilitating tracheal intubation and improving mechanical ventilation in ARDS patients. Since tracheal intubation is performed most of the time in emergency, succinylcholine is the gold standard for rapid sequence induction avoiding gastric content inhalation. However succinylcholine has contra-indications that favour the use of rocuronium in some patients. Patients who require muscle paralysis to be maintained, receive most of the time a continuous infusion of cisatracurium. Continuous administration of muscle relaxants improves gas exchanges and aims decreasing barotrauma in ARDS patients. Muscle relaxant administration in ICU patients is thought to be associated with ICU-acquired neuromuscular pathology although this remains to be clearly demonstrated owing to the multiple mechanisms that could be implicated.

Elders, triage and the intensivist

In France, the COVID-19 pandemic revealed the frailty of a health system that was considered unsinkable. Rationed for three decades, the human and material resources of our hospitals have been exhausted in less than two weeks, while those responsible for this precariousness and their successors were swaggering in the media. Caregivers then redoubled their efforts and initiatives to never abandon patients, sometimes to the detriment of their personal lives and their own health. The capacity of the intensive care units has been increased in proportion to the space and equipment available (especially respirators). The facilities and personnel of other specialties (operating rooms, technical platforms, intermediate care units) were also mobilized, leading to the deprogramming of surgical or exploratory procedures deemed non-urgent. As a result of the massive surge of patients and the scarcity of resources, the issue of access to critical care for the elderly has emerged early in the public debate. Apart from any controversy, well before the crisis, there was a body of scientific work evaluating the benefits or risks of a stay in intensive care for our elderly, according to specific medical criteria and a multidimensional approach to old age. © 2022 Elsevier Masson SAS

[Psychological state of Covid-19 patients after resuscitation]. / État psychologique des patients Covid-19 après réanimation.

The epidemic of Covid-19 was characterized, from its beginning, by "emergency". A state of emergency enacted by the state authorities to fight, on one hand, against the pandemic as such and, on the other hand, to manage the influx of patients admitted in intensive care. In this unprecedented context, the suffering of the people goes beyond the emergency situation and persists in forms ranging from a pseudo-banality to the complexity of an insidious evolution.

Les vieux, le tri et le réanimateur

Résumé En France, la pandémie COVID-19 a révélé la fragilité d’un système de santé pourtant réputé insubmersible. Rationnées depuis trois décennies, les ressources humaines et matérielles de nos hôpitaux ont été épuisées en moins de deux semaines, tandis que les responsables de cette précarité et leurs successeurs plastronnaient dans les médias. Les soignants ont alors redoublé d’efforts et d’initiatives pour ne jamais abandonner les patients, parfois au détriment de leur vie personnelle et de leur propre santé. Les capacités d’accueil des unités de réanimation ont été accrues en proportion des surfaces et du matériel disponibles (les respirateurs surtout). Les locaux et les personnels d’autres spécialités (blocs opératoires, plateaux techniques, soins intensifs) ont également été mobilisés, entraînant la déprogrammation d’actes chirurgicaux ou exploratoires considérés comme non urgents. Conséquence de l’afflux massif de patients et de la pénurie des ressources, la question de l’accès aux soins critiques des personnes âgées s’est rapidement invitée dans le débat public. À l’écart de toute polémique, il existait, bien avant la crise, un corpus de travaux scientifiques évaluant le bénéfice ou les risques d’un séjour en réanimation pour nos aînés, selon des critères médicaux spécifiques et une approche multidimensionnelle du grand âge. Summary In France, the COVID-19 pandemic revealed the frailty of a health system that was considered unsinkable. Rationed for three decades, the human and material resources of our hospitals have been exhausted in less than two weeks, while those responsible for this precariousness and their successors were swaggering in the media. Caregivers then redoubled their efforts and initiatives to never abandon patients, sometimes to the detriment of their personal lives and their own health. The capacity of the intensive care units has been increased in proportion to the space and equipment available (especially respirators). The facilities and personnel of other specialties (operating rooms, technical platforms, intermediate care units) were also mobilized, leading to the deprogramming of surgical or exploratory procedures deemed non-urgent. As a result of the massive surge of patients and the scarcity of resources, the issue of access to critical care for the elderly has emerged early in the public debate. Apart from any controversy, well before the crisis, there was a body of scientific work evaluating the benefits or risks of a stay in intensive care for our elderly, according to specific medical criteria and a multidimensional approach to old age.

[Trauma of intensive care workers in the face of a health crisis: a two-step psychological support]. / Traumatisme des soignants de réanimation face à la crise sanitaire.

The COVID-19 crisis has profoundly affected intensive care units. To protect themselves from the violence of the circumstances, the caregivers relied on their team membership, but it is in the aftermath that these situations seem to take their full traumatic dimension. A clinical case illustrates the two-step work of the psychologist with the caregivers and his role in the traumatic elaboration passing by an individual and collective reconquest of the caregiving function.

Le syndrome post-réanimation (SPR) et les programmes de réhabilitation post-réanimation

Résumé En 2021, l’enjeu d’une hospitalisation en réanimation n’est plus seulement la survie à la phase aiguë, mais d’obtenir une récupération des patients avec un minimum de séquelles. Le syndrome post-réanimation (SPR) touche environ 50–70 % des patients à leur sortie de réanimation. Cette entité comprend à distance de l’hospitalisation des troubles psychologiques, une altération des capacités neuromusculaires, des troubles cognitifs et des dysfonctions d’organes, altérant de la qualité de vie des patients et de leurs familles. La période COVID a accru considérablement le nombre de patients qui pourraient développer un PICS, et souligne à nouveau l’urgence de dépister ces patients, afin de prévenir et de limiter d’éventuelles séquelles de la réanimation. Le suivi systématique des patients après la réanimation est différent selon les pays, mais reste peu développé. L’intérêt et les modalités de réalisation de ce suivi sont débattus. Les objectifs sont : le dépistage précoce du PICS et l’orientation des patients dans une filière spécialisée. Le médecin anesthésiste-réanimateur doit être au cœur de la filière post-réanimation, afin de sélectionner les patients et de coordonner les acteurs du suivi. In 2021, the issue of intensive care hospitalization is no longer just survival in the acute phase, but also reducing the post-intensive care consequences. Post-intensive care syndrome (PICS) affects approximately 50–70% of patients upon discharge from intensive care. This entity includes psychological disorders, impaired neuromuscular capacities, cognitive disorders and organ dysfunctions that may persist for months or years impairing the quality of life of the patients and their families. The current COVID-19 crisis has incredibly increased the number of patients who could develop PICS, and support the urgent need for screening these patients, in order to prevent possible sequelae of intensive care. There are different types of “post-intensive care” follow-up, even their interest is debated. However, early detection of PICS is important to address the patients to supportive program of care. The intensive care physicians really need to identify PICS in their patients and coordinate their management distant from the ICU hospitalisation.

[Teaming up for resuscitation on the Covid-19 front]. / En équipe en réanimation sur le front de la Covid-19.

The first wave of the COVID-19 pandemic in France severely tested the healthcare system and its teams from the first weeks of 2020. With two years of hindsight, healthcare professionals have learned a great deal from this health crisis which, despite vaccination, maintains pressure on social activities and on the daily lives of caregivers. Looking back to the early days of this crisis, a nurse and her former trainer report on the spontaneous collaborations deployed to reinforce the resuscitation teams. Their complicity and the reversal of roles are recounted by four hands in the form of crossed views.

How patient age affects triage in the Covid-19 pandemic

The Author draws upon a set of guidelines issued by the Italian Society of Anaesthesia, Analgesia, Reanimation and Intensive Care (ISAARIC) and discusses the role played by patient age, at the triage stage, as the Covid-19 pandemic relentlessly unfolds. The limiting standard for admitting patients to intensive care units that best serves in terms of transparency and equality is the "first come, first served" approach;yet, in times of pandemic, patient age carries substantial weight in that selection process. In order to avoid wasting available resources and to treat as many patients as possible, therapies are discontinued for patients who do not seem to positively respond to them (as it frequently happens with elderly patients) and given to those with better chances of survival. Age is even more relevant in relation to the prognosis-based standard. Preexisting conditions, commonly associated with old age, could preclude access to intensive care. In order to avoid age-based discrimination, a) age should constitute but one standard through which the patient's chances of survival are determined;b) residual life expectancy should be disregarded;c) patients should never be cut off from receiving intensive care based on their age alone. Considering the primacy of the right to life over any other, it could be deemed ethically admissible to exclude patients, from receiving intensive care, only after the government institutions have taken any possible organizational measure, aimed at broadening health care access, while avoiding wasteful spending in the public provision of services. © 2021, William S. Hein & Co., Inc.. All rights reserved.

[The specificities of the interventions of physiotherapists in intensive care]. / Les spécificités des interventions des masseurs-kinésithérapeutes en réanimation.

The intervention of physiotherapists in the intensive care unit allows the optimisation of the care project through the assessment and management of the motor, respiratory and swallowing functions of patients. If COVID-19 has only slightly modified the practice of these professionals, the impact of the pandemic on intensive care units has reinforced the added value of their care.

[Resuscitation and care organisation in the face of a pandemic]. / Organisation de la réanimation et des soins à l'épreuve de la pandémie.

Resuscitation units, and the care practices they implement, require specific procedures and technologies, as well as particular and distinct knowledge, skills and human qualities within the care setting. Already facing tensions related to the challenges and vital issues of their mission, these resuscitation units have been destabilised by the influx of patients and the unprecedented complexity of the Covid-19 pandemic, which has forced them to rethink their organisation to a large extent and to envisage the future differently.

[The clinical practice of the psychologist in intensive care]. / La pratique clinique du psychologue en réanimation.

The intensive care psychologist was strongly mobilised during the COVID-19 health crisis. His clinical practice is both specific, with regard to the situations of extreme suffering that he is led to encounter, but also plural, as he is faced with the intersecting vulnerabilities of patients, families and carers.

Workhorse Free Functional Muscle Transfer Techniques for Smile Reanimation in Children with Congenital Facial Palsy: Case Report and Systematic Review of the Literature.

BACKGROUND: Pediatric facial palsy represents a rare multifactorial entity. Facial reanimation restores smiling, thus boosting self-confidence and social integration of the affected children. The purpose of this paper is to present a systematic review of microsurgical workhorse free functional muscle transfer procedures with emphasis on the long-term functional, aesthetic, and psychosocial outcomes. MATERIALS AND METHODS: We performed a literature search of the PubMed database from 1995 to 2019 using the following search strategy: "facial paralysis"[Title/Abstract] OR "facial palsy"[Title]. We used as limits: full text, English language, age younger than 18 years, and humans. Two independent reviewers performed the online screening process using Covidence. Forty articles met the inclusion criteria. The protocol was aligned with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and was registered at the International Prospective Register of Systematic Reviews (PROSPERO, CRD42019150112) of the National Institute for Health Research. RESULTS: Free functional muscle transfer procedures include mainly segmental gracilis, latissimus dorsi, and pectoralis minor muscle transfer. Facial reanimation procedures with the use of the cross-face nerve graft (CFNG) or masseteric nerve result in almost symmetric smiles. The transplanted muscle grows harmoniously along with the craniofacial skeleton. Muscle function and aesthetic outcomes improve over time. All children presented improved self-esteem, oral commissure opening, facial animation, and speech. CONCLUSIONS: A two-stage CFNG plus an FFMT may restore a spontaneous emotive smile in pediatric facial palsy patients. Superior results of children FFMT compared to adults FFMT are probably attributed to greater brain plasticity.

[2020, Mulhouse, Covid-19: a lesson in history, Europe and resilience]. / 2020, Mulhouse, Covid-19 : une leçon d'histoire, d'Europe, de résilience.

In March 2020, Covid-19, caused by the severe acute respiratory syndrome coronavirus 2, struck the Haut-Rhin region with extreme violence, overwhelming hospitals and requiring the massive opening of new resuscitation beds. The military resuscitation element of the French military health service was deployed for the first time in Mulhouse (68), in eastern France. Alsace-Lorraine, a European crossroads and the birthplace of European institutions, was once again at the heart of history. Perspectives.

[Application of the white plan in intensive care units during the covid-19 pandemic.] / Application du plan blanc en service de réanimation lors de la pandémie de Covid-19.

The deployment of the white plan in intensive care as part of the management of COVD-19 required a new organisation at every level of Raymond-Poincaré hospital in Garches. The closure of certain wards enabled equipment and staff to be pooled, and support services stepped up to the plate by reinventing themselves.

[Breathing filters in hospital, COVID first-wave experience]. / Filtres respiratoires à l'hôpital, l'expérience de la première vague de COVID.

During the coronavirus pandemic, breathing filters have been essential in the medical care of infected patients. The worldwide demand caused a disruption in the supply, which led to a multiplication of the references used. The lack of formation available on the subject was an impediment for pharmacists (buyer, medical devices, intensive car unit) and it appears to be necessary to redact a formation about those filters, from the experience acquired during the sanitary crisis. Multiple breathing filters references exist which may be classify according to their filtration mechanism (mechanical filtration or electrostatic filtration) and by the eventual presence of a humidifying action (Heat and Moisture Exchangers; hydrophobic, hygroscopic, or mixed). In anaesthesia, the use of pure mechanical filter is preferred; in resuscitation unit, heat and moisture exchangers filter or simple filter plus heated humidifier are used. During the COVID-19 pandemic, the filters duration of use has been lengthened to limit the disruption risk.

[COVID-19 epidemic, a challenge successfully overcome by intensive care nurses]. / L'épidémie de Covid-19, une mise à l'épreuve réussie pour les infirmiers de réanimation.

The COVD-19 wave of spring 2020 had a major impact on French intensive care departments. The intense activity, the support of reinforcements in the acquisition of the necessary skills and their capacity to adapt made intensive care nurses key players in this crisis. Grouped together within the French National Federation of Intensive Care Nurses, they are campaigning to have the specificity of their practice to be recognised and for the creation of certified training in order to meet public healthcare needs not currently fulfilled.