Recommendations for sepsis management in resource-limited settings

Dita Aditianingsih Department of Anesthesia and Intensive Care FKUI –RSCM

2004 .Incidence (millions) of selected conditions by WHO region.

Incidence (millions) of selected conditions by WHO region. 2004 .

Lancet Infect Dis 9:577-582. released guidelines for severe and septic shock management.Introduction • Infection and sepsis – leading cause of death worldwide • The Surviving Sepsis Campaign in 2004 and 2008 . World Health Organization. Implementation guideline + timely administration essential therapies  improve management and outcome Becker JU. (2009)Surviving sepsis in low-income and middle-income countries: new directions for care and research. et all. The global burden of disease:2004 .

• Problem : Most items in this surviving sepsis campaign guideline cannot be implemented in most middle.or lowincome countries due to lacking resources .

• The recommendations were developed by the Global Intensive Care working group of the European Society of Intensive Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies to improve intensive care for critically ill patients in resource-limited settings .

personal libraries Literature review Based on survey data on the avaibility of resources to implement the SSC guideline and pediatric guideline in middle and low income countries Identify clinical evidence on sepsis management originating from resource-limited settings Scientific evidence. clinical experienced Not to replace the surviving sepsis campaign guideline but can be considered if the latter are impossible to implement due to resource constraints Conseptualized in summer 2010 at The 23rd ESICM congrss in Barcelona/Spain and 31st ISICEM in Brussels/Belgium . middleand low income countries Working group Articles.The global intensive care working group of the european society of intensive care medicine + The world federation of pediatric intensive and critical care societies Critical care physicians + nurses from high-. expert opinion. textbooks. the latest sepsis guidelines.

SEPSIS .

The Surviving Sepsis Campaign The sepsis continuum Infection Sepsis Severe sepsis Shock sepsis • General variables • Inflammatory variables • Hemodynamic variables • Organ dysfunction variables • Tissue perfusion variables • Refractory hypotension .

000µL-1) Leukopenia (WBC count <4000µL-1) Normal WBC count with >10% immature forms Hemodynamic variables Arterial hypotension (SBP <90mmHg.3⁰C) Hypothermia (core temperature <36⁰C) Heart rate >90min-1 or >2 SD above the normal Tacypnea Recommendations in resource-limited settings General variables Fever (>38. MAP <70mmHg. MAP <70mmHg. or an SBP decrease >40mmHg in adults or <2 SD below normal Hemodynamic variables Arterial hypotension (SBP <90mmHg. or an SBP decrease >40mmHg in adults or <2 SD below normal .000µL-1) Leukopenia (WBC count <4000µL-1) Normal WBC count with >10% immature forms Plasma C-reactive protein >2 SD above the normal value Plasma procalcitonin >2 SD above the normal value Inflammatory variables Leukocytosis (WBC count>12.3⁰C) Hypothermia (core temperature <36⁰C) Heart rate >90min-1 or >2 SD above the normal value Tacypnea Altered mental status Altered mental status Significant edema or positive fluid balance (>20mL/kg over 24 hrs) Hyperglicemia (plasma glucoe >140mg/dl in the absence of diabetes Inflammatory variables Leukocytosis (WBC count>12.Diagnostic criteria for sepsis • Proven or highly suspected infection The Surviving Sepsis Campaign General variables Fever (>38.

The Survival Sepsis Campaign The sepsis continuum Infection Sepsis Severe sepsis Shock sepsis • General variables • Inflammatory variables • Hemodynamic variables • Organ dysfunction variables • Tissue perfusion variables • Refractory hypotension .

2 µmol/L Coagulation abnormalities (INR>1. or a systolic arterial blood pressure decrease[40 mmHg . despite adequate fluid resuscitation) Creatinin increase >0. crepitations.Diagnostic criteria for severe sepsis • Sepsis The Surviving Sepsis Campaign Organ dysfunction variables Arterial hypoxemia (PaO2/FiO2 <300) Recommendations in resource-limited settings Organ dysfunction variables SpO2<90% with or without oxygen central cyanosis Signs of respiratory distress (dyspnoe.5ml/kg hr or 45 mmol/L for at least 2 hrs.5ml/kg hr or 45 mmol/L for at least 2 hrs. mean arterial blood pressure\70 mmHg. mean arterial blood pressure\70 mmHg.000 µL-1 ) Hyperbilirubinemia (plasma total bilirubin >4mg/dL or 70 µmol/L) Tissue perfusion variables Decreased capillary refill or skin mottling Hyperlactatemia ([1 mmol/L) Arterial hypotension Systolic arterial blood pressure\90 mmHg.5 or PTT>60 sec) Ileus (absent bowel sounds) Thrombocytopenia (platelet count <100. wheezing. despite adequate fluid resuscitation Ileus (absent bowel sounds) Petechiae or ecchymoses Bleeding/oozing from puncture sites Jaundice Acute oliguria (urine output<0.5 mg/dl or 44. unability to talk sentences) Acute oliguria (urine output<0. or a systolic arterial blood pressure decrease[40 mmHg Tissue perfusion variables Decreased capillary refill or skin mottling Peripheral cyanosis Arterial hypotension Systolic arterial blood pressure\90 mmHg.

The Surviving Sepsis Campaign The sepsis continuum Infection Sepsis Severe sepsis Shock sepsis • General variables • Inflammatory variables • Hemodynamic variables • Organ dysfunction variables • Tissue perfusion variables • Refractory hypotension .

Diagnostic criteria for septic shock The Surviving Sepsis Campaign Recommendations in resource-limited settings Sepsis induced arterial hypotension despite adequate fluid resuscitation (note that patients on inotropics or vasopressors may not be hypotensive despite of presence of shock) and signs of tissue hypoperfusion Sepsis induced arterial hypotension despite adequate fluid resuscitation (note that patients on inotropics or vasopressors may not be hypotensive despite of presence of shock) and signs of tissue hypoperfusion .

or lowincome countries due to lacking resources .• Problem : Most items in this surviving sepsis campaign guideline cannot be implemented in most middle.

should be simultaneouslyv Antimicrobial Therapy Diagnosis Source Control Post-Acute Interventions . dopamine with hydrocortisone (300mg/day) or prenisolon 75mg/day if hypoperfussion persist -Keep airway clear -Oxygen for SaO2 > 90 -Semirecumbent -NIV -Culture before antimicrobial -Antimicrobial IV within 1 hour with adequate doses -History. head to toe examination -Imaging if available -Specimen culture -Culture before antimicrobial -Antimicrobial IV within 1 hour in adequate doses Circulation Ventilation Acute Intervention Depends on patient condition. interventions.Recommendations in resource-limited settings Management of severe sepsis and septic shock Pro-active search for signs of sepsis Sign of sepsis 6 hours after admision -Achieve adequate tissue perfussion .Epinephrine.

because invasive intervention has potential to harm .Recommendations in resource-limited settings Management of severe sepsis and septic shock Post-Acute Interventions Antimicrobial therapy • Reasses effectiveness therapy regularly • Administer adequate doses but not prolonged time Glucose Control • Check regularly • Maintain blood glucose > 70 mg/dl Deep Vein Thrombosis • Prophylactic Heparin or elastic bandage for adult patients • No need in children Enteral Nutrition and Stress Ulcer Prophylaxis Sedation and Analgesic • Opioid in stable patient • Sedate agitated. uncooperative patient • Early mobilzation Wean Invasive Support • As soon as possible the patient improving.

5 – 1 ml/kg/hour .Target : Adequate Tissue Perfussion Clinical indicators of adequate tissue hypoperfusion • Normal capillary refill time • Absence of skin mottling • Warm and dry extremities • Well felt peripheral pulses (eg radial or dorsalis pedis pulses) • Return to baseline mental status before sepsis onset • Urine output > 0.

Common causes for treatment failure in sepsis in resource-limited settings • Inadequate empirical anti-infective therapy • Missed or insufficient control • Insufficient supportive therapy (suboptimal fluid resuscitation) • Development of new antimicrobial resistance • Occurrence of a new hospital-acquired infection • Clinical symptomps are due to other disease than sepsis .

Suggested therapies to be avoided in the septic patient (level of evidence: D) .

pyrazinamide. rifampicin 4 months HIV/AIDS • Bactrim 3 weeks for Pneumocystis jiroveci • Steroid if hypoxemia • Malnutrition : stepwise daily caloric intake. rifampicin.Management of sepsis due to specific causes Malaria • In children parenteral antibiotics should be given in addition to antimalarial therapy • Early empirical and adequate antimicrobial therapy • Blood tranfusion if Hb<6 gr/dl Tuberculosis • Initiation isoniazide. ethambutol 2 months • Isoniazid. avoid large carbohydrate (refeeding syndrome) .

Suggested care bundles for sepsis management in resource-limited settings Acute Care Bundle • Oxygen therapy • Fluid Resuscitation • Early and adequate antimicrobial therapy Post-Acute Care Bundle • Reevaluation of antimicrobial therapy • Deep vein thrombosis prophylaxis • Glucose control • Weaning of invasive support .

a multidisciplinary approach . audits and feedback. dissemination of educational materials. • Multifaceted approaches typically involve daily application of checklists. educational outreach.Implementing current recommendations into clinical practice • Common interventions include reminders.

How About Indonesia? Recomendation of Indonesian sepsis resuscitation and management bundle .

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