Le processus décisionnel en situation d’urgence chirurgicale digestive au sein du binôme médecin anesthésiste-réanimateur / chirurgien

Making the decision to perform major emergency digestive surgery in some patients, particularly elderly and comorbid, can be difficult for anesthesiologists and digestive surgeons. No studies have examined the experience and decision-making process of the anesthesiologists / digestive surgeon pair in these situations. We conducted a qualitative research among anesthesiologists and digestive surgeons performing emergency digestive surgery. A clinical case was proposed followed by a semi-structured interview. In March 2020, 4 digestive surgeons and 4 anesthesiologists practicing in university hospitals were included. They all perceived the decision to disqualify surgery in a life-threatening emergency context equivalent to a decision of withholding or withdrawing life sustaining therapies. There was no consensus on the criteria for deciding between patients: only those already under palliative care or severely bedridden or demented were easily disqualified. It was an anxiety-provoking decision for the doctors, who favored anticipation or transfer to a multidisciplinary team, after having carried out surgery followed by a standby resuscitation. The sharing of the decision was defended in the sense of a common construction. The anesthesiologist was recognized as a specialist in general condition; whereas digestive surgeons oscillated between a purely technical opinion and a legitimacy to assess the overall condition of the patient. The intensivist helped to form a medical and surgical team, participating in decision-making when no other external professional was available. Conflicts were frequent, but attributed to organizational difficulties rather than to the decision to operate per se. The patient's geographical location within the hospital structure determined who was to inform him, leaving the anesthesiologist in a supporting role to the surgeon or the intensivist. Anesthesiologists and digestive surgeons are in agreement with the few existing recommendations regarding peri-operative limitations of life sustaining therapies. The reality of the apparent consensus in the discourse could be questioned by a larger survey with an anthropological observation side.Prendre la décision d’effectuer une chirurgie digestive lourde en urgence chez certains patients, notamment âgés et comorbides, peut s’avérer difficile pour les médecins anesthésistes-réanimateurs (MAR) et les chirurgiens digestifs. Aucune étude ne s’est intéressée au vécu et au processus décisionnel à l’œuvre au sein du binôme MAR / chirurgien digestif face à ces situations. Nous avons mené une étude qualitative auprès de MAR et de chirurgiens digestifs exerçant dans des centres pratiquant la chirurgie digestive en urgence, en France. Une vignette clinique était proposée suivie d’un entretien semi directif. Les résultats étaient analysés manuellement, selon la méthode d’analyse de contenu thématique. En Mars 2020, 4 chirurgiens digestifs et 4 MAR exerçant en CHU étaient inclus. Ils percevaient tous la décision de récusation pour une chirurgie dans un contexte d’urgence vitale comme une décision de limitation de soins à part entière. Aucun critère ne faisait consensus pour départager les patients : seuls ceux déjà en cours de prise en charge palliative ou grands déments grabataires étaient aisément récusables. Il s’agissait d’une prise de décision anxiogène pour les médecins, qui plébiscitaient l’anticipation ou le transfert à une équipe pluridisciplinaire, après avoir mené une chirurgie suivie d’une réanimation d’attente. Le partage de la décision était défendu dans le sens d’une construction commune, où chacun apportait sa part d’expertise. Le MAR était reconnu comme spécialiste de l’état général ; tandis que les chirurgiens digestifs oscillaient entre un avis purement technique et une légitimité à évaluer l’état global du patient. Le réanimateur venait former un trio médico-chirurgical participant à la prise de décision quand aucun autre professionnel extérieur n’était mobilisable. Les conflits, fréquents, étaient attribués à des difficultés organisationnelles plutôt qu’à la décision d’opérer en elle-même. La situation géographique du patient au sein de la structure hospitalière déterminait qui devait l’informer, laissant ainsi le MAR dans un rôle de soutien auprès du chirurgien, de l’urgentiste ou du réanimateur. Les MAR et les chirurgiens digestifs sont en accord avec le peu de recommandations existantes concernant les limitations et arrêts de traitement péri opératoires. La réalité du consensus apparent dans le discours pourrait être interrogée via une étude de plus grande envergure avec un versant d’observation anthropologique

Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study

Erratum inCorrection to Lancet Respir Med 2021; published online April 19. https://doi.org/10.1016/S2213-2600(21)00096-5.International audienceBackground: In the Île-de-France region (henceforth termed Greater Paris), extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) was considered early in the COVID-19 pandemic. We report ECMO network organisation and outcomes during the first wave of the pandemic.Methods: In this multicentre cohort study, we present an analysis of all adult patients with laboratory-confirmed SARS-CoV-2 infection and severe ARDS requiring ECMO who were admitted to 17 Greater Paris intensive care units between March 8 and June 3, 2020. Central regulation for ECMO indications and pooling of resources were organised for the Greater Paris intensive care units, with six mobile ECMO teams available for the region. Details of complications (including ECMO-related complications, renal replacement therapy, and pulmonary embolism), clinical outcomes, survival status at 90 days after ECMO initiation, and causes of death are reported. Multivariable analysis was used to identify pre-ECMO variables independently associated with 90-day survival after ECMO.Findings: The 302 patients included who underwent ECMO had a median age of 52 years (IQR 45-58) and Simplified Acute Physiology Score-II of 40 (31-56), and 235 (78%) of whom were men. 165 (55%) were transferred after cannulation by a mobile ECMO team. Before ECMO, 285 (94%) patients were prone positioned, median driving pressure was 18 cm H2O (14-21), and median ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen was 61 mm Hg (IQR 54-70). During ECMO, 115 (43%) of 270 patients had a major bleeding event, 27 of whom had intracranial haemorrhage; 130 (43%) of 301 patients received renal replacement therapy; and 53 (18%) of 294 had a pulmonary embolism. 138 (46%) patients were alive 90 days after ECMO. The most common causes of death were multiorgan failure (53 [18%] patients) and septic shock (47 [16%] patients). Shorter time between intubation and ECMO (odds ratio 0·91 [95% CI 0·84-0·99] per day decrease), younger age (2·89 [1·41-5·93] for ≤48 years and 2·01 [1·01-3·99] for 49-56 years vs ≥57 years), lower pre-ECMO renal component of the Sequential Organ Failure Assessment score (0·67, 0·55-0·83 per point increase), and treatment in centres managing at least 30 venovenous ECMO cases annually (2·98 [1·46-6·04]) were independently associated with improved 90-day survival. There was no significant difference in survival between patients who had mobile and on-site ECMO initiation.Interpretation: Beyond associations with similar factors to those reported on ECMO for non-COVID-19 ARDS, 90-day survival among ECMO-assisted patients with COVID-19 was strongly associated with a centre's experience in venovenous ECMO during the previous year. Early ECMO management in centres with a high venovenous ECMO case volume should be advocated, by applying centralisation and regulation of ECMO indications, which should also help to prevent a shortage of resources