Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources.

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 48h 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 For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount.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.

[Sciatic perineural catheters: an alternative analgesia for diabetic patients]. / Cathéters sciatiques: une alternative analgésique chez les patients diabétiques.

INTRODUCTION: Patients with diabetes mellitus have chronic neuropathic pain. The aim of our study was to 1) evaluate the feasibility of providing analgesia with a long-term sciatic perineural catheter in a medical unit for diabetic patients and 2) evaluate its effectiveness. METHODS: A prospective, monocentric, non-randomized study was conducted over two years. All diabetic patients with an ineffective optimal systemic treatment were included. Written consent was obtained. Popliteal-sciatic nerve catheters were inserted under ultrasound guidance; ropivacaine was started. The primary endpoint was pain at Day 2. Pain intensity was measured using a numeric rating scale (NRS). Secondary endpoints were patient's pain relief, the impact on quality of life, and morphine consumption, evaluated at Day 0, Day 2, at the time of catheter removal, and one month after catheter removal. RESULTS: Feasibility was evaluated over one year. Fifty-five perineural catheters were placed in 32 patients. The median duration of catheter placement across patients was 13 [4-23] days. No toxic or infectious complications were seen. Effectiveness was evaluated during the second year of the study. Seventeen catheters were placed in 12 patients; 83% of patients had a NRS score ≤3 at Day 2. More than 70% of patients experienced pain relief while the catheter was in place and at one month after its removal. The impact on quality of life was negligible. Morphine consumption was less on Day 2, at the time of catheter removal and one month after removal. CONCLUSION: The use of sciatic perineural catheters as an alternative analgesia technique in a non-surgical environment for diabetic patients with chronic pain was possible and effective.