Résumé
La question de l’admission en réanimation de patients atteints de pathologies neurodégénératives se pose de plus en plus fréquemment. C’est le cas de la maladie de Parkinson. Dans cette pathologie, la fréquence d’hospitalisation est en effet plus élevée que dans la population générale, en raison de survenue de pneumopathies infectieuses, d’infections urinaires ou de traumatismes liés aux chutes. Ces complications peuvent conduire à une admission en réanimation; mais les données concernant les conditions d’hospitalisation en réanimation et le pronostic spécifique des patients parkinsoniens sont peu nombreuses. Les facteurs associés à une réduction de la survie et à une altération de la qualité de vie qui doivent guider la décision d’admission sont la présence de troubles cognitifs et les chutes récurrentes. La durée d’évolution, l’âge de début et la gravité apparente des symptômes moteurs à l’admission semblent moins pertinents. L’intubation orotrachéale et le sevrage ventilatoire peuvent être difficiles du fait de l’hypertonie axiale et des troubles respiratoires centraux. Les traitements antiparkinsoniens ne doivent pas être interrompus devant le risque d’un syndrome de sevrage. Le traitement médicamenteux doit donc être adapté : l’utilisation de L-Dopa sous forme dispersible, d’agonistes dopaminergiques par voie transdermique ou sous-cutanée sont des alternatives en cas de troubles de déglutition ou de conscience. La stimulation cérébrale profonde ne doit pas être arrêtée sauf nécessité absolue. Le respect de ces règles permettrait d’éviter des limitations de thérapeutiques actives non justifiées, de raccourcir la durée de ventilation et d’améliorer le pronostic moteur au décours du séjour en réanimation chez les patients parkinsoniens.
Abstract
Improvement of quality of care in neurodegenerative diseases like Parkinson’s disease (PD) explains why the rate of admission in the intensive care unit (ICU) of patients with chronic neurological impairments has increased. In PD patients, hospital admissions in relation to aspiration pneumonia, urinary infections or fall-induced injuries is higher than in the general population. Such conditions represent possible causes of ICU admission. However, guidelines regarding ICU admission and specific aspects of care in PD patients are lacking. The main factors associated with reduced survival and altered quality of life, that should be taken into account for the decision of ICU admission are the occurrence of recurrent falls and cognitive deficits. In the ICU, care of PD patients is characterized by specific issues: orotracheal intubation and weaning from mechanical ventilation may be difficult due to axial hypertonia and central respiratory disorders. Antiparkinsonian treatments should not be stopped at any time due to the risk of withdrawal syndrome. Alternative strategies for dopaminergic drugs administration in case of swallowing deficits or altered consciousness include L-Dopa administered by enteral tubes and dopamine agonists by transdermal patches or subcutaneous infusion. Compliance to these specific rules for PD patients in the ICU could help avoiding unjustified restrictions of care, reducing ventilation duration, and improving the final motor outcome after ICU discharge.
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Gombert, C., Nadjar, Y. & Grabli, D. Maladie de Parkinson et réanimation : des problèmes spécifiques ?. Réanimation 22, 616–623 (2013). https://doi.org/10.1007/s13546-013-0722-7
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DOI: https://doi.org/10.1007/s13546-013-0722-7