Life-Threatening Prognosis in Tunisia

What is a Life-Threatening Prognosis?

A life-threatening prognosis (or critical condition) is a medical situation where the patient's life is threatened in the short or medium term (hours to days). These patients require immediate management in an intensive care unit to benefit from continuous monitoring, invasive monitoring, and support for failing vital functions.

Situations involving a life-threatening prognosis are numerous:

• Severe acute respiratory failure (ARDS, hypoxemic pneumonia, massive pulmonary embolism, decompensated COPD with acidosis).
• Circulatory failure (shock): septic shock, cardiogenic shock (extensive infarction), hypovolemic shock (massive hemorrhage), obstructive shock (tamponade, massive PE).
• Severe acute neurological failure: severe traumatic brain injury (GCS ≤ 8), massive ischemic or hemorrhagic stroke, bacterial meningitis, status epilepticus, toxic or metabolic coma.
• Acute kidney injury (AKI) anuric or oliguric with hyperkalemia, acidosis, fluid overload.
• Acute liver failure (fulminant hepatitis, hepatocellular failure with hepatic encephalopathy).
• Hematological failure (severe DIC, bone marrow aplasia, complicated acute leukemia).
• Polytrauma (multiple life-threatening injuries, ISS > 25).
• Resuscitated cardiac arrest (post-cardiac arrest, post-anoxic coma).
• Severe sepsis or septic shock (multiorgan failure of infectious origin).
• Severe poisonings (barbiturates, cyanide, paraquat, methanol).
• Extensive burns (> 20-30% of body surface area in adults).
• Post-operative period after major surgery (cardiac, thoracic, neurosurgical, transplantation).

What are the Signs and Severity Scores of a Life-Threatening Prognosis?

Severity assessment is based on clinical signs, laboratory tests, and standardized prognostic scores.

Clinical Signs of Severity:

• Respiratory distress: respiratory rate > 30/min, SpO2 < 90% on oxygen, cyanosis, use of accessory muscles, PaO2/FiO2 < 300, PaCO2 > 45 mmHg with pH < 7.35.
• Hemodynamic instability: SBP < 90 mmHg, MAP < 65 mmHg, tachycardia > 120/min, mottling, capillary refill time > 3 sec, lactate > 2 mmol/L.
• Altered consciousness: Glasgow Coma Scale ≤ 12 (moderate), ≤ 8 (severe), rapid worsening.
• Oliguria or anuria: urine output < 0.5 mL/kg/h for > 6h, or even anuria.
• Jaundice, ecchymosis, purpura (signs of liver failure or DIC).
• High fever (> 39°C) or hypothermia (< 36°C) (sepsis).

Prognostic Scores Used in Intensive Care:

How is the Management of Patients with a Life-Threatening Prognosis in Tunisia?

Management takes place in a multidisciplinary intensive care unit with a 24/7 team.

Admission and Initial Workup in Intensive Care

• Transfer from the emergency department, operating room, or general ward (or direct admission).
• Continuous monitoring: cardiac monitor, pulse oximetry, invasive arterial pressure (radial/femoral catheter), central venous pressure (CVP), core temperature, hourly urine output (urinary catheter).
• Extensive laboratory tests: CBC, platelets, PT/PTT, D-dimers (DIC), electrolytes, creatinine, liver function tests, lactate, troponin, procalcitonin, CRP, arterial blood gas (pH, PaO2, PaCO2, HCO3, BE).
• Imaging studies: chest X-ray, lung ultrasound, CT scan (if transport possible), echocardiography (search for hemodynamic cause).
• Calculation of severity scores (SOFA, IGS II, APACHE II) on admission.

Organ Failure Support

Respiratory support (respiratory failure)

• High-flow nasal oxygen (Optiflow) if PaO2/FiO2 between 200-300.
• Non-Invasive Ventilation (NIV) if moderate respiratory acidosis and preserved consciousness.
• Invasive mechanical ventilation (intubation) if PaO2/FiO2 < 150, pH < 7.25, coma, exhaustion. Modes: VC, PC, SIMV. Lung protection: tidal volume 4-8 mL/kg, PEEP 5-15 cmH2O, plateau pressure < 30 cmH2O.
• Prone positioning if PaO2/FiO2 < 150 (severe ARDS).
• Venovenous ECMO (VV ECMO) for refractory ARDS (PaO2/FiO2 < 80).

Circulatory support (circulatory failure - shock)

• Fluid resuscitation: crystalloids (0.9% NaCl or Ringer's Lactate) 30 mL/kg, reassessment clinically and by ultrasound (respiratory variability of the inferior vena cava, aortic VTI).
• Vasopressors: norepinephrine (1st line), target MAP ≥ 65 mmHg. Initial dose 0.05-0.1 µg/kg/min, titrate up to 0.5-1 µg/kg/min. If doses > 1 µg/kg/min: consider adding vasopressin (0.03-0.04 IU/min) or epinephrine (0.05-0.2 µg/kg/min).
• Inotropes: dobutamine (2.5-20 µg/kg/min) in case of cardiogenic shock (low cardiac output).
• Mechanical circulatory support: venoarterial ECMO (VA ECMO) for refractory cardiogenic shock, intra-aortic balloon pump (IABP) (less recommended 2024).

Renal replacement therapy (acute kidney injury - AKI)

• Indications: anuria/oliguria (urine output < 0.3 mL/kg/h for > 6h, or < 0.5 mL/kg/h for > 12h), urea > 30-40 mmol/L, creatinine > 400-500 µmol/L, refractory hyperkalemia > 6-6.5 mmol/L, metabolic acidosis pH < 7.2, fluid overload with pulmonary edema refractory to diuretics.
• Continuous hemofiltration (CVVHDF): preferred dialysis mode in intensive care (hemodynamic tolerance). Target dose: 25-35 mL/kg/h.
• Intermittent hemodialysis (IHD) if patient stable.

Sedation and analgesia (ventilated patients or severe agitation)

• Light sedation protocol (except severe shock, ARDS, ICH). Target: RASS (Richmond Agitation-Sedation Scale) 0 to -2.
• Medications: propofol (1-3 mg/kg/h), midazolam (0.05-0.2 mg/kg/h), dexmedetomidine (0.2-0.7 µg/kg/h).
• Analgesia: fentanyl (0.5-2 µg/kg/h), morphine, sufentanil.

Specific etiological treatment

• Sepsis/septic shock: empirical antibiotics < 1h, rapid de-escalation, source control (drainage, catheter removal, surgery).
• Cardiogenic shock: coronary angiography with angioplasty (STEMI < 2h), coronary artery bypass grafting (CABG), thrombolysis (if delay > 2h).
• Hemorrhagic shock: massive transfusion (1:1:1 ratio), tranexamic acid (Exacyl® 1g), surgical/embolization control.
• Coma/severe traumatic brain injury: neurosurgery (hematoma evacuation, craniectomy), ICP monitoring, ICH treatment (mannitol, hypertonic saline).
• Poisonings: antidotes (naloxone, flumazenil), renal replacement therapy, activated charcoal (if recent ingestion).

Advanced Monitoring in Intensive Care

• Arterial catheter: continuous MAP, blood gas sampling.
• Central venous catheter: CVP, administration of vasopressors/inotropes, sampling, hemofiltration.
• Pulmonary artery catheter (Swan-Ganz): measurements (PAP, PCO, CVP, cardiac output) for complex shocks.
• Non-invasive cardiac output monitoring (PiCCO, Vigileo, transesophageal echocardiography).
• Intracranial pressure (ICP) for severe traumatic brain injury (intraparenchymal transducer).
• Continuous EEG for coma, status epilepticus, suspected non-convulsive seizures.

Supportive Care and Complication Prevention

• Artificial nutrition: enteral preferred (nasogastric/nasojejunal tube), continuous infusion, target 20-25 kcal/kg/day (up to 30 kcal/kg/day during recovery). Protein supplementation (1.2-2 g/kg/day). If digestive intolerance: supplemental parenteral nutrition.
• Pressure ulcer prevention: alternating pressure mattresses, position changes every 2 hours, protection of pressure points.
• Deep vein thrombosis (DVT) prevention: LMWH (enoxaparin 40 mg/day, unless high bleeding risk), compression stockings or intermittent compression.
• Stress ulcer prophylaxis: proton pump inhibitors (PPIs) (esomeprazole, pantoprazole) if ventilated patient, coagulopathy, severe stress.
• Prevention of nosocomial infections: hand hygiene, oral care, sterile tracheal suction, early catheter removal, antibiotic de-escalation, isolation if MDRO.
• Strict glycemic control: target 6-10 mmol/L (IV insulin if needed, avoid hypoglycemia).
• Correction of hydro-electrolyte imbalances: sodium, potassium, calcium, magnesium, phosphorus.
• Delirium prevention: reorientation, light therapy, naps, avoid benzodiazepines, use dexmedetomidine if agitation.

What are the Prognoses and Severity Factors?

Prognosis depends on several factors:

• Number of organ failures (SOFA score): mortality:
  • SOFA 0-6: < 5%
  • SOFA 7-12: 15-30%
  • SOFA 13-17: 40-60%
  • SOFA 18-24: 70-90%
• Age: > 65 years (mortality multiplied by 2-3).
• Comorbidities: immunosuppression, chronic kidney disease, cirrhosis, heart failure, COPD.
• Prior functional status (dependency).
• Cause of admission: sepsis (mortality 30-50%), polytrauma (10-20%), cardiac arrest (30-80%), severe ARDS (40-60%).
• Time to management: the earlier the support, the better the prognosis.

Therapeutic Limitations and Palliative Care in Intensive Care

In cases of a life-threatening prognosis with no reasonable chance of recovery (persistent vegetative state, irreversible multiorgan failure), a limitation of active treatments may be discussed by the team (intensivists, specialists, nurses) and with relatives (end-of-life law). Decisions include: DNR, stopping vasopressors, stopping mechanical ventilation, stopping renal replacement therapy, palliative care (sedation, analgesics, comfort). In Tunisia, these decisions follow international ethical recommendations.

What to Do After Intensive Care? Post-Intensive Care Rehabilitation

Discharge from intensive care (duration from a few days to several months) is followed by a phase of post-intensive care rehabilitation (Post-Intensive Care Syndrome - PICS):

• Intensive physical therapy: restoration of muscle strength (acquired weakness 30-50%), gait retraining, balance.
• Speech therapy / neuropsychology: cognitive rehabilitation (memory, attention, executive functions, language), swallowing rehabilitation (aspiration).
• Occupational therapy: relearning activities of daily living, home adaptation.
• Psychologist / Psychiatrist: post-traumatic stress disorder (30-50%), anxiety, depression, behavioral disorders.
• Specialized follow-up: cardiology (heart failure), pulmonology (COPD, ARDS sequelae), nephrology (chronic kidney disease), neurology (stroke, TBI sequelae).
• Social worker: return to work, disability support, financial aid, orientation to rehabilitation facilities.

Why Choose Tunisia for the Management of Patients with a Life-Threatening Prognosis?

Tunisia has intensivists trained in the best European centers (Paris, Lyon, Marseille, Lille, Geneva, Brussels). Intensive care units (university hospitals and private clinics) are modern: invasive monitoring (arterial, central, Swan-Ganz catheters), latest generation ventilators (Dräger, Hamilton, Maquet), continuous hemofiltration machines (Prismaflex, MultiFiltrate), high-resolution ultrasound machines, ECMO capability (venovenous and venoarterial) in university hospitals.

Advantages of Tunisia:

• Compliance with international guidelines (SRLF, ESICM, Surviving Sepsis Campaign, ERC, ATLS).
• 24/7 medical, surgical, neurosurgical, cardiac intensive care available.
• Nurse-to-patient ratio compliant with international standards (1 nurse for 2-3 patients in intensive care, sometimes 1:1 for ECMO, CVVHDF, severe instability).
• All-inclusive packages: our packages include ICU hospitalization, invasive monitoring, mechanical ventilation, sedation, vasopressors/inotropes, hemofiltration (if necessary), enteral nutrition, daily laboratory tests, imaging (ultrasound, X-ray, CT scan), and the start of early rehabilitation.
• Management of foreign patients: simplified administrative procedures, coordination with international insurance companies, multilingual reception (French, English, Arabic, Italian).

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