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Development of a triage protocol for critical care during an influenza pandemic.docx

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Biological Sciences
Danillo Viana

Development of a triage protocol for critical care during an influenza pandemic Summary Notes Background: - Outbreaks of avian influenzainfluenza pandemic in humans - Particular concern in this planning is the allocation of resources such as ventilators and antiviral medications, which will likely become scarce during a pandemic - When resource scarcities occur, the tenets of biomedical ethics and international law dictate that triage be used to guide resources allocation o International law requires a triage plan will equitably provide everyone the “opportunity” to survive Methods - Group of clinical with expertise in critical care infectious disease, medical ethics, military medicine, triage and disaster manage o The good review in depth of medical literature by searching MIDLINE for articles published from January 1966 to December 2004  Using the terms :  Triage, intensive care, mechanical ventilation, influenza and pandemic Result - The literature search internet search and consultations experts failed to identify any general triage protocols for critical care - The protocol is designed to provide guidance for making triage decisions during the initial days to weeks of an influenza pandemic if the critical care system is overwhelmed - The triage protocol would apply to all patients who are being considered for critical care, not just those with influenza since all patients must started a single pool resources - The triage protocol has 4 main components: o Inclusion criteria  Identify patients who may benefit from admission to critical care and primarily focus on respiratory failure-purpose of the ventilator support o Exclusion criteria  Can be broken down into 3 categories  Patients who have poor prognosis despite care in an ICU o The first category reflects the “hard” boundaries that many intensivists recognize from their day to day care of patient such as burn , cancer end-stage cancer  Patients who require resources that simply cannot be provided during a pandemic and patient o Includes patients who my benefits from critical care but would require intense use of resources and prolonged care that cannot be justified st  1 category:  Patients with advanced medical illness who underlying illness has a poor prognosis with a high likelihood of death  2 Category:  Patients who may benefit from critical care but would require intense use of resources and prolonged care that cannot be justified during a pandemic, when the goal is to do the most for the most with the limited resources available. rd  3 Category:  Patients who have high resource requirements and are likely to experience significant complications from influenza (e.g., patients with advanced cancer or immunosuppression).  Other Category:  Patients who have end-stage cardiac, hepatic or pulmonary failure o Minimum qualifications for survival  The “minimum qualifications for survival” form the third component of the triage protocol. These qualifications represent a ceiling on the amount of resources that can be expended on any one person.  The minimum qualifications for survival dictate reassessment at 48 and 120 hours  Ongoing cut-off ceiling if a patient ever has a SOFA score of 11 or higher or any other exclusion criteria  The key component of the minimum qualifications for survival:  The attempt to identify at an early stage patients who are not improving and who are likely to have a poor outcome. o Prioritization tool  The final component of the triage protocol is a tool for the prioritization of patients for admission to the ICU and access to ventilation  Depending on their condition and medical issues, patients may either continue to have curative medical care on a ward or palliative care.  In selecting the patients for this category, the aim is to find those who are sick enough to require the resource and whose outcome will be poor if they do not receive it but are not so sick that they will not recover even if they do receive ICU care.  The goal is to optimize the effectiveness of the triage protocol so that every patient who receives resources will survive.  Blue or Black: fall into the expectant category and should not receive critical care  Red: Have the highest priority for ICU admission and mechanical ventilation, if required  Pt w/ single organ failure, particularly those w/ respiratory failure d/t influenza who otherwise a have low SOFA  In the red category assuming they have no exclusion criteria  Yellow:  At baseline  Are very sick  May or may not benefit from critical care  Should only receive care ONLY if available and no one in the red category needs it  Green:  Patients who should be considered transfer out of the ICU because they are well enough to be cared for w/o mechanical ventilation or other specific interventions Interpretation - This triage protocol is a tool aimed at maximizing benefits for the largest number of
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