Een bijzondere aanpak voor het reanimeren van COVID-19 patiënten
Reanimeren…
Elke verpleegkundige wordt er mee geconfronteerd, de één al wat vaker dan de ander. Uniforme Europese richtlijnen maken dat zorgverleners exact weten hoe ze te werk moeten gaan. Deze richtlijnen worden vierjaarlijks geüpdatet door de European Resuscitation Council (ERC). Wanneer de situatie het echter niet toelaat deze richtlijnen toe te passen, wordt het een moeilijkere kwestie. Als intensieve zorgen verpleegkundige hebben mijn collega’s en ik dit in levenden lijve ondervonden.
Dankzij COVID-19 ontstonden er tal van nieuwe uitdagingen op intensieve zorgen. Eén daarvan is het reanimeren (CPR) van patiënten die op hun buik gelegen zijn (de “prone positie”). Deze positie werd in eerder uitzonderlijke gevallen reeds toegepast op intensieve zorgen bij patiënten met ernstig longfalen. Door de huidige pandemie wordt deze positie echter toegepast zoals nooit tevoren. Tot 70% van de kunstmatig beademde COVID patiënten verblijft namelijk in deze positie. Kritiek zieke COVID patiënten hebben bovendien een verhoogd risico op een hartstilstand. In medische termen noemt men dit een cardiorespiratoir arrest. Bij een hartstilstand is het van belang dat er onmiddellijk wordt gestart met reanimeren. Bij elke minuut uitstel tot reanimatie verlaagt de overlevingskans namelijk met 5,5 %. De patiënt dient hiervoor op de rug te liggen zodat de hartmassage kan worden toegediend op de borstkas. Dit wil zeggen dat de prone gelegen patiënt eerst op de rug zou moeten worden gedraaid. Maar dit draaien brengt risico’s mee voor de patiënt én zorgverlener (zie tabel). Zeker wanneer dit haastig en onvoorbereid moet gebeuren, zoals het geval is in een reanimatie setting.
Is there no better way?
Mijn onderzoeksvraag had dan ook betrekking tot de mogelijkheid iemand te reanimeren in buikligging. Slechts een handjevol zorgverleners zijn bekend met dit concept dat “prone CPR” noemt. Bovendien is de literatuur rond prone CPR beperkt gezien er tot voor kort weinig noodzaak was aan onderzoek. Er is echter voldoende bewijs om te stellen dat deze vorm van reanimatie effectief is. Tijdens mijn literatuurstudie vond ik voornamelijk c.s. reports waarbij prone CPR in de operatiekamer werd toegepast. In 92% van deze gevallen kon de hartstilstand worden hersteld! Prone CPR blijkt bovendien hogere bloeddrukken te genereren dan standaard CPR. De bloeddruk is tijdens een reanimatie van grote betekenis gezien deze ervoor zorgt dat de vitale organen van bloed en dus zuurstof voorzien worden en daardoor zo weinig mogelijk schade oplopen.
Aan het eind van mijn onderzoek kan ik dus wel stellen dat prone CPR een acceptabele manier is om CPR toe te passen. Er zijn echter 2 belangrijke vereisten. Enerzijds is het een techniek die enkel in een gecontroleerde setting kan worden toegepast (op spoedgevallen en in de operatiekamer), gezien patiënten daar aan de bewaking zijn gekoppeld. Op die manier kan men beoordelen hoe effectief de reanimatie is. Indien dit ontoereikend blijkt te zijn, dient de patiënt alsnog gedraaid te worden om vervolgens over te gaan tot standaard reanimatie. Anderzijds dient de patiënt reeds kunstmatig beademd te zijn. Bij patiënten die niet beademd zijn dient men in het geval van een hartstilstand bij een COVID patiënt namelijk zo snel mogelijk een kunstmatige luchtweg te voorzien in de luchtpijp van de patiënt. Het spreekt voor zich dat dit een onmogelijke opgave is wanneer de patiënt op de buik ligt.
Om verpleegkundigen correct en efficiënt te kunnen instrueren m.b.t. de techniek stelde ik aan de hand van beschikbare literatuur en de huidige ERC richtlijnen een algoritme en richtlijnenbundel op.
Ik ontwikkelde ook een instructievideo die bondig toont hoe zo een reanimatie in zijn werk gaat. Deze video kan worden bekeken via onderstaande URL.
https://www.youtube.com/watch?v=qAbj0LEMzOs
In de huidige pandemie is het namelijk meer dan ooit van belang dat zorgverleners in de frontlinie voorbereid zijn op situaties waarmee ze nooit eerder geconfronteerd werden!
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