Endorsed by Global Sepsis Alliance
Madiha Hashmi1*, Fazal Hameed Khan1, Ali bin Sarwar Zubairi1, S. Tipu Sultan2, Saeeda Haider3 Sadqa Aftab4, Javed Husain5, Anwar ul Haq1, Zahid Akhtar Rao6, Amin Khuwaja7, Syed Farjad Sultan3, Zunairah Rais8, Roohina Baloch9, Naseem Salahuddin3, Aslam Khan10, Faisal Sultan11, Kamran Chima12, Amjad Ali13, Gohar Ali14; Pakistan Society of Critical Care Medicine; Pakistan Society of Anaesthesiologists; Medical Microbiology & Infectious Diseases Society of Pakistan and Pakistan Chest Society.
1Aga Khan University, Karachi
2Sind Institute of Urology and Transplant, Karachi
3The Indus Hospital, Karachi
4Dow University of Health Sciences and Civil Hospital, Karachi
5South City Hospital, Karachi
6PNS Shifa Hospital, Karachi
7National Institute of Cardiovascular Diseases, Karachi
8Liaquat National Hospital, Karachi
9Jinnah Post Graduate Medical Center, Karachi
10Military Hospital, Rawalpindi
11Shaukat Khanum Memorial Hospital and Research Center, Lahore
12 Services Institute of Medical Sciences, Lahore
13Bolan Medical College, Quetta
14Lady Readings Hospital, Peshawar
*Correspondence: Madiha Hashmi, President PSCCM, Director SICU and Assistant Professor
Department of Anaesthesiology, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800 (Pakistan); E-mail: hashmi_madiha@yahoo.ie
ABSTRACT
Background: The purpose of developing ‘Sepsis Guidelines for Pakistan’ (SGP) is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of Surviving Sepsis Campaign (SSC) tailored to available resources. These recommendations are not meant to replace the SSC Guidelines.
Methodology: SGP is an initiative of Pakistan Society of Critical Care Medicine (PSCCM). Four key decision points to be addressed in the guidelines were identified by a thirteen member multidisciplinary committee i.e., grading the hospitals in the country, recognition of sepsis and associated organ dysfunction, essential interventions to manage sepsis, and general measures for provision of a comprehensive care to patients in sepsis according to the level of education and training of healthcare providers and facilities and resources available in different levels of hospitals. The draft was presented at the 3rd Sepsis Symposium held on 13th September, 2014 in Karachi. The final document was approved by a panel of experts from across the country, representatives of relevant societies and Global Sepsis Alliance (GSA).
Recommendations: Hospitals are divided into basic, intermediate and tertiary depending on the availability of diagnostic facilities and training of the medical personnel. Modified definitions of sepsis, severe sepsis, and septic shock are used given the lack of facilities to diagnose sepsis according to international definitionsand criteria in Pakistan. Essential interventions include fluid resuscitation, vasopressors to support the circulation, maintaining oxygen saturation ≥ 90% with oxygen, non-invasive ventilation or mechanical ventilation with lung protective strategies, prompt administration of antibiotics as recommended by the Medical Microbiology & Infectious Diseases Society of Pakistan (MMIDSP) and early source control. It is recommended to avoid starvation, keep an upper blood glucose ≤180 mg/dL, use daily pharmacoprophylaxis against venous thromboembolism (VTE), use stress ulcer prophylaxis, target haemoglobin of 7-9 g/dl in the absence of ischaemic heart disease, avoid sodium bicarbonate therapy as long as pH > 7.20, avoid fresh frozen plasma in the absence of bleeding, transfuse platelets if indicated, not use intravenous immunoglobulins and avoid neuromuscular blocking agents (NMBAs) in the absence of ARDS, target specific titration endpoints when continuous or intermittent sedation is required in mechanically ventilated patients and use continuous renal replacement therapy (CRRT) to facilitate management of fluid balance in hemodynamically unstable septic patients in tertiary care centers. In addition a comprehensive, meticulous and multidisciplinary general care is required to improve outcome of sepsis by reinforcing hand hygiene and other infection control measures, adequate monitoring and documentation tailored to the available resources. Goals of care and prognosis should be discussed with patients and families early and either shifting the patient to a hospital with better facilities or limiting or withdrawing therapy in case of poor prognosis should be considered.
Key words:Sepsis syndrome; Septic shock; Hypotension; Sepsis
Citation: Hashmi M, KhanFH, Zubairi ABS, Sultan ST, Haider S, Aftab S, Husain J, Haq AU, Rao ZA, Khuwaja A, Sultan SF, Rais Z, Baloch R, Salahuddin N, Khan A, Sultan F, Chima K, Ali A, Ali G; Pakistan Society of Critical Care Medicine; Pakistan Society of Anaesthesiologists; Medical Microbiology & Infectious Diseases Society of Pakistan; Pakistan Chest Society. Pakistan Society of Critical Care Medicine: Developing local guidelines for management of sepsis in adults: Sepsis Guidelines for Pakistan (SGP). Anaesth Pain & Intensive Care 2015;19(2):196-208
- INTRODUCTION
The Surviving Sepsis Campaign (SSC)1 Guidelines provide a framework for clinical decisions in the management of severe sepsis and septic shock.Despite their obvious benefits2,3, the SSC guidelines have not been fully implemented in low and middle income countries (LMIC) due to lack of awareness, limited resources, financial constraints and a wide variation in the available healthcare facilities within most of the countries falling in the LMIC category4,5,6,7. Even in Pakistan the healthcare facilities range from well-equipped urban university hospitals to small hospitals lacking qualified medical personnel or basic life-saving equipment.
Most of the interventions in the resuscitation and treatment bundles recommended by SSC are independent therapies based on evidence and inability to comply with the full ‘bundle’ should not prevent the healthcare workers from implementing part of the ‘bundle’. The purpose of developing ‘Sepsis Guidelines for Pakistan’ is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of SSC tailored to available resources. These recommendations are not meant to replace the SSC Guidelines.
The ultimate goal of developing Sepsis Guidelines for Pakistan is to reduce the unacceptable and undesirable variation in practice of healthcare professionals from different disciplines and different healthcare set ups and to improve sepsis outcomes.
- METHODOLOGY
Sepsis Guidelines for Pakistan (SGP) is an initiative of Pakistan Society of Critical Care Medicine (PSCCM). The executive committee of PSCCM (Karachi Chapter) convened in 2014 and formed a multidisciplinary committee of physicians managing critically ill patients in teaching and non-teaching hospitals of Karachi in both government and private healthcare setup. The thirteen member committee consisted of eight anaesthesiologists, three pulmonary and critical care physicians, one full time intensivist, and one paediatric intensivist- all heading the intensive care units in their respective hospitals. No external funding was used and none of the authors had any financial conflict of interest in drugs or techniques discussed in the manuscript.
The task of the committee was to recommend interventions to recognize sepsis and associated organ dysfunction and to institute essential therapies according to available resources targeting all healthcare workers entrusted with the care of adult patients in sepsis.
Step 1: Key decision points:
Based on informal consensus discussions amongst the members of the committee, following key decision points to be addressed in the guidelines were identified;
- Grading the hospitals in the country
- Recognition of sepsis and associated organ dysfunction according to the level of education and training of healthcare providers and diagnostic facilities available in different levels of healthcare setup.
- Essential interventions to manage sepsis according to facilities and resources available in different levels of healthcare setup.
- General measures for provision of comprehensive care to patients in sepsis according to facilities and resources available in different levels of healthcare setup.
Step 2: Literature and evidence:
Expert opinion and clinical experience of the authors working in hospitals with a wide variation in available resources was considered to grade the healthcare facilities in three categories. Interventions to address rest of the key decision points were based on 2012 Surviving Sepsis Campaignguidelines for the management of severe sepsis and septic shock1 and relevant literature for implementing these guidelines in resource poor settings was reviewed. Five articles on sepsis management from resource-limited settings were selected by consensus8,9,10,11,12 from a reference list prepared by conducting a structured literature review using the key words sepsis, management, resource-limited, resource poor and low-middle income countries. The coordinator of the committee circulated the key background material electronically to all members of the committee. A list of all possible interventions recommended in these articles was prepared. Feasibility of each intervention was debated in view of availability of resources and training of medical personnel in different healthcare facilities and accepted, rejected or modified based on the majority vote of the members of the committee. If an intervention was accepted as recommended by SSC, the original assessment of quality of evidence and strength of recommendations was quoted. None of the committee members were trained in application of Grading of Recommendations Assessment, Development and Evaluation (GRADE) system so in case an intervention was modified we did not use the GRADE system but mentioned that the recommendation was based on ‘consensus opinion’.
Quality of evidence |
|
A |
High |
B |
Moderate |
C |
Low |
D |
Very Low |
UG |
Ungraded |
Strength of Recommendations |
|
Grade 1 |
Strong |
Grade 2 |
Weak |
Step 3: Drafting the Document:
The chairman of the SGP Committee prepared a draft of the proposed guidelines and circulated amongst the members of the committee. In-person discussions were held at the PSCCM monthly meetings to improve the draft. Disagreements amongst the members were resolved by adopting a consensus process. The draft was approved by all committee members and was presented in 3rd Sepsis Symposium held on 13th September, 2014 at Avari Hotel, in Karachi to commemorate the 3rd World Sepsis Day. Comments from audience and input from the founding member of MMIDSP were incorporated by the Chairman of the committee. The document was then reviewed by outside-committee experts from rest of the provinces of Pakistan, i.e. Punjab, Baluchistan, and Khyber Pakhtunkhwa. Guidelines were also presented in a tabulated format for easy retrieval and assimilation of information applicable to the various grades of the existing healthcare facilities.
Step 4: Dissemination Plan:
Multifaceted interventions will be utilized to disseminate and implement the guidelines. Anaesthesiologists are the backbone of critical care in Pakistan, supported by pulmonary and critical care physicians. The guidelines will be propagated from the platform of Pakistan Society of Critical Care Medicine (PSCCM), Pakistan Society of Anaesthesiologists (PSA), Infectious Diseases Society of Pakistan (IDSP) and Pakistan Chest Society (PCS) in the form of presentations in the respective annual conferences. Posters based on a flow-chart format will be created for dissemination.
- RECOMMENDATIONS
- Grading the Hospitals according to available resources:
- BASIC: Hospitals that have no intensive care unit backup and where only general physicians are available as medical personnel. These have access to outsourced laboratory facilities but there are no on-site radiological diagnostic facilities.
- INTERMEDIATE: Hospitals with level-2 intensive care units that are managed by non-intensivist medical personnel. These have access to in-house basic laboratory and diagnostic radiological facilities.
- TERTIARY: Hospitals with level-3 intensive care units, that are managed by physicians trained in intensive care medicine. These have access to advanced laboratory and diagnostic radiological facilities.
This grading is arbitrary and there will be hospitals that fall in-between the above mentioned categories. The aim of providing this framework is to allow the users to acknowledge the resources available in their hospitals. The available resources should be utilized to recognize sepsis, severity of organ dysfunction and the most likely source of infection and to provide essential interventions to manage sepsis or consider transfer to another hospital with better facilities.
- Recognition of sepsis and associated organ dysfunction (Table 1):
Recognizing a patient in sepsis is an essential step for effective treatment. A delay in diagnosis results in progression of sepsis and decreases chances of survival. Modified definitions of sepsis severe sepsis, and septic shock have to be applied given the lack of facilities to diagnose sepsis according to international definitions13 and criteria in Pakistan.
a. SEPSIS:
Sepsis is defined as proven or highly suspected infection associated with some of the following conditions:
- Altered mental state/confusion
- Temperature ≥38°C or ≤ 36°C
- Heart rate ≥90 bpm
- Respiratory rate ≥ 20 bpm or PaCO2 ≤ 32 mmHg
- WBC ≤ 4000 /mm3or ≥ 12000/mm3 or ≥ 10% immature forms
- Thrombocytopenia (platelet count, ≤ 100,000/mm3)
- Hyperglycemia (plasma glucose > 140 mg/dL in the absence of diabetes)
b. SEVERE SEPSIS:
When ‘sepsis’ leads to tissue hypoperfusion or organ dysfunction it becomes ‘severe sepsis’.
i. TISSUE HYPOPERFUSION
- Systolic blood pressure ≤ 90 mmHg or a systolic blood pressure decrease ≥40 mmHg from the baseline or mean arterial pressure (MAP) ≤ 65 mmHg.
- Decreased capillary refill or skin mottling
ii. ORGAN DYSFUNCTION:
a) Pulmonary dysfunction:
- Signs of respiratory distress (i.e., dyspnea, added sounds on auscultation, cough, sputum)
- Arterial Hypoxaemia (PaO2/FiO2 ≤ 300)
b) Renal dysfunction
- Acute oliguria (urine output ≤ 0.5 ml/kg/h for at least 2 h despite adequate fluid resuscitation)
- Creatinine increase ≥ 0.5 mg/dL
c) Hepatic dysfunction
- Jaundice
- Hyperbilirubinaemia (plasma total bilirubin ≥ 4 mg/dl)
d) Coagulation dysfunction
- Petechae or ecchymosis
- Bleeding/oozing from puncture sites
- Coagulation abnormalities (INR ≥1.5 or aPTT ≥ 60 s)
e) Gastrointestinal dysfunction
- Ileus (absent bowel sounds)
c. SEPTIC SHOCK
When sepsis-induced hypotension or signs of tissue hypoperfusion persist despite adequate fluid resuscitation, the condition is labeled as ‘septic shock’.
3. Essential interventions (Table 2):
Essential interventions refer to treatments recommended to be administered without delay to maintain a near normal physiology. The compromised organ systems need support while identification of source of sepsis and its control is of paramount importance. Although these essential interventions are presented in a certain order, they may have to be performed simultaneously, depending on the condition of the patient.
a. Circulation
- Fluid resuscitation in patients with sepsis induced tissue hypoperfusion or organ dysfunction is the corner stone of sepsis management. Initial fluid challenge of a minimum of 20-30 ml/kg should be followed by continuous infusion for 24–48 h, though a more rapid administration and larger volume of fluid may be needed in some patients (grade 1C). Use of crystalloids is strongly recommended (LoE: 1B) because synthetic colloids have shown to precipitate acute kidney injury and should be avoided (LoE: 1B). Albumen can be used if excessive fluid requirement has a risk of aggravating tissue or pulmonary oedema or precipitating abdominal compartment syndrome (LoE: 2C).
- In the basic setup, the clinicians should target an improvement in pulse volume, capillary re-fill, level of consciousness, urine output and a systolic arterial blood pressure > 90 mmHg, while frequently auscultating the chest for any sign of fluid overload (consensus opinion). If resources are available target for a mean arterial pressure (MAP) > 65 mmHg, CVP 8-12 mmHg, and urine output > 0.5 ml/kg/hr (LoE: 1C). In tertiary care hospitals target for ScvO2 more than 70% and to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (LoE: 2C).
- Use of vasopressors is recommended in patients with persistent hypotension (MAP < 65) despite initiating fluid resuscitation (LoE: 1C). Norepinephrine is the vasopressor of choice (LoE: 1B) but dopamine can be used in selected patients in whom risk of tachyarrhythmias is low or they have absolute or relative bradycardia (LoE: 2C) or if norepinephrine is not available (consensus opinion). Epinephrine worsens metabolic acidosis and should be used in septic patients only when an additional agent is needed to maintain adequate blood pressure (grade 2B). Vasopressin at a rate of 0.03 units/minute can be added to norepinephrine (NE) to raise MAP or decrease NE dosage (UG), when available in a tertiary care setup. In patients requiring vasopressors, central access should be taken safely and invasive arterial blood pressure measured continuously (consensus opinion).
- Intravenous hydrocortisone (50 mg every six hours) should be administered if haemodynamic targets are not met with adequate fluid resuscitation and dose requirement of vasopressors rapidly escalates (LoE: 2C).
b. Ventilation:
- Oxygen saturation should be kept ≥ 90%. If pulse oximeter is not available patients with severe sepsis or septic shock should be given oxygen empirically (consensus opinion). If hypoxaemia persists despite oxygen therapy, use of non-invasive ventilation (NIV) is recommended, provided medical staff is adequately trained in its use (LoE: 2B) and patient is awake and able to clear and protect the airway. However a low threshold for endotracheal intubation should be maintained.
- For mechanical ventilation of patients with sepsis induced ARDS, lung protective strategies should be used i.e. a tidal volume of 6-8 ml/kg of predicted body weight (LoE: 1A), adequate PEEP to avoid alveolar collapse (LoE: 1B) and measuring and keeping plateau pressure < 30 mmHg (LoE: 1B). Mechanically ventilated patients should be placed in a semi-recumbent position (head of the bed raised to 30–45°) to reduce the risk of aspiration and ventilator-induced pneumonia, unless contraindicated (LoE: 1B).
- Lung recruitment maneuvers and prone positioning is recommended to manage severe hypoxaemia (PaO2 /FiO2 <100), in tertiary care setup, according to the hospital protocols (LoE: 2C).
c. Antimicrobial therapy
Prompt administration of appropriate intravenous antimicrobials to cover the most likely infection should be the goal of therapy.
- MMIDSP Recommendations before selecting empirical antibiotic therapy:
- Selection of antibiotic must be based on clinical assessment of site of infection
- Viraemia, severe malaria or fungaemia must be considered as possible causes of sepsis
- Antibiotics must be administered as soon as possible, within 2 hours of admission to ER or ICU
- Two sets of blood cultures, urine analysis and urine culture must be drawn prior to institution of antibiotic
- Obtain history of previous use of antibiotics in past 3 months. Avoid same antibiotic if possible
- Dose must be prescribed on weight basis
- Dose must be adjusted for renal or hepatic insufficiency
- Hematologic malignancy or febrile neutropenia must be considered
- Combination therapy may be prescribed for suspected highly resistant pathogens
- Only intravenous antibiotic should be used until there is clinical improvement
2. MMIDSP Recommendations during antibiotic therapy:
- Once culture and sensitivity reports are available, de-escalate to a narrower spectrum antibiotic
- Once patient shows clinical improvement and is stable, de-escalate to oral preparation, if an equally effective oral preparation is available
- Antibiotic should be given for no longer than 7-10 days
- Source control is essential, i.e. drainage of abscess, repair or resection of perforated viscus, removal of cannula, catheter or devices and debridement of infected tissue.
d. Source control
- A detailed history of illness from the patients or the relatives along with a thorough clinical examination is essential to identify the likely source of infection.
- Appropriate imaging techniques should be utilized for specific anatomical diagnosis of infection and surgical and interventional radiology expertise sought as early as feasible for source control.
- Implants, devices, or central lines should be removed if suspected to be the source of infection.
- Use of oral chlorhexidine gluconate should be promoted in mechanically ventilated patients in intermediate and tertiary care set up as a form of oropharyngeal decontamination to reduce the risk of ventilator-associated pneumonia (LoE: 2B).
e. Nutrition
Complete fasting should be avoided in septic patients and oral or tube-feeding should be started within the first 48 hours after a diagnosis of sepsis (LoE: 2C). Feed should be started with 500 calories per day and gradually advanced as tolerated (LoE:2B). Total parenteral nutrition (TPN) alone or to supplement enteral feeding is not recommended in the first 7 days of a severe infection (LoE: 2B).
f. Other measures
- Two consecutive blood glucose levels >200 mg/dL should prompt initiation of intravenous insulin infusion with an aim to keep an upper blood glucose ≤180 mg/dL Blood glucose values should be monitored frequently until glucose values and insulin infusion rate stabilizes. Intermediate and tertiary care hospitals should exercise a protocolised approach to blood glucose management in patients with severe sepsis (consensus opinion).
- Daily pharmacoprophylaxis against venous thromboembolism (VTE) is recommended according to the hospital policy (consensus opinion).
- When stress ulcer prophylaxis is indicated in patients with severe sepsis/septic shock due to the presence of bleeding risk factors, proton pump inhibitors should be preferred over H2 -receptor blockers (LoE: 2D).
- Sodium bicarbonate therapy should be used to improve hemodynamics or reduce vasopressor requirements only if there is life threatening lactic acidosis i.e. pH < 7.20 (consensus opinion).
- In the absence of bleeding and myocardial ischaemia target haemoglobin of 7-9 g/dl or 10 g/dl if there is a history of ischaemic heart disease (consensus opinion). Fresh Frozen Plasma should not be transfused in the absence of bleeding only to correct lab abnormalities. Transfuse platelets if <10,000/mm3 and no risk of bleeding, <20,000/mm3 if there is significant risk of bleeding and < 50,000/mm3 if bleeding continues, or patient going for surgery or invasive procedure.
- Intravenous immunoglobulins are not indicated in adult patients with severe sepsis or septic shock (LoE: 2B).
- Neuromuscular blocking agents (NMBAs) should be avoided if possible in the septic patient without ARDS. Target specific titration endpoints when continuous or intermittent sedation is required in mechanically ventilated patients (LoE: 1B)
- Renal replacement therapy may be required in patients with severe sepsis and acuterenal failure in tertiary care hospitals. Use of continuous therapies (CRRT) facilitates management of fluid balance in hemodynamically unstable septic patients (LoE: 2D).
- General considerations:
A comprehensive, meticulous and multidisciplinary general care is required in addition to therapies targeted at optimizing organ function and eradicating the source of infection in order to improve outcome of sepsis. The level of monitoring, documentation and investigations will depend upon the level of training of medical personnel and available resources. Hand hygiene and other infection control measures should be adopted enthusiastically. It is also important to discussgoals of care and prognosis with patients and families early and consider either shifting the patient to a hospital with better facilities or limit or withdraw therapy in case of poor prognosis.
D. CONCLUSION
A multidisciplinary national panel of experts developed consensus sepsis guidelines to streamline provision of uniform sepsis care and improve sepsis outcome. The guidelines provide a framework to identify sepsis and associated organ dysfunction in a timely manner and recommend essential interventions, taking into account the knowledge and training of medical personnel and resources available in various grades of hospitals in Pakistan.
E. ACKNOWLEDGEMENT
- Prof. Konrad Reinhart
Chairman Global Sepsis Alliance
Director Dep. for Anaesthesiology and Intensive Care
Jena University Hospital
Germany
- Niranjan Kissoon
Vice President Medical Affairs
BC Children’s Hospital and Sunny Hill Health Centre for Children
UBC & BC Children’s Hospital Professor in Critical Care – Global Child Health
Department of Pediatrics and Emergency Medicine, UBC
Vancouver, Canada
- Professor Flavia Machado
Chair of Anesthesiology, Pain and Intensive Care Department
Federal University of Sao Paulo
- Ron Daniels
Chief Executive- Global Sepsis Alliance
CEO- UK Sepsis Trust
Clinical Adviser (Sepsis) to NHS England
UK
- Professor Simon Finfer
Senior Staff Specialist in Intensive Care
Royal North Shore Hospital of Sydney and Sydney Adventist Hospital
Australia
TABLE 1: SEPSIS RECOGNITION
|
Basic setup |
Intermediate setup |
Tertiary care setup |
|
|
In addition
In addition
|
In addition
In addition;
|
WBC = white blood cells, INR = international normalized ratio, PaO2 = partial pressure of arterial oxygen
FiO2 = fractional inspired oxygen
TABLE 2:ESSENTIAL INTERVENTIONS
|
Basic setup |
Intermediate setup |
Tertiary care setup |
Circulation |
WARNING:
|
WARNING:
|
In addition
WARNING:
|
Ventilation |
|
WARNING: Use NIV only if patient is awake and able to clear secretions and protect airway |
In addition
|
*Antimicrobial therapy |
|
|
|
Source control |
|
In addition
WARNING: Consider removing |
In addition
WARNING: Promote use of oral chlorhexidine gluconate in ventilated patients as a form of oropharyngeal decontamination |
Nutrition |
|
WARNING: |
WARNING: |
Others |
|
WARNING:
|
WARNING:
|
MAP = mean arterial pressure, CVP = central venous pressure, NIV = non-invasive ventilation, CPAP = continuous positive airway pressure, BIPAP = Bilevel positive airway pressure, ABG = arterial blood gas, PBW = predicted body weight, PEEP = positive end-expiratory pressure, CT= computerized tomography, TPN = total parenteral nutrition, PPI = proton pump inhibitors, DVT = deep vein thrombosis, UFH = unfractionated heparin, LMWH = low molecular weight heparin, IHD = ischaemic heart disease, FFP = fresh frozen plasma, CRRT = continuous renal replacement therapy, HD = haemodialysis, ARDS = acute respiratory distress syndrome.
GENERAL CONSIDERATIONS
|
Basic setup |
Intermediate setup |
Tertiary care setup |
Hygiene |
|
|
|
Monitoring |
Clinically monitor pulse, blood pressure, temperature & mental state | In addition
|
In addition monitor invasive arterial blood pressure & CVP |
Documentation |
|
In addition document
|
In addition document
|
Investigations |
|
In addition
|
In addition
|
Multidisciplinary care |
Take opinion from medicine and surgery | Involve Anaesthesia Team | In addition involve critical care team
|
Estimate prognosis and limit therapy |
|
|
|
TPR = temperature, pulse rate, respiratory rate, BP = blood pressure, AVPU = awake, responds to verbal command, responds to painful stimulus, unresponsive, Hb = haemoglobin, Hct = haematocrit, RBS = random blood sugar, SaO2 = arterial oxygen saturation, ECG = electrocardiogram, GCS = Glasgow coma scale, UCE = urea-creatinine-electrolytes, LFT = liver function tests, CRP = C-reactive protein, SOFA-score = sequential organ failure assessment score, APACHE-score = acute physiology and chronic health evaluation score
REFERENCES
- Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637.
[PubMed] doi: 10.1097/CCM.0b013e31827e83af.
- Levy MM, Dellinger RP, TownsendSR, Linde-Zwirble WT, Marshall JC, Bion J, et al. The survivingsepsis campaign: results of aninternational guideline-basedperformance improvement programtargeting severe sepsis. Intensive CareMed 2010; 36: 222–231.
[PubMed][Free full text] doi: 10.1007/s00134-009-1738-3.
- Ferrer R, Artigas A, Levy MM, Blanco J, González-Díaz G, Garnacho-Montero J, et al. Improvement in process of care andoutcome after a multicenter severesepsis educational program in Spain.JAMA 2008; 299: 2294–2303
[PubMed][Free full text] doi: 10.1001/jama.299.19.2294.
- Baelani I, Jochberger S, Laimer T, Otieno D, Kabutu J, Wilson I, et al. Availability ofcritical care resources to treat patientswith severe sepsis or septic shock inAfrica: a self-reported, continent-widesurvey of anaesthesia providers. CritCare 2010;15(1):R10.
[PubMed][Free full text] doi: 10.1186/cc9410
- Bataar O, Lundeg G, Tsenddorj G, Jochberger S, Grander W, Baelani I, et al. Nationwide survey on resourceavailability for implementing currentsepsis guidelines in Mongolia. BullWorld Health Organ 2010; 88: 839–846.
[PubMed][Free full text] doi: 10.2471/BLT.10.077073.
- Kissoon N. Out of Africa—amother’s journey. Pediatr Crit CareMed 2011; 12:73-79
[PubMed] doi: 10.1097/PCC.0b013e3181ce74ef.
- Santhanam I, Kissoon N, Kamath SR,Ranjit S, Ramesh J, Shankar J. GAP between knowledge and skillsfor the implementation of the ACCM/PALS septic shock guidelines in India:is the bridge too far? Indian J Crit CareMed 2009; 13: 54–58.
[PubMed][Free full text] doi: 10.4103/0972-5229.56049.
- Dünser MW, Festic E, Dondorp A, Kissoon N, Ganbat T, Kwizera A, et al. Recommendations for sepsis management in resource-limited settings. Intensive Care Med 2012; 38: 557–574.
[PubMed][Free full text] doi: 10.1007/s00134-012-2468-5.
- Becker JU, Theodosis C, Jacob ST, Wira CR, Groce NE. Surviving sepsis in low-income and middle-income countries: new directions for care and research. Lancet Infect Dis 2009; 9: 577-82.
[PubMed] doi: 10.1016/S1473-3099(09)70135-5.
- Cheng AC, West TE, Limmathurotsakul D, Peacock SJ. Strategies to Reduce Mortality from Bacterial Sepsis in Adults in Developing Countries. PLoS Med 2008;5(8):e175
[PubMed][Free full text] doi: 10.1371/journal.pmed.0050175.
- Jacob ST, Lim M, Banura P, Bhagwanjee S, Bhagwanjee S, Bion J, Cheng AC, et al. Integrating sepsis management recommendations into clinical care guidelines for district hospitals in resource-limited settings: the necessity to augment new guidelines with future research. BMC Med 2013;11:107.
[PubMed][Free full text] doi: 10.1186/1741-7015-11-107.
- Kissoon N. Sepsis Guideline implementation: benefits, pitfalls and possible solutions. Crit care 2014;18:207.
[PubMed][Free full text] doi: 10.1186/cc13774.
- American College of Chest Physicians/Society of Critical CareMedicine Consensus Conference. Definitions for sepsis andorgan failure and guidelines for the use of innovative therapiesin sepsis. Crit Care Med 1992;20:864-74.
[PubMed]
APPENDIX I
MEMBERS OF
SEPSIS GUIDELINES FOR PAKISTAN (SGP) COMMITTEE
Chair:
Professor Fazal Hameed Khan FCPS, EDIC
Professor of Anaesthesiology
Interim Chair Emergency Department
Aga Khan University, Karachi
Members:
- Professor S. Tipu Sultan
Patron PSCCM
Professor of Anaesthesiology
Sind Institute of Urology and Transplant
Karachi
- Professor Saeeda Haider
Professor of Anaesthesiology
The Indus Hospital
Karachi
- Professor Sadqa Aftab
Professor of Anaesthesiology
DUHS & Civil Hospital
Karachi
- Professor Roohina Baloch
Chair Department of Anaesthesia
Jinnah Post Graduate Medical Centre (JPMC)
Karachi
- Dr Ali bin Sarwar Zubairi
Associate Professor & Section Head, Pulmonary & Critical Care Medicine
Aga Khan University
Karachi
- Dr Javed Hussain
Consultant Pulmonary & Critical Care Medicine
South City Hospital
NFT, Aga Khan University
Karachi
- Dr Anwar ul Haq
Associate Professor & Director PICU
Aga Khan University
Karachi
- Dr Madiha Hashmi
President PSCCM
Director SICU & Assistant Professor, Department of Anaesthesiology
Aga Khan University
Karachi
- Dr Zahid Akhtar Rao
Director SICU
PNS Shifa Hospital
Karachi
- Dr Amin Khawaja
National Institute of Cardiovascular Diseases (NICVD)
Karachi
- Dr Zunairah Rais
Consultant Pulmonary & Critical Care Medicine
Liaquat National Hospital (LNH)
Karachi
- Dr Syed Farjad Sultan
Director ICU
The Indus Hospital
Karachi
Outside-Committee-Panel of Experts:
PUNJAB:
- Brig Aslam Khan
Professor of Medicine & Consultant Pulmonologist and Intensivist
Military Hospital
Rawalpindi.
BALUCHISTAN:
- Prof. Amjad Ali
Head of the Department
Bolan Medical College
Quetta
KPK:
- Prof. Gohar Ali
Head of the Department
Lady Reading Hospital
Peshawar
MMIDSP:
- Prof Naseem Salahuddin
Founder MMIDSP
Infectious Diseases Consultant
The Indus Hospital
Karachi
- Dr Faisal Sultan
Consultant Physician, Internal Medicine & Infectious Disease
Shaukat Khanum Memorial Cancer Hospital & Research Centre
PCS:
- Prof Kamran Cheema
President PCS
Professor of Pulmonary Medicine
Services Institute of Medical Sciences
Appendix II
MMIDSP RECOMMENDATIONS FOR EMPIRIC ANTIBIOTIC THERAPY
Source of infection |
Likely pathogen |
Best empirical antibiotic |
Urinary tract | E. coli | Carbapenem or Piperacillin –tazobactam orCefaperazone-sulbactam |
Genital tract | E. coli, Enterococcus, S hemolyticus, Anaerobes | Carbapenem or Piperacillin –tazobactam orCefaperazone-sulbactam + vancomycin |
Respiratory tract (CAP) |
S. pneumoniae, atypical pathogens | Ceftriaxone +levofloxacin or clarithromycin |
Respiratory tract (HAP) |
GPC, GNR, atypical | Carbapenem or Piperacillin –tazobactam orCefaperazone-sulbactam |
+ levofloxacin or clarithromycin
Respiratory tract
(VAP)
GNR, MRSACarbapenem or Piperacillin –tazobactam orCefaperazone-sulbactam + vancomycinIntra-abdominalGram negatives, anerobesCarbapenem or Piperacillin –tazobactam orCefaperazone-sulbactam + vancomycinSSTI (necrotizing fasciitis)
S. aureus, Streptococci
anerobes
Amoxicilin/clavulanate or clindamycin+vancomycinBurn sepsisS. aureus, Streptococci, Pseudomonas, CandidaCarbapenem or Piperacillin –tazobactam orCefaperazone-sulbactam + vancomycinLine sepsisS. aureus, (MSSA, MRSA), PseudomonasCeftazidime or amikacin+ vancomycinInfected deviceS. aureus, (MSSA, MRSA), PseudomonasCeftazidime or amikacin+ vancomycinBacterial meningitisS pneumonia, MeningococcusCeftriaxone + vancomycin + steroid
Appendix II
ANTIBIOTIC GROUPS, THEIR CHARACERISTICS AND USES
Class |
Spectrum |
Available preparations |
Route of administration |
Effective against |
Not effective against |
Carbapenem |
Broad |
Meroponem/imepenem / ertapenem |
Intravenous |
GPC, GNB, anaerobes |
MRSA, VRE. Ertapenem ineffective against pseudomonas |
B lactamase inhibitor |
Broad |
Piperacillin –tazobactam |
Intravenous |
GPC, GNB, anaerobes. |
MRSA, VRE |
3rd gen Cephalosporin |
Broad |
Cefaperazone-sulbactam |
Intravenous |
GPC, GNB, anaerobes. |
MRSA, VRE |
1st gen cephalosporin |
Narrow |
Cefazolin, Cephradine |
Intravenous |
Strept |
MRSA, VRE, anaerobes |
3rd gen Cephalosporin |
Broad |
Ceftriaxone |
Intravenous |
Strept, GNR |
MRSA, VRE, anaerobes |
3rd gen Cephalosporin |
Broad |
Ceftazidime |
Intravenous |
GNR, esp pseudom |
MRSA, VRE, anaerobes |
Glycopeptide |
Narrow |
Vancomycin |
Intravenous |
MRSA, enterococcus |
GNR, anaerobes |
Aminoglycoside |
Narrow |
Amikacin, Tobramycin, Gentamicin |
Intravenous |
GNR |
Strept and Entero,, anaerobes |
B lactamase inhibitor |
Broad |
Amoxicillin-clavulanate |
Intravenous and oral |
GPC, some GNR, anaerobes |
E coli, enterobacteriacae |
Fluoroquinolones |
Broad |
Levofloxacin |
Intravenous and oral |
GPC, atypical resp pathogens |
Anaerobes |
Macrolides |
Narrow |
Azithromycin, clarithromycin |
Oral |
Atypical resp pathogens |
GNR, anaerobes |
Lincosamide |
Narrow |
Clindamycin |
Intravenous and oral |
Strep, Staph (MSSA) |
GNR |
GPC gram positive cocci
GNR gram negative rods
MSSA methicillin sensitive Staph aureus
MRSA methicillin resistant Staph aureus