Bixio Mattia, Carenzo Luca, Accurso Giuseppe, Balagna Roberto, Bazurro Simone, Chiarini Giovanni, Cortegiani Andrea, Faraldi Loredana, Fontana Costantino, Giannarzia Emilio, Giarratano Antonino, Molineris Enrico, Raineri Santi Maurizio, Marin Paolo
UO Anestesia E Rianimazione, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, Milan, Rozzano, 20089, Italy.
J Anesth Analg Crit Care. 2024 Nov 6;4(1):74. doi: 10.1186/s44158-024-00209-8.
The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has developed a good clinical practice to address the challenges of treating critically ill patients in resource-limited austere environments, exacerbated by recent pandemics, natural disasters, and conflicts. The methodological approach was based on a literature review and a modified Delphi method, which involved blind voting and consensus evaluation using a Likert scale. This process was conducted over two rounds of online voting. The document covers six critical topics: the overall impact of austere conditions on critical care, airway management, analgesia, bleeding control, vascular access, and medical devices and equipment. In these settings, it is vital to apply basic care techniques flexibly, focusing on immediate bleeding control, airway management, and hypothermia treatment to reduce mortality. For airway management, rapid sequence intubation with ketamine for sedation and muscle relaxation is suggested. Effective pain management involves a multimodal approach, including patient-controlled analgesia by quickly acting safe drugs, with an emphasis on ethical palliative care when other options are unavailable. Regarding hemorrhage, military-derived protocols like Tactical Combat Casualty Care significantly reduced mortality and influenced the development of civilian bleeding control devices. Establishing venous access is crucial, with intraosseous access as a swift option and central venous access for complex cases, ensuring aseptic conditions. Lastly, selecting medical equipment that matches the specific logistical and medical needs is essential, maintaining monitoring standards and considering advanced diagnostic tools like point-of-care ultrasounds. Finally, effective communication tools for coordination and telemedicine are also vital.
意大利麻醉、镇痛、复苏与重症监护学会（SIAARTI）制定了一项良好临床实践，以应对在资源有限的严峻环境中治疗重症患者所面临的挑战，近期的大流行病、自然灾害和冲突使这些挑战更加严峻。该方法基于文献综述和改良德尔菲法，其中包括使用李克特量表进行无记名投票和共识评估。此过程通过两轮在线投票进行。该文件涵盖六个关键主题：严峻条件对重症监护的总体影响、气道管理、镇痛、出血控制、血管通路以及医疗设备。在这些情况下，灵活应用基本护理技术至关重要，重点是立即控制出血、气道管理和低温治疗以降低死亡率。对于气道管理，建议使用氯胺酮进行快速顺序诱导插管以实现镇静和肌肉松弛。有效的疼痛管理采用多模式方法，包括通过快速起效的安全药物进行患者自控镇痛，在没有其他选择时强调符合伦理的姑息治疗。关于出血，像战术战伤护理这样源自军事的方案显著降低了死亡率，并影响了民用出血控制设备的发展。建立静脉通路至关重要，骨内通路是一种快速选择，复杂病例则采用中心静脉通路，同时确保无菌条件。最后，选择符合特定后勤和医疗需求的医疗设备至关重要，要维持监测标准并考虑使用即时超声等先进诊断工具。最后，有效的协调和远程医疗沟通工具也至关重要。
