D-18. The patient in room 172 has been fighting the Covid-19 for the last eighteen days. Intubated and ventilated, the man is 52 years old. Several probes gravitate around his naked body. His cheeks are pale, his eyelids yawn, his swollen hands are motionless. Everything seems extinct in him. Only his chest moves, under the impulse of the artificial respirator. At D-15, the resuscitators tried to free him from the machine. The latest analyzes indicated that the patient had regained enough strength to oxygenate himself. The family had been notified. But when he was extubated, the patient whistled, unable to breathe: edema had formed in his windpipe. We put him back to sleep and put the hose back on. “In the face of this disease, the fight for recovery is not a sprint. It’s a marathon “, recalls Jérôme Fichet, physician-resuscitator at the North Cardiological Center of Saint-Denis.
In this private clinic in Seine-Saint-Denis, 33 other patients
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The prescription of a sedative medication, Rivotril, for the relief of patients with acute respiratory distress is the subject of unfounded ethical controversy.
On March 28, the government authorized the sale of a drug, Rivotril, in pharmacies for the care of patients with coronavirus who are in acute respiratory distress. Rivotril has powerful sedative effects. It can therefore be used to sedate, reduce the “alertness”, and therefore the consciousness, of patients facing intense suffering that cannot be relieved otherwise. This is the case for the very distressing feeling of suffocation that end-of-life patients may experience. When injected in excessive doses, Rivotril, like any drug of this type, can cause the death of the patient. It must therefore be used with the necessary precautions, respecting the recommendations made by the competent bodies.
By authorizing the sale of Rivotril in pharmacies, the government is finally responding to the demand from doctors practicing outside hospitals to have drugs that are powerful enough to save the seriously ill from treating very trying ends of life.
It is an altogether inappropriate accusation to see in it the intention to open the way to disguised euthanasia of elderly people living in retirement homes or nursing homes. In this collective test, we must encourage all caregivers who, on the front line and in emergency situations, work passionately to take care of the sick and their families with the requirement of respect for people and the rules of medical ethics. The duty of ethical vigilance also consists in not letting unfounded accusations spread.
We thank Pr Frédéric Guirimand and Dr Claire Fourcade for having authorized us to reproduce below their duly argued point of view, and to continue to attest, with all the health personnel mobilized, of one of the highest values of the humanity: caring for others.
The Biomedical Ethics Department of the Sèvres Center.
Download the declaration
A decree authorizing the transitory availability in the city of certain drugs (injectable paracetamol, Rivotril®, etc.) has caused trouble for some with the fear of a “legalization” of euthanasia which would not say its name in particular in establishments for elderly (Ehpad).
Covid-19 infection in some patients, especially the most fragile, causes severe respiratory damage that can sometimes lead to death by asphyxiation. The resuscitation required to manage these respiratory disorders is extremely heavy and cannot be supported by the most vulnerable.
An early reflection on the adaptation of the level of care is essential on a case-by-case basis for each sick person. To avoid an unreasonable obstinacy, a decision of non-resuscitation can be taken, with the patient if he is able to express his will or if not in a collegial manner, that is to say after a reflection involving his doctors, its healthcare team and whenever possible a palliative care team or a geriatric team. You must also take into account advance directives or, failing this, consult the support person or the family (Law of 2/2/2016 on end of life).
Providing these patients with dignified support and relieving their symptoms remains a priority. To avoid the feeling of suffocation sedation (decrease in consciousness) may be necessary and sometimes urgent because the degradation to asphyxia can sometimes be rapid.
There are a large number of sedative medications, of which Rivotril® is one. Like the others (Valium®, Seresta®, Lysanxia®, Temesta®, Xanax®, Lexomil®…), depending on the dose, it acts against anxiety with an amnesic effect and then as a sedative. Some are very difficult to obtain at present due to the large number of patients to be treated. It was therefore useful to make Rivotril® more easily accessible.
The fear of an intention of euthanasia relayed by social networks is unfounded. Let us all remain responsible for our words. It is difficult for caregivers, nurses and doctors to do this asleep a patient in asphyxiation as it is difficult for families not to be able to accompany their loved one. To the suffering, let’s not add guilt.
Pr. Frédéric Guirimand,
Associate Professor of Palliative Medicine. University of Versailles Saint Quentin
Jeanne Garnier Medical Center – Paris
Dr. Claire Fourcade,
Vice-president of SFAP. Palliative care center, Polyclinique le Languedoc, Narbonne.
Faced with the unprecedented scale of the crisis and the influx of patients, stocks are running out. First those of protective masks. Then reagents used in diagnostic tests from Covid-19. And the respirators, whose production is struggling to keep up with demand. Little by little, everything necessary for hospitalization and treatment of patients is running out. Even the most common equipment, the most common drugs.
“Hospital stocks of muscle relaxants, sedatives and painkillers are consumed quickly”, is alarmed by the European Alliance of European University Hospitals, and “At their current rate of consumption, stocks will be empty within a few days in the hospitals hardest hit, and within two weeks for those with the largest reserves.” In their press release published on Tuesday, forty doctors and directors of establishments in France and other European countries call their respective leaders to coll
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Damien Roux, university professor and hospital practitioner of intensive resuscitation medicine, works in the medical and surgical resuscitation department of Louis-Mourier Hospital (AP-HP), located in Colombes, in the Hauts-de-Seine. As of last weekend, this doctor was responsible for reflecting – in collaboration with other colleagues from the Public Assistance taking care of Covid-19 patients – on the means of optimizing the use of drugs in the services of resuscitation, due to the ever increasing number of serious patients. “The aim was to anticipate the overconsumption of certain drugs in the same way that we have been trying to increase the number of nurses for the past month»He explains. Except that a week later, the fear of an imminent shortage of certain molecules became a reality in Ile-de-France. “Despite our prospects and our vigilance on the issue, it is clear that suppliers and manufacturers are no longer able to monitor the consumption of drugs or certain medical devices in our hospitals.He warns.
AP-HP Director General Martin Hirsch acknowledged at a press conference on Friday that “stocks are very short on certain drugs.“This Saturday evening, it’s Edouard Philippe who admits the existence of”supply tensions here and there” “We regulate them by ensuring the circulation of these products throughout the territory, because there are stocks.We guarantee it by making sure to encourage increased domestic and global productionAdded the Prime Minister. Update with Professor Roux.
What is the situation of Louis-Mourier resuscitation service today?
We fear the beginning of a stock shortage for the end of the weekend. We have visibility over two days. That is to say, we are not sure that our internal pharmacy will be able to supply us with all of the drugs necessary for optimal patient management. There is great concern because it is very likely that the AP-HP central pharmacy, despite all its efforts, may not be able to meet the demands of all hospitals and that we will end up with shortages during the restocking. This shortage situation is new but ultimately quite logical. Instead of having a variety of patients who require very different treatments, resuscitation services are currently finding themselves with a majority of Covid + patients who need the same molecules. It is this quantity of identical patients, hitherto unknown in our units, which causes the drug shortage.
Which families of molecules are likely to be lacking?
There is a strong tension on hypnotics. These are the molecules we use to keep patients in sleep in intensive care. The equation is therefore simple: if we run out of stocks, we will no longer be able to take care of new patients. It’s a real danger. We also fear a rapid shortage of curares, which allow the patient, once asleep, to prevent him from moving and therefore consume less oxygen. Curares are necessary because they allow these patients with acute respiratory distress syndrome (ARDS) to be completely ventilated by the ventilator. The last other concern concerns antibiotics. As we speak, I do not believe that an AP-HP hospital is lacking. But there is a risk of overconsumption in the days and weeks to come, because these serious patients in intensive care are at high risk of nosocomial infection. As you can see, the supply of these three groups of molecules is essential to save lives.
Your working group’s mission was to think of new protocols to save your stocks. A summary of your recommendations is currently being sent to all AP-HP hospitals. What does it contain?
At this stage, we propose an optimization of the sedation protocols in order to limit any use which is not absolutely necessary. A close relationship between the pharmacy and the resuscitation service is also necessary in order to anticipate any shortage of a molecule to refer to another close molecule. We also underlined the interest of associating other molecules making it possible to reduce the quantity of usual molecules to be administered. More specifically for sedation, one of the recommendations would also be to use the usual method of anesthesia in the operating room. It is a procedure that uses halogenated gases to put people to sleep and that we never use in most resuscitation services. This technique would also limit the use of curares.
At Louis-Mourier Hospital, where are you with your stock of syringe pumps, which allow the infusion of treatments? Some hospital structures already seem to be lacking…
We did the drawer bottoms and requisitioned all the units a little to find as many as possible. But indeed, faced with the impressive influx of resuscitation patients, we had to resolve to work with fewer electric syringe pumps per patient. For the moment, it does not degrade the quality of care but it causes discomfort in work for nurses who must regularly move this type of equipment from one room to another. Unless suppliers, especially Chinese, can quickly send us a large quantity of electric syringe pumps, we will have to modify the way we administer treatments to patients using less precise techniques.
WORLD: When painful treatment is due, dentists resort to local anesthesia – it prevents you from feeling anything during the procedure. Why do patients want to be sedated even more when the pain is turned off?
Dietmar Austria: Of course, the fear of the intervention plays a role. The mouth, jaw and face area is one of the most sensitive areas of the whole body. Pain or changes are perceived much more intensely there than in other places. If, for example, you have hair in the oral cavity, you will notice it immediately and it will be terribly disturbing – because the tactile sensation is very pronounced there. In this respect, the perception of pain and manipulation in the oral cavity is an unpleasant topic for many people; We know from surveys that roughly one in two people have a bad feeling or fear when it comes to dental treatment. Sometimes there is even a real anxiety disorder: five percent suffer from dentist phobia.
WORLD: Does it often happen in your practice that you do more than one local anesthetic?