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. 2020 Jun;39(3):333-339.
doi: 10.1016/j.accpm.2020.05.008. Epub 2020 May 17.

Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources

Thomas Leclerc  1 , Nicolas Donat  2 , Alexis Donat  3 , Pierre Pasquier  4 , Nicolas Libert  2 , Elodie Schaeffer  5 , Erwan D'Aranda  6 , Jean Cotte  6 , Bruno Fontaine  7 , Pierre-François Perrigault  8 , Fabrice Michel  9 , Laurent Muller  10 , Eric Meaudre  11 , Benoît Veber  12
Affiliations

Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources

Thomas Leclerc et al. Anaesth Crit Care Pain Med. 2020 Jun.

Abstract

Background: Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources.

Rationale: Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients.

Prioritisation strategy: Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount.

Perspective: Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.

Keywords: COVID-19; Critical care; Ethics; Pandemic; Prioritisation; Triage.

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Figures

Fig. 1
Fig. 1
Critically ill patients in COVID-19 pandemic with scarce resources: prioritisation for initiation of critical care treatments.
Fig. 2
Fig. 2
Critically ill patients in COVID-19 pandemic with scarce resources: prioritisation for continuation of critical care treatments.
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Sequential Organ Failure Assessment (SOFA) score, after .
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KDIGO stage of chronic kidney disease, after .
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