April 24, 2020 20: 30
Updated at 21h04
Anesthesia: the return of good old techniques
“When I was training, my boss, I had arrived one morning : “today, we have five patients and you don’t have the right to take the same drug twice.” The next day : “We are going to use just the drugs that start with A!” I didn’t think this course then I would for real one day!”
Jean-François Courval is an anesthesiologist for 25 years and president of the Association of anesthesiologists of Quebec (NAQ). He has never forgotten these challenges imposed by its teacher. She was able to hone the versatility of the future specialist physician, faculty of crucial importance in the health care environment during the crisis of the COVID-19.
The prime minister of Québec, François Legault, and his minister of Health, Danielle McCann, worried publicly over the last three weeks of a shortage of medicines, anaesthetics.
Especially propofol, which has become a precious commodity and very much sought after everywhere in the world in these times of pandemic, in the same way as protection masks and respirators mechanical.
“There has been a little improvement”, advanced Ms McCann with caution, in the press point on Thursday. “We have ordered quite a good amount. And there, I’m very cautious. It was still a form of guarantee that you will receive. But you know, in the current context, it is expected to receive to say that we have the command.”
Not ideal for the COVID-19
Also known under the trade name Diprivan, such as Tylenol-acetaminophen, propofol is the king of medicines, anaesthetics. The endormeur par excellence. Among others, for the patients infected with the novel coronavirus, needing to be intubated.
“We use it every day : to the emergency room to the operating theatre, the intensive care unit. It is used every day, and almost all the patients” who require a general anaesthetic, sums up Guillaume Leblanc, both anesthesiologist and intensivist at the hôpital de l’enfant-Jésus de Québec for the past four years.
The first documented use of propofol in humans dates back to 1977. But his ascension to the rank of a feature in hospitals all over the world came to fruition in the 1990s. Its success has not faltered since.
Why we love the propofol? Its action is rapid, powerful and does not last long.
“It is having an effect in a few seconds. And as soon as one stops giving, the end of his action is also very fast, in a few minutes. While for other drugs, it can be a few hours. ”
“Is that the propofol is used a lot? Yes. But is this the only molecule that we can use? Absolutely not. It has more than one string to our arsenal”, illustrates Dr. Courval, who works at the Centre hospitalier universitaire de Montréal (CHUM) and specializes in normal times, in gynecological cancer.
Some of the options even seem to be better correspond to the needs of a patient COVID-19, intubated and ventilated in the intensive care unit.
“This is perhaps not the ideal choice, because it consumes a lot and because it is necessary to give it continuously. We have already begun to change the practices and use of molecules with long duration of action. And as the patients of the COVID are intubated between 10 and 14 days, it doesn’t change anything for them.
“Everything that could happen is that it might take a little more time to extuber the person, to remove the tube and remove the respirator,” Dr. Courval. But over a period of 10 to 14 days, it does not change large-thing, and on the consumption, it will have a big impact.”
I killed Michael Jackson
With the gradual recovery of activities in the operating theatres of Quebec announced by Mrs McCann, it is especially in the intensive care techniques that will need to be adapted.
“These days, we use other molecules to protect our stocks of propofol, confirmed by Dr. Leblanc. To keep the patients asleep in an induced coma, use of benzodiazepines, it is Midazolam, and it looks like the Ativan, as an intravenous infusion.”
His colleague Courval talking about giving preference to the morphine, Dilaudid (hydromorphone), fentanyl, also more short action, or Nozinan (lévomépromazine).
“All of the molecules that I used it was 20, 25 years when I was in intensive care! exclaims the president of the NAQ. And we managed to ventilate patients, to oxygenate, to put on fans using these molecules-there is a safe.
“The young anesthesiologists have not always learned these old techniques there. But this is not a big deal, it will teach us soon enough. The saying is perhaps going to change. Going to have to teach the younger monkeys to make old faces!” guffaws-t-it.
Speaking of monkey, maybe you had already heard about the propofol. This is what killed Michael Jackson in 2009. The interpreter Thriller and Beat It in used as a sleeping pill, at home. Suspicion fell not on his faithful pet monkey Bubbles, at that time already retired in Florida, but rather to his personal doctor, then convicted of manslaughter.
Quebec supplies of propofol in the United States and Europe.
Fifty of 740 to 750 anesthesiologists quebec are missing in this moment the call during the crisis of the COVID-19, being in isolation medical or preventive withdrawal because of their advanced age. Of the lot, 140 volunteered to go and help in NURSING homes.