At the heart of intensive care

They have become the image of the pandemic, these intubated patients, then affixed to the life by a long oxygen tube. In Quebec, it is estimated that 10 days is the average duration of intubation, but some patients are immersed between life and nothingness for several weeks.

This is what reveal the first five weeks spent in various intensive care units of the metropolis, more specifically in the “red zones” where there are concentrations of patients with the COVID-19.

“The lucky ones, often younger, will remain intubated for 24 to 48 hours, but the average turn around of 10 days. And some of them are available since almost the very beginning of our entry into the epidemic, or from three to four weeks, ” says Dr. Antoine Delage, pulmonologist, intensivist at the Charles-LeMoyne hospital and president of the Association of lung specialists of Quebec.

According to figures from the ministry of Health, approximately 62 % of the patients hospitalized to the intensive care unit are currently under intubation, 127 of 206. And 86 % of the patients admitted in these units come out alive.

However, after more than a month of experience in the vortex of the COVID-19, several intensivists quebec found that after-effects caused by long periods of intubation are very heavy and sometimes insurmountable. In the presence of factors such as high blood pressure, obesity or diabetes, approximately 50 % of intubated patients die, according to what keep these doctors.

“In the United Kingdom, studies have shown that one quarter of the patients COVID-19 admitted to intensive care usually die. It looks like more or less to what we see up to now in Quebec, ” says Dr. Germain Poirier, president of the Association of internists, which includes approximately 200 physicians intensivists in Quebec. The mortality rate for young people with co-morbid factors fluctuated around 20% to 25%.

The load entity is there. But we want to be at the front. Because there are also beautiful stories of people who have come back to life after two weeks.

— Stéphane Ahern

“There are also patients who are overweight between the ages of 20 to 55 years old who are very sick, for which overweight is a major factor. After having been asleep for three weeks, they lose their ability to come back, ” explains Dr. Stéphane Ahern, intensivist and chief of internal medicine at the Maisonneuve-Rosemont hospital.

“We expected a respiratory disease pure, but there was damage to various organs. We have seen many patients that have had to be put under dialysis, ” adds Dr. Delage. Some patients intubated for a long time have even had to undergo trachéotomies.

On the ground, the forms of delirium and post-traumatic stress disorder are even observed in patients who have gone through this ordeal extremely trying. For each week where a patient is intubated under deep sedation, it takes five to six weeks of slow rehabilitation, ” says Dr. Ahern. “For intubation of two to three weeks, it is several months of rehabilitation. “

“It is like being weightless in space for a few weeks. There is often a lung disease chronic. Only those who have little fibrosis in the lungs can hope to return to normal, ” says Dr Poirier.

For all these reasons, intensivists have adjusted their ways to make these last few weeks and they use now, when it is possible, to solutions other than deep sedation and intubation.

Try to avoid intubation

Now, intubated or not, a vast majority of patients are placed in prone position to facilitate oxygenation without sedation

If few elderly people die in the icu, is that most of them die before getting there. In several cases, guidelines, end-of-life have been given to their relatives informing them not to intubate these patients or be limited to comfort care. This is why a large part of the patients intubated for several weeks are rather young.”

Data we are missing on the mortality of young patients, because many are still in intensive care. It is clear that, for them, it is for the duration of the intubation, or in people 50 to 60 years old who still have a life ahead of them, ” says Dr. Delage. “If these young people remain on life support for weeks, it really is because they think they have a chance to get out of it,” stresses Dr Poirier.

There is no clear directive at the current time the maximum time during which a patient COVID-19 can be kept alive under intubation. “Families refuse to go to compassionate care because of their conception of life, or religion. They don’t understand that their loved ones will not come back to home, back to their life as before. Our role is to educate families, ” a joust Poirier.

And for that, the life of intensivists has changed dramatically in the last few weeks. The link with the families, private access to the red zone of intensive care (some exceptions), is done using an iPad, a cell phone. “We’re trying to create humanity through a zoom lens, it is not easy. No one has been trained to do interviews of end-of-life-by-phone “, laments Dr. Ahern.

Fatigue and stress are also beginning to make themselves felt in the ranks of intensivists, where many donned shifts of 36 hours in the areas COVID-19, ” said Dr. Patrick Gosselin, intensivist at the hôpital Pierre-Le Gardeur.

“A hundred intensivists died in Europe. It takes a simple distraction to contaminate. We must not let our guard down. After a month, this is where the risk is growing, ” says Dr. Poirier.

With the breath dried up by the heat and the continuous wear of N95 masks, the days in the icu are long and difficult for all staff, admits Dr. Ahern. “The burden of moral is there. But we want to be at the front. Because there are also beautiful stories of people who have come back to life after two weeks. This is a small number, but it is for them that we fight, for those who will be able to review their children, and their families. “

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