The practice is called mechanical containment. Although it is far from being recommended or even acceptable by specialists in intensive care medicine, it has been usual in ICUs for years, according to three intensivists heard by the sheet.
The method ends up being used to avoid serious damage to patients’ health. It is a necessary evil, according to doctors. The pandemic, for a number of factors, made containment even more common in ICUs.
A sheet he obtained photos and videos of patients with their hands tied to their beds at the Hospital de Campanha Zona Leste, known as Cero, in Porto Velho. The images show patients intubated and moving slowly, with both arms tied with cloths to the edges of hospital beds.
The director general of the hospital, Richael Costa, confirmed to the report that the images are of patients with Covid-19 admitted to Cero.
Health professionals relate the containment of these people to the lack of sedatives and tranquilizers in the unit. Medicines from the so-called intubation kit were scarce in this critical phase of the pandemic, in which 17 states and the DF – Rondonia among them – have ICUs with more than 90% occupation, according to a survey by Fiocruz (Fundação Oswaldo Cruz).
Anvisa (National Health Surveillance Agency) relaxed rules to try to prevent depletion of sedatives and neuromuscular blockers in the states.
A sheet showed on the 20th that health professionals are resorting to second or third line drugs to ensure sedation or to compensate for the absence of blockers with more sedatives.
The director-general of Cero said that the mechanical containment of patients is not done due to the lack of medication in the intubation kit. “The sedatives are not over. And we have blockers. We have all the drugs in the unit, ”he said. According to Costa, what can be seen in the images is the moment of “weaning” from sedatives, the awakening of intubated patients during the process of gradual removal of the tube, due to the improvement of the clinical condition.
“It is common to contain the bed. If the hands are loose, the patient can pull the tube out ”, said the director. The “weaning” can last from two to three days, according to him. “As the sedation decreases, the patient will open his eye, he will move, he will not know who those people are there. The tube cannot be removed at once. ”
Costa acknowledged that there is a difficulty in acquiring medicines from the intubation kit and that this leads to the use of “second or third choice” drugs. “The containment of patients can only occur with a medical order,” he said.
The Rondônia Health Department said in a statement that there was no shortage of sedatives in the field hospital.
“The applied procedure, containing patients in bed, is a practice guaranteed by law and is part of the dynamics of patient care. It is used only when the patient is physically or aggressively agitated and serves only as protection for the patient and the team, ”he said.
Doctors linked to Amib (Brazilian Association of Intensive Medicine) report that the practice of containment intensified in ICUs with the pandemic, and point out several reasons for this. The most obvious is the sheer number of serious new cases requiring intubation. Added to this is the lack of nursing professionals in sufficient quantity to accompany the entire process of “weaning” from sedation, alongside the patients.
Professionals report that the lack of tranquilizers also contributes to the adoption of the technique. According to them, there are health units that had abandoned the practice and had to resume it in the face of the collapse in the care of patients with Covid-19.
An alternative to containment, according to these professionals, would be the manufacture of gloves with fabric or tape, in order to prevent patients from being able to pull out equipment. In view of the overcrowding of beds and the overload of health teams, the method is not widely adopted.
The intensive care doctor Rodrigo Biondi, who works in Brasília, adds another factor, which contributes to the greater need for containment: patients with Covid-19 are more difficult to sedate and demand a greater amount of sedatives.
“This could be the result of Covid’s direct action on the central nervous system. It is an aggravating factor, which determines that we use a greater amount of sedatives, which makes them end more quickly. If it is more difficult to sedate, it is also more difficult to control the patient ”, says Biondi.
Eduardo Nogueira, who chairs the Society for Intensive Care in Sergipe, says that “delirium” – an agitated and combative awakening of the patient – is frequent in patients with Covid-19 in serious condition, during the withdrawal phase of sedatives.
“These intubated patients, in general, have severe lung disease, due to the inflammatory process caused by Covid. They usually need deeper sedation and often a neuromuscular blocker for a longer time. This may be one of the main factors [de maior ocorrência de ‘delirium’ e, consequentemente, de mais contenção]”, Says Nogueira.
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