Recommendations for sepsis management in resource-limited settings

Dita Aditianingsih Department of Anesthesia and Intensive Care FKUI RSCM

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

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

Introduction
Infection and sepsis leading cause of death worldwide The Surviving Sepsis Campaign in 2004 and 2008 , released guidelines for severe and septic shock management. Implementation guideline + timely administration essential therapies improve management and outcome

Becker JU, et all. (2009)Surviving sepsis in low-income and middle-income countries: new directions for care and research. Lancet Infect Dis 9:577-582. World Health Organization. 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

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-, middleand low income countries

Working group Articles, the latest sepsis guidelines, textbooks, 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, expert opinion, 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

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

Diagnostic criteria for sepsis

Proven or highly suspected infection
The Surviving Sepsis Campaign
General variables Fever (>38,3C) Hypothermia (core temperature <36C) Heart rate >90min-1 or >2 SD above the normal Tacypnea

Recommendations in resource-limited settings

General variables Fever (>38,3C) Hypothermia (core temperature <36C) 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>12.000L-1) Leukopenia (WBC count <4000L-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>12.000L-1) Leukopenia (WBC count <4000L-1) Normal WBC count with >10% immature forms

Hemodynamic variables Arterial hypotension (SBP <90mmHg; MAP <70mmHg; or an SBP decrease >40mmHg in adults or <2 SD below normal

Hemodynamic variables Arterial hypotension (SBP <90mmHg; MAP <70mmHg; or an SBP decrease >40mmHg in adults or <2 SD below normal

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

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, wheezing, crepitations, unability to talk sentences) Acute oliguria (urine output<0,5ml/kg hr or 45 mmol/L for at least 2 hrs, despite adequate fluid resuscitation Ileus (absent bowel sounds) Petechiae or ecchymoses Bleeding/oozing from puncture sites Jaundice

Acute oliguria (urine output<0,5ml/kg hr or 45 mmol/L for at least 2 hrs, despite adequate fluid resuscitation)
Creatinin increase >0,5 mg/dl or 44,2 mol/L Coagulation abnormalities (INR>1,5 or PTT>60 sec) Ileus (absent bowel sounds) Thrombocytopenia (platelet count <100.000 L-1 ) Hyperbilirubinemia (plasma total bilirubin >4mg/dL or 70 mol/L)

Tissue perfusion variables Decreased capillary refill or skin mottling Hyperlactatemia ([1 mmol/L) Arterial hypotension Systolic arterial blood pressure\90 mmHg; mean arterial blood pressure\70 mmHg; 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; mean arterial blood pressure\70 mmHg; or a systolic arterial blood pressure decrease[40 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

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

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, 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, should be simultaneouslyv

Antimicrobial Therapy Diagnosis

Source Control

Post-Acute Interventions

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, because invasive intervention has potential to harm

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 > 0,5 1 ml/kg/hour

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)

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, rifampicin, pyrazinamide, ethambutol 2 months Isoniazid, rifampicin 4 months

HIV/AIDS Bactrim 3 weeks for Pneumocystis jiroveci Steroid if hypoxemia Malnutrition : stepwise daily caloric intake, 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

Implementing current recommendations into clinical practice

Common interventions include reminders, dissemination of educational materials, audits and feedback. Multifaceted approaches typically involve daily application of checklists, educational outreach, a multidisciplinary approach

How About Indonesia?

Recomendation of Indonesian sepsis resuscitation and management bundle