Elaboration/Evaluation d'un Test Diagnostique Philippe Montravers DAR CHU Jean Verdier Bondy.
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Gestion PARAMÉDICALE de la SÉDATION
Dr Jean-Pierre QUENOT [email protected]
Service de Réanimation Médicale CHU Dijon
18ème
Édition !
ACTUALITÉS EN RÉANIMATIONRéanimation, Surveillance Continue
et Urgences Graves
Prise en charge GLOBALE du patient sous ventilation mécanique
La SÉDATION est-elle nécessaire ?
§ Prévention des complications de décubitus § Prévention des PAVM § PEC de la douleur § PEC psychique § Contention § ….
A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trialThomas Strøm, Torben Martinussen, Palle Toft
www.thelancet.com Published online January 29, 2010 DOI:10.1016/S0140-6736(09)62072-9
No sedation (n=55) Sedation (n=58)
Age (years) 67 (54–74) 65 (54–74)
Women 13 (24%) 24 (41%)
Weight (kg) 80·0 (74·0–92·0) 78·5 (70·0–91·0)
APACHE II 26 (19–30) 26 (22–31)
SAPS II 46 (36–56) 50 (43–63)
SOFA (at day 1) 7·5 (5·0–11·0) 9·0 (5·5–11·0)
Diagnosis at admission to intensive care unit
Respiratory disorder* 26 (47%) 27 (47%)
Sepsis 15 (27%) 19 (33%)
Pancreatitis 2 (4%) 3 (5%)
Peritonitis 0 1 (2%)
Gastro-intestinal bleeding 5 (9%) 0
Liver and biliary disease 2 (4%) 0
Trauma 2 (4%) 3 (5%)
Other 3 (5%) 5 (9%)
Data are in number (%) or median (IQR). APACHE II=acute physiology and chronic health evaluation. SAPS II=simplifi ed acute physiology score. SOFA=sequential organ-failure assessment. *Pneumonia, chronic obstructive pulmonary disease, and asthma.
No sedation • Morphine • Halopéridol • Diprivan pour 6 h
Sedation • Morphine • Diprivan • Hypnovel
Ramsay
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A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trialThomas Strøm, Torben Martinussen, Palle Toft
www.thelancet.com Published online January 29, 2010 DOI:10.1016/S0140-6736(09)62072-9
No sedation (n=55) Sedation (n=58) p value
Days without mechanical ventilation (from intubation to day 28) 13·8 (11·0); 18·0 (0–24·1) 9·6 (10·0); 6·9 (0–20·5) 0·0191*†
Length of stay (days)
Intensive care unit 13·1 (5·7– ··)‡ 22·8 (11·7– ··)‡ 0·0316*§
Hospital 34 (17–65) 58 (33–85) 0·0039*§¶
Mortality
Intensive care unit 12 (22%) 22 (38%) 0·06
Hospital 20 (36%) 27 (47%) 0·27
Drug doses (mg/kg) ||
Propofol (per h of infusion)** 0 (0–0·515) 0·773 (0·154–1·648 ) 0·0001
Midazolam (per h of infusion) 0 (0–0) 0·0034 (0–0·0240) <0·0001
Morphine (per h of mechanical ventilation) 0·0048 (0·0014–0·0111) 0·0045 (0·0020–0·0064) 0·39
Haloperidol (per day of mechanical ventilation) 0 (0–0·0145) 0 (0–0) 0·0140
Tracheostomy 16 (29%) 17 (29%) 0·98
Ventilator-associated pneumonia 6 (11%) 7 (12%) 0·85
Data are mean (SD), median (IQR), or number (%). ··=data not available because of censoring at day 28. *Corrected for baseline variables: age, sex, weight, acute physiology and chronic health evaluation (APACHE II), simplifi ed acute physiology score (SAPS II), and sequential organ-failure assessment (SOFA) at day 1. †Calculated from multiple linear regression. ‡More than 25% of patients remained in the intensive care unit for more than 28 days (fi gure 2). §Calculated from Cox regression analysis. ¶Calculated for the fi rst 30 days to agree with the proportional hazards assumption. ||Drug dose (mg) as a proportion of bodyweight (kg). **Maximum dose during 48 h of treatment.
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A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trialThomas Strøm, Torben Martinussen, Palle Toft
www.thelancet.com Published online January 29, 2010 DOI:10.1016/S0140-6736(09)62072-9
Ratio IDE/Patients = 1/1
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Le sevrage de la VM est-elle possible ?
Rôle du KINÉSITHÉRAPEUTE
Rôle du MÉDECIN Rôle de l’IDE/AS
Ø Guérison en cours Ø Antécédents… Ø Echecs de sevrage
Ø Contact avec le patient Ø Management FiO2, AI,
antalgie, sédation, nutrition, catécholamines…
Ø Contrôle des entrées…
Ø Évaluation MRC, toux, déglutition… Ø Cough assist….
PATIENT
Quel NIVEAU de SÉDATION ? L
a SÉ
DAT
ION
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AMERICAN THORACIC SOCIETYDOCUMENTS
An Official American Thoracic Society/American Association ofCritical-Care Nurses/American College of Chest Physicians/Society ofCritical Care Medicine Policy Statement: The Choosing Wisely® Top 5List in Critical Care MedicineScott D. Halpern, Deborah Becker, J. Randall Curtis, Robert Fowler, Robert Hyzy, Lewis J. Kaplan, Nishi Rawat,Curtis N. Sessler, Hannah Wunsch, and Jeremy M. Kahn; on behalf of the Choosing Wisely Taskforce
THIS OFFICIAL STATEMENT WAS APPROVED BY THE AMERICAN THORACIC SOCIETY (ATS), JUNE 2014; THE AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES
(AACN), MARCH 2014; THE AMERICAN COLLEGE OF CHEST PHYSICIANS (ACCP), APRIL 2014; AND THE SOCIETY OF CRITICAL CARE MEDICINE (SCCM),MARCH 2014
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 7 | October 1 2014
AMERICAN THORACIC SOCIETYDOCUMENTS
An Official American Thoracic Society/American Association ofCritical-Care Nurses/American College of Chest Physicians/Society ofCritical Care Medicine Policy Statement: The Choosing Wisely® Top 5List in Critical Care MedicineScott D. Halpern, Deborah Becker, J. Randall Curtis, Robert Fowler, Robert Hyzy, Lewis J. Kaplan, Nishi Rawat,Curtis N. Sessler, Hannah Wunsch, and Jeremy M. Kahn; on behalf of the Choosing Wisely Taskforce
THIS OFFICIAL STATEMENT WAS APPROVED BY THE AMERICAN THORACIC SOCIETY (ATS), JUNE 2014; THE AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES
(AACN), MARCH 2014; THE AMERICAN COLLEGE OF CHEST PHYSICIANS (ACCP), APRIL 2014; AND THE SOCIETY OF CRITICAL CARE MEDICINE (SCCM),MARCH 2014
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 7 | October 1 2014
Table 2. Final Top 5 List Approved by Societies’ Leadership and Included in Choosing Wisely Campaign
1. Do not order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.Many diagnostic studies (including chest radiographs, arterial blood gases, blood chemistries and counts, and ECGs) are ordered at regularintervals (e.g., daily). Compared with a practice of ordering tests only to help answer clinical questions, or when doing so will affectmanagement, the routine ordering of tests increases health-care costs, does not benefit patients, and may in fact harm patients. Potentialharms include anemia due to unnecessary phlebotomy, which may necessitate risky and costly transfusion, and the aggressive work-upof incidental and nonpathological results found on routine studies.
2. Do not transfuse RBCs in hemodynamically stable, nonbleeding ICU patients with an Hb concentration greater than 7 mg/dl.Most red blood cell transfusions in the ICU are for benign anemia rather than acute bleeding that causes hemodynamic compromise. For allpatient populations in which it has been studied, transfusing RBCs at a threshold of 7 mg/dl is associated with similar or improved survival,fewer complications, and reduced costs compared with higher transfusion triggers. More aggressive transfusion may also limit theavailability of a scarce resource. It is possible that different thresholds may be appropriate in patients with acute coronary syndromes,although most observational studies suggest harms of aggressive transfusion even among such patients.
3. Do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 d of an ICU stay.For patients who are adequately nourished before ICU admission, parenteral nutrition initiated within the first 7 d of an ICU stay has beenassociated with harm, or at best no benefit, in terms of survival and length of stay in the ICU. Early parenteral nutrition is also associatedwith unnecessary costs. These findings are true even among patients who cannot tolerate enteral nutrition. Evidence is mixed regardingthe effects of early parenteral nutrition on nosocomial infections. For patients who are severely malnourished directly before their ICUadmission, there may be benefits to earlier parenteral nutrition.
4. Do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lightensedation.
Many mechanically ventilated ICU patients are deeply sedated as a routine practice despite evidence that using less sedation reduces theduration of mechanical ventilation and ICU and hospital length of stay. Several protocol-based approaches can safely limit deep sedation,including the explicit titration of sedation to the lightest effective level, the preferential administration of analgesic medications beforeinitiating anxiolytics, and the performance of daily interruptions of sedation in appropriately selected patients receiving continuoussedative infusions. Although combining these approaches may not improve outcomes compared to one approach alone, each has beenshown to improve patient outcomes compared with approaches that provide deeper sedation for ventilated patients.
5. Do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patientsand their families the alternative of care focused entirely on comfort.
Patients and their families often value the avoidance of prolonged dependence on life support. However, many of these patients receiveaggressive life-sustaining therapies, in part due to clinicians’ failures to elicit patients’ values and goals and to provide patient-centeredrecommendations. Routinely engaging high-risk patients and their surrogate decision makers in discussions about the option of forgoinglife-sustaining therapies may promote patients’ and families’ values, improve the quality of dying, and reduce family distress andbereavement. Even among patients pursuing life-sustaining therapy, initiating palliative care simultaneously with ongoing disease-focusedtherapy may be beneficial.
MISE AU POINT
Le rôle de l’équipe infirmière dans la réalisation dela sédation des patients en réanimation médicaleThe role of the nursing team in implementing sedation in critical carepatients
A.-S. Coupet, A. Follie, T. Devaux, F. Mouchon, N. Jacquiot,S. Prin, A. Pavon, S. Barbar, P.-E. Charles, J.-P. Quenot ∗
Réanimation (2010) 19, 527—532
Les différentes ETAPES
CONSTAT Etape 1 Dysfonctionnement
Mise en place d’un GROUPE de TRAVAIL Etape 2 Protocole
Diffusion du PROTOCOLE Applicabilité Etape 3
Etape 4 Evaluation CLINIQUE Indicateurs
Etape 5 Pérennité du PROTOCOLE POS Formation continue
Exemple CONCRET
Constat Patient « mal » ou « trop bien » adapté au respirateur
Absence de protocole
Ramsay, SAS RAAS…ATICE
Comment ÉVALUER ?
Echelle de Cambridge Niveau I Agité Niveau II Réveillé Niveau III Endormi mais réveillable à la voix Niveau IV Endormi mais réveillable par les soins Niveau V Non réveillable
Comment ÉVALUER ?
Niveau II/III = Majorité des patients pour un « confort » sous le respirateur
Niveau IV/V = SDRA…Etat de mal asthmatique
Comment PRESCRIRE ?
Niveau I Agité Niveau II Réveillé Niveau III Endormi mais réveillable à la voix Niveau IV Endormi mais réveillable par les soins Niveau V Non réveillable
PROTOCOLE disponible dans chaque CHAMBRE H
YPN
OVE
L D
IPR
IVA
N
Appel médecin si : • 3 bolus insuffisants • Agitation sous sédation
PROTOCOLE disponible dans chaque CHAMBRE H
YPN
OVE
L D
IPR
IVA
N
Quelle dose de Diprivan (mg/h) administrée au PSE ?
0 70
140 210
Mr D. Poids = 73 Kg
Initiation d’une SÉDATION
Après INDUCTION
J1 Diprivan Niveau II/III
Mr D. Poids = 73 Kg
Réalisation du premier bolus
PSE = 140 mg/h
70 mg
Evaluation = niveau I
70 mg
Réalisation du deuxième bolus
Evaluation = niveau II/III
Evaluation = niveau I
J1 Diprivan Niveau II/III
Mr D. Poids = 73 Kg
Réalisation du premier bolus
PSE = 140 mg/h
70 mg
Evaluation = niveau I
70 mg
Réalisation du deuxième bolus
Evaluation = niveau II/III
J4 Diprivan Niveau II/III Sevrage de la VM
Diminution de 35 mg/h
Evaluation = niveau IV/V
Evaluation = niveau IV/V
Diminution de 35 mg/h Evaluation n°6 = niveau II/III
Stop Diprivan
Surveillance/3 H
Diprivan = 210 mg/h
J4 Diprivan Niveau II/III Sevrage de la VM
Diminution de 35 mg/h
Evaluation = niveau IV/V
Evaluation = niveau IV/V
Diminution de 35 mg/h Evaluation n°6 = niveau II/III
Stop Diprivan
Surveillance/3 H
Diprivan = 210 mg/h
Crit Care Med 2007;35:2032-2038
Crit Care Med 2007;35:2032-2038
Crit Care Med 2007;35:2032-2038
Evaluation régulière pour un score tendant vers 3
Prise en charge de la douleur de fond Etape 1 :
Antalgiques paliers I et II selon prescriptions Etape 2 :
Si Score > 3 à distance de stimulation douloureuse Appel médecin et
Déclanchement de l’administration de sufentanyl selon protocole
Début à 0,2 yg.kg.h-1
Prise en charge des douleurs aigues provoquées Sous Sufentanyl :
Bolus 0,1 yg.kg-1 anticipé de 10 minutes Absence de sufentanyl
Bolus de 0,1mg.kg-1 de morphine en IVD anticipé de 10 minutes
Les LIMITES
Patient CURARISÉ DV, refroidissement…
Patient très ALGIQUE Echelle d’évaluation douleur
Formation/Evaluation CONTINUE
Organisation/Culture de service