{"id":60668,"date":"2020-03-26T13:00:50","date_gmt":"2020-03-26T18:00:50","guid":{"rendered":"https:\/\/www.apsf.org\/?p=60668"},"modified":"2020-05-08T01:04:32","modified_gmt":"2020-05-08T06:04:32","slug":"declaration-de-consensus-sur-la-ventilation-simultanee-de-plusieurs-patients","status":"publish","type":"post","link":"https:\/\/www.apsf.org\/fr\/news-updates\/declaration-de-consensus-sur-la-ventilation-simultanee-de-plusieurs-patients\/","title":{"rendered":"D\u00e9claration de consensus sur la ventilation simultan\u00e9e de plusieurs patients"},"content":{"rendered":"

\"Logos<\/p>\n<\/div>L\u2019Anesthesia Patient Safety Foundation (ASPF), la Soci\u00e9t\u00e9 de m\u00e9decine des soins critiques (SCCM), l\u2019Association am\u00e9ricaine pour les soins respiratoires (AARC), l\u2019American Society of Anesthesiologists (ASA), l\u2019Association am\u00e9ricaine des infirmi\u00e8res et infirmiers en soins intensifs (AACN), et l\u2019American College of Chest Physicians (CHEST) se sont r\u00e9unis pour \u00e9tudier la question de l\u2019utilisation d\u2019un ventilateur pour la ventilation simultan\u00e9e de plusieurs patients en d\u00e9faillance respiratoire. La presse \u00e9crite et les r\u00e9seaux sociaux, ainsi que certains groupes du domaine m\u00e9dical, ont r\u00e9cemment \u00e9mis l\u2019id\u00e9e que le probl\u00e8me de p\u00e9nurie de ventilateurs pouvait \u00eatre r\u00e9solu en utilisant un ventilateur pour la ventilation de plusieurs patients en d\u00e9faillance respiratoire. L\u2019APSF et d\u2019autres organisations pensent que cette approche pourrait nuire aux patients et qu\u2019il existe des m\u00e9thodes alternatives pour accro\u00eetre la capacit\u00e9 de ventilation, qui pr\u00e9senteront moins de risque pour les patients.<\/p>\n

[PDF Version]<\/strong><\/a><\/p>\n

D\u00e9claration de consensus sur la ventilation simultan\u00e9e de plusieurs patients<\/h3>\n

26 mars 2020 : La Soci\u00e9t\u00e9 de m\u00e9decine des soins critiques (SCCM), l\u2019Association am\u00e9ricaine pour les soins respiratoires (AARC), l\u2019American Society of Anesthesiologists (ASA), l\u2019Anesthesia Patient Safety Foundation (ASPF), l\u2019Association am\u00e9ricaine des infirmi\u00e8res et infirmiers en soins intensifs (AACN), et l\u2019American College of Chest Physicians (CHEST) publient la pr\u00e9sente d\u00e9claration de consensus sur le concept de l\u2019utilisation d\u2019un seul ventilateur m\u00e9canique pour ventiler plusieurs patients.<\/p>\n

Les organisations susmentionn\u00e9es conseillent aux cliniciens qu\u2019il ne faut pas tenter de partager les ventilateurs m\u00e9caniques car le mat\u00e9riel actuel ne permet pas de r\u00e9aliser cette proc\u00e9dure en toute s\u00e9curit\u00e9. La physiologie des patients pr\u00e9sentant un d\u00e9but de syndrome de d\u00e9tresse respiratoire aigu\u00eb (SDRA) li\u00e9 au COVID-19 est complexe. M\u00eame dans des circonstances id\u00e9ales, la ventilation d\u2019un seul patient atteint du SDRA et atteint d\u2019une maladie pulmonaire h\u00e9t\u00e9rog\u00e8ne est difficile et associ\u00e9e \u00e0 un taux de mortalit\u00e9 compris entre 40 et 60 %. Compte tenu des probl\u00e8mes d\u00e9crits ici, la tentative de ventilation de plusieurs patients atteints du COVID-19 pourrait causer des \u00e9v\u00e8nements ind\u00e9sirables et des taux de mortalit\u00e9 \u00e9lev\u00e9s pour tous les patients rassembl\u00e9s. Dans le cadre des d\u00e9cisions de triage extr\u00eamement difficiles, mais pas inhabituelles, souvent prises dans des situations de crise m\u00e9dicale, il est pr\u00e9f\u00e9rable de cibler l\u2019utilisation du ventilateur sur le patient qui est le plus susceptible d\u2019en b\u00e9n\u00e9ficier, plut\u00f4t que d\u2019\u00e9chouer dans la pr\u00e9vention du d\u00e9c\u00e8s de plusieurs patients, voire le causer.<\/p>\n

Contexte :<\/strong> l\u2019int\u00e9r\u00eat de l\u2019utilisation d\u2019un seul ventilateur pour la ventilation de plusieurs patients a \u00e9t\u00e9 attis\u00e9 par ceux qui souhaiteraient \u00e9largir l\u2019acc\u00e8s aux ventilateurs m\u00e9caniques dans le cadre de l\u2019\u00e9pid\u00e9mie de COVID-19. Les premi\u00e8res descriptions contemporaines de l\u2019utilisation d\u2019un seul ventilateur pour plusieurs patients ont \u00e9t\u00e9 avanc\u00e9es par Neyman et al en 20061<\/sup> et par Paladino et al en 2013.2<\/sup> Toutefois, dans chaque cas, Branson, Rubinson et d\u2019autres ont \u00e9mis des mises en garde contre l\u2019utilisation de cette technique.3\u20105<\/sup> Avec l\u2019\u00e9quipement actuel con\u00e7u pour un seul patient, nous recommandons aux cliniciens de ne pas tenter de ventiler plusieurs patients avec un seul ventilateur tant qu\u2019aucune th\u00e9rapie fiable, s\u00fbre et cliniquement prouv\u00e9e n\u2019existe pas (c.-\u00e0-d. en cas d\u2019extr\u00eame urgence provisoire).<\/p>\n

La tentative de ventilation de plusieurs patients n\u00e9cessiterait probablement de disposer les patients comme les rayons d\u2019une roue autour du ventilateur qui serait plac\u00e9 au centre. Cette disposition \u00e9loignerait les patients des alimentations en oxyg\u00e8ne, en air et en aspiration \u00e0 la t\u00eate du lit. D\u2019autre part, les patients seraient tr\u00e8s proches les uns des autres, permettant la transmission d\u2019organismes. Un plus grand espacement des patients causerait probablement une hypercapnie.<\/p>\n

La respiration spontan\u00e9e d\u2019un seul patient d\u00e9tect\u00e9e par le ventilateur d\u00e9terminerait automatiquement la fr\u00e9quence respiratoire de tous les autres patients. Le volume des circuits suppl\u00e9mentaires pourrait emp\u00eacher le d\u00e9clenchement. Il est \u00e9galement possible que les patients partagent les gaz d\u2019un circuit \u00e0 un autre en l\u2019absence de valves unidirectionnelles. L\u2019effet \u00ab pendelluft \u00bb entre patients est possible, causant une infection crois\u00e9e et une distension excessive. La mise en place d\u2019alarmes permettra uniquement de surveiller la r\u00e9ponse globale du syst\u00e8me respiratoire des patients dans leur ensemble. Cela masquerait des changements qui surviendraient chez un seul patient. Les raisons d\u2019\u00e9viter la ventilation de plusieurs patients avec un seul ventilateur sont multiples.<\/p>\n

Ces raisons sont les suivantes :<\/p>\n

    \n
  • Les volumes seraient achemin\u00e9s aux segments pulmonaires les plus conformes.<\/li>\n
  • La pression expiratoire positive, qui a une importance critique pour ces patients, serait impossible \u00e0 g\u00e9rer.<\/li>\n
  • Le monitorage des patients et la mesure de la m\u00e9canique pulmonaire seraient compliqu\u00e9s, voire impossibles.<\/li>\n
  • Il ne serait pas possible de recourir au monitorage et \u00e0 la gestion par alarmes.<\/li>\n
  • La gestion individualis\u00e9e de l\u2019am\u00e9lioration ou de la d\u00e9t\u00e9rioration clinique serait impossible.<\/li>\n
  • En cas d\u2019arr\u00eat cardiaque, la ventilation de tous les patients devraient \u00eatre interrompue pour permettre de passer \u00e0 la ventilation par insufflateur, sans a\u00e9rosolisation du virus et sans exposer les soignants. Cette situation modifierait \u00e9galement la dynamique de la ventilation pour les autres patients.<\/li>\n
  • Le volume du circuit suppl\u00e9mentaire ne permet pas de r\u00e9aliser le test op\u00e9rationnel automatique (le test \u00e9choue). Le clinicien devrait faire fonctionner le ventilateur sans b\u00e9n\u00e9ficier d\u2019un test, ajoutant aux erreurs de mesure.<\/li>\n
  • Il faudrait un monitorage externe suppl\u00e9mentaire. Le ventilateur surveille les pressions et les volumes moyens.<\/li>\n
  • M\u00eame si tous les patients connect\u00e9s \u00e0 un seul ventilateur ont les m\u00eames caract\u00e9ristiques cliniques initiales, ils pourraient se d\u00e9t\u00e9riorer et se r\u00e9tablir \u00e0 des rythmes diff\u00e9rents, et la distribution de gaz \u00e0 chaque patient serait in\u00e9gale et ne serait pas surveill\u00e9e. Le patient le plus malade recevrait le plus petit volume respiratoire et le patient qui s\u2019am\u00e9liorerait recevrait le plus grand volume respiratoire.<\/li>\n
  • Les plus grands risques surviennent lorsque l\u2019\u00e9tat d\u2019un seul patient se d\u00e9t\u00e9riore rapidement (par ex. pneumothorax, tube endotrach\u00e9al coud\u00e9), avec le solde de la ventilation r\u00e9partie entre les autres patients.<\/li>\n
  • Enfin, il y a des questions d\u2019\u00e9thique. Si le ventilateur peut permettre de sauver la vie d\u2019une seule personne, son utilisation simultan\u00e9e avec plusieurs patients risque un \u00e9chec mortel du traitement pour tous.<\/li>\n<\/ul>\n

    Documents de r\u00e9f\u00e9rence<\/strong><\/p>\n

      \n
    1. Neyman G, Irvin CB. A single ventilator for multiple simulated patients to meet disaster surge. Acad Emerg Med.<\/em> 2006 Nov;13(11):1246\u20101249.<\/li>\n
    2. Paladino L, Silverberg M, Charcaflieh JG, et al. Increasing ventilator surge capacity in disasters: ventilation of four adult\u2010human\u2010sized sheep on a single ventilator with a modified circuit. Resuscitation.<\/em> 2008 Apr;77(1):121\u2010126.<\/li>\n
    3. Branson RD, Rubinson L. One ventilator, multiple patients: what the data really supports. Resuscitation.<\/em> 2008 Oct;79(1):171\u2010172; author reply 172\u2010173.<\/li>\n
    4. Branson RD, Rubinson L. A single ventilator for multiple simulated patients to meet disaster surge. Acad Emerg Med.<\/em> 2006 Dec;13(12):1352\u20101353; author reply 1353\u20101354.<\/li>\n
    5. Branson RD, Blakeman TC, Robinson BR, Johannigman JA. Use of a single ventilator to support 4 patients: laboratory evaluation of a limited concept. Respir Care.<\/em> 2012 Mar;57(3):399\u2010403.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

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