Recommendations for sepsis management in resource-limited settings

Abstract

PurposeTo provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis.MethodsThe medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings.ResultsRecommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included.ConclusionOnly scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-012-2468-5) contains supplementary material, which is available to authorized users.

Sepsis guidelines: Suggestions to improve adherence

“…For instance, the characteristics of the guidelines may render it impractical to implement -in some cases they are too detailed, while in others they may suggest the use of resources such as laboratory tests, methods of monitoring and treatment options that are not available locally. 2,5,6 Local factors such as lack of time, lack of resources, lack of reimbursement and organizational constraints may also preclude adoption of guidelines. For instance, in areas where there are critical staff shortages, it is unreasonable to place increased burdens such as frequent monitoring and documentation, which may be the standard of care in areas with substantially more resources.…”

“…Such guidelines for adults and children in resource poor areas have also been proposed by the Global Intensive Care Working Group of the European Society of Intensive Care. 2 While those efforts are laudable, adherence to these guidelines has met with suboptimal results (adherence rates of 0e30%) in both resource poor and rich regions. Therefore, while resources to implement guidelines are important, other factors beyond resources also limit successful adoption.…”

Nursing intensive care skills training: A nurse led, short, structured, and practical training program, developed and tested in a resource-limited setting

“…Our course was structured around a framework developed by Welch [12]. Training material was adapted to the target setting (eg, sepsis management in resourcelimited environments [13]) where necessary. The course combined short didactic sessions with small group workshops and skills stations and was conducted entirely in English.…”

Patient safety without borders: measuring the global burden of adverse events

“…As counterintuitive as it may seem, a short trial of intensive care will become more feasible and cost effective in LMICs. Contributing factors include rapid urbanisation (driving the burden of infections32 but also making hospital care more accessible) and knowledge translation programs for sepsis33 34 and obstetrical care 35…”