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Granholm A, Perner A, Krag M, Hjortrup PB, Haase N, Holst LB, Marker S, Collet MO, Jensen AKG, Møller MH. Development and internal validation of the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU). Acta Anaesthesiol Scand 2018; 62:336-346. [PMID: 29210058 DOI: 10.1111/aas.13048] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/18/2017] [Accepted: 11/17/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Intensive care unit (ICU) mortality prediction scores deteriorate over time, and their complexity decreases clinical applicability and commonly causes problems with missing data. We aimed to develop and internally validate a new and simple score that predicts 90-day mortality in adults upon acute admission to the ICU: the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU). METHODS We used data from an international cohort of 2139 patients acutely admitted to the ICU and 1947 ICU patients with severe sepsis/septic shock from 2009 to 2016. We performed multiple imputations for missing data and used binary logistic regression analysis with variable selection by backward elimination, followed by conversion to a simple point-based score. We assessed the apparent performance and validated the score internally using bootstrapping to present optimism-corrected performance estimates. RESULTS The SMS-ICU comprises seven variables available in 99.5% of the patients: two numeric variables: age and lowest systolic blood pressure, and five dichotomous variables: haematologic malignancy/metastatic cancer, acute surgical admission and use of vasopressors/inotropes, respiratory support and renal replacement therapy. Discrimination (area under the receiver operating characteristic curve) was 0.72 (95% CI: 0.71-0.74), overall performance (Nagelkerke's R2 ) was 0.19 and calibration (intercept and slope) was 0.00 and 0.99, respectively. Optimism-corrected performance was similar to apparent performance. CONCLUSIONS The SMS-ICU predicted 90-day mortality with reasonable and stable performance. If performance remains adequate after external validation, the SMS-ICU could prove a valuable tool for ICU clinicians and researchers because of its simplicity and expected very low number of missing values.
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Affiliation(s)
- A. Granholm
- Department of Intensive Care 4131; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
| | - A. Perner
- Department of Intensive Care 4131; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Centre for Research in Intensive Care; Copenhagen Denmark
| | - M. Krag
- Department of Intensive Care 4131; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Centre for Research in Intensive Care; Copenhagen Denmark
| | - P. B. Hjortrup
- Department of Intensive Care 4131; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
| | - N. Haase
- Department of Intensive Care 4131; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
| | - L. B. Holst
- Department of Intensive Care 4131; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
| | - S. Marker
- Department of Intensive Care 4131; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Centre for Research in Intensive Care; Copenhagen Denmark
| | - M. O. Collet
- Department of Intensive Care 4131; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Centre for Research in Intensive Care; Copenhagen Denmark
| | - A. K. G. Jensen
- Centre for Research in Intensive Care; Copenhagen Denmark
- Section of Biostatistics; University of Copenhagen; Copenhagen Denmark
| | - M. H. Møller
- Department of Intensive Care 4131; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Centre for Research in Intensive Care; Copenhagen Denmark
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Lie KC, Lau CY, Van Vinh Chau N, West TE, Limmathurotsakul D. Utility of SOFA score, management and outcomes of sepsis in Southeast Asia: a multinational multicenter prospective observational study. J Intensive Care 2018; 6:9. [PMID: 29468069 PMCID: PMC5813360 DOI: 10.1186/s40560-018-0279-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 02/05/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Sepsis is a global threat but insufficiently studied in Southeast Asia. The objective was to evaluate management, outcomes, adherence to sepsis bundles, and mortality prediction of maximum Sequential Organ Failure Assessment (SOFA) scores in patients with community-acquired sepsis in Southeast Asia. METHODS We prospectively recruited hospitalized adults within 24 h of admission with community-acquired infection at nine public hospitals in Indonesia (n = 3), Thailand (n = 3), and Vietnam (n = 3). In patients with organ dysfunction (total SOFA score ≥ 2), we analyzed sepsis management and outcomes and evaluated mortality prediction of the SOFA scores. Organ failure was defined as the maximum SOFA score ≥ 3 for an individual organ system. RESULTS From December 2013 to December 2015, 454 adult patients presenting with community-acquired sepsis due to diverse etiologies were enrolled. Compliance with sepsis bundles within 24 h of admission was low: broad-spectrum antibiotics in 76% (344/454), ≥ 1500 mL fluid in 50% of patients with hypotension or lactate ≥ 4 mmol/L (115/231), and adrenergic agents in 71% of patients with hypotension (135/191). Three hundred and fifty-five patients (78%) were managed outside of ICUs. Ninety-nine patients (22%) died. Total SOFA score on admission of those who subsequently died was significantly higher than that of those who survived (6.7 vs. 4.6, p < 0.001). The number of organ failures showed a significant correlation with 28-day mortality, which ranged from 7% in patients without any organ failure to 47% in those with failure of at least four organs (p < 0.001). The area under the receiver operating characteristic curve of the total SOFA score for discrimination of mortality was 0.68 (95% CI 0.62-0.74). CONCLUSIONS Community-acquired sepsis in Southeast Asia due to a variety of pathogens is usually managed outside the ICU and with poor compliance to sepsis bundles. In this population, calculation of SOFA scores is feasible and SOFA scores are associated with mortality. TRIAL REGISTRATION ClinicalTrials.gov, NCT02157259. Registered 5 June 2014, retrospectively registered.
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Affiliation(s)
- Khie Chen Lie
- Department of Internal Medicine, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Chuen-Yen Lau
- Collaborative Clinical Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - Nguyen Van Vinh Chau
- Department of Internal Medicine, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Department of Internal Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - T. Eoin West
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA USA
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400 Thailand
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Argent AC. Considerations for Assessing the Appropriateness of High-Cost Pediatric Care in Low-Income Regions. Front Pediatr 2018; 6:68. [PMID: 29637061 PMCID: PMC5880905 DOI: 10.3389/fped.2018.00068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/08/2018] [Indexed: 12/24/2022] Open
Abstract
It may be difficult to predict the consequences of provision of high-cost pediatric care (HCC) in low- and middle-income countries (LMICs), and these consequences may be different to those experienced in high-income countries. An evaluation of the implications of HCC in LMICs must incorporate considerations of the specific context in that country (population age profile, profile of disease, resources available), likely costs of the HCC, likely benefits that can be gained versus the costs that will be incurred. Ideally, the process that is followed in decision making around HCC should be transparent and should involve the communities that will be most affected by those decisions. It is essential that the impacts of provision of HCC are carefully monitored so that informed decisions can be made about future provision medical interventions.
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Affiliation(s)
- Andrew C Argent
- Paediatric Critical Care, Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Jacquet GA, Hamade B, Diab KA, Sawaya R, Dagher GA, Hitti E, Bayram JD. The Emergency Department Crash Cart: A systematic review and suggested contents. World J Emerg Med 2018; 9:93-98. [PMID: 29576820 DOI: 10.5847/wjem.j.1920-8642.2018.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart (EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifically discussing EDCCs or proposing detailed features for an EDCC suitable for both adult and pediatric patients. METHODS The authors performed a systematic review of EDCC-specific literature indexed in Pubmed and Embase on December 20, 2016. In addition, the authors reviewed the 2015 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, the 2015 European Resuscitation Council (ERC) guidelines for resuscitation, and the 2013 American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) 9th edition. RESULTS There were a total of 277 results, with 192 unique results and 85 duplicates. After careful review by two independent reviewers, all but four references were excluded. None of the four included articles described comprehensive contents of equipment and medications for both the adult and pediatric populations. This article describes in detail the final four articles specific to EDCC, and proposes a set of suggested contents for the EDCC. CONCLUSION Our systematic review shows the striking paucity of such a high impact indispensable item in the ED. We hope that our EDCC content suggestions help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.
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Affiliation(s)
- Gabrielle A Jacquet
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA; Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Bachar Hamade
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karim A Diab
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA
| | - Rasha Sawaya
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gilbert Abou Dagher
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Eveline Hitti
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jamil D Bayram
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sepsis in tropical regions: Report from the task force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2017; 46:115-118. [PMID: 29310974 DOI: 10.1016/j.jcrc.2017.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 12/23/2017] [Indexed: 12/22/2022]
Abstract
Sepsis and septic shock in the tropics are caused by a wide array of organisms. These infections are encountered mainly in low and middle-income countries (LMIC) where a lack of infrastructure and medical facilities contribute to the high morbidity and mortality. Published sepsis guidelines are based on studies primarily performed in high income countries and as such recommendations may or may not be relevant to practice in the tropics. Failure to adhere to guidelines, particularly among non-intensive care specialists even in high-income countries, is an area of concern for sepsis management. Additionally, inappropriate use of antimicrobials has led to significant antimicrobial resistance. Access to rapid, low-cost, and accurate diagnostic tests is critical in countries where tropical diseases are prevalent to facilitate early diagnosis and treatment. Implementation of performance improvement programs may improve outcomes for patients with sepsis and the addition of resuscitation and treatment bundles may further reduce mortality. Associated co-morbidities such as malnutrition and HIV influence outcomes and must be considered.
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Abstract
BACKGROUND Sepsis, worldwide the leading cause of death in children, has now been recognized as the global health emergency it is. On May 26, 2017, the World Health Assembly, the decision-making body of the World Health Organization, adopted a resolution proposed by the Global Sepsis Alliance to improve the prevention, diagnosis, and management of sepsis. OBJECTIVE To discuss the implications of this resolution for children worldwide. CONCLUSIONS The resolution highlights sepsis as a global threat and urges the 194 United Nations member states to take specific actions and implement appropriate measures to reduce its human and health economic burden. The resolution is a major step toward achieving the targets outlined by the Sustainable Developmental Goals for decreasing mortality in infants and children, but implementing it will require a concerted global effort.
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Abdu M, Wilson A, Mhango C, Taki F, Coomarasamy A, Lissauer D. Resource availability for the management of maternal sepsis in Malawi, other low-income countries, and lower-middle-income countries. Int J Gynaecol Obstet 2017; 140:175-183. [PMID: 29027207 DOI: 10.1002/ijgo.12350] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 08/25/2017] [Accepted: 10/12/2017] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess the availability of key resources for the management of maternal sepsis and evaluate the feasibility of implementing the Surviving Sepsis Campaign (SSC) recommendations in Malawi and other low-resource settings. METHODS A cross-sectional study was conducted at health facilities in Malawi, other low-income countries, and lower-middle-income countries during January-March 2016. English-speaking healthcare professionals (e.g. doctors, nurses, midwives, and administrators) completed a questionnaire/online survey to assess the availability of resources for the management of maternal sepsis. RESULTS Healthcare centers (n=23) and hospitals (n=13) in Malawi showed shortages in the resources for basic monitoring (always available in 5 [21.7%] and 10 [76.9%] facilities, respectively) and basic infrastructure (2 [8.7%] and 7 [53.8%], respectively). The availability of antibiotics varied between Malawian healthcare centers (9 [39.1%]), Malawian hospitals (8 [61.5%]), hospitals in other low-income countries (10/17 [58.8%]), and hospitals in lower-middle-income countries (39/41 [95.1%]). The percentage of SSC recommendations that could be implemented was 33.3% at hospitals in Malawi, 30.3% at hospitals in other low-income countries, and 68.2% at hospitals in lower-middle-income countries. CONCLUSION The implementation of existing SSC recommendations is unrealistic in low-income countries because of resource limitations. New maternal sepsis care bundles must be developed that are applicable to low-resource settings.
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Affiliation(s)
- Mohammed Abdu
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Amie Wilson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Chisale Mhango
- Department of Obstetrics and Gynaecology, College of Medicine, Blantyre, Malawi
| | - Fatima Taki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - David Lissauer
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Clinical outcomes and mortality before and after implementation of a pediatric sepsis protocol in a limited resource setting: A retrospective cohort study in Bangladesh. PLoS One 2017; 12:e0181160. [PMID: 28753618 PMCID: PMC5533322 DOI: 10.1371/journal.pone.0181160] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 06/26/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Pediatric sepsis has a high mortality rate in limited resource settings. Sepsis protocols have been shown to be a cost-effective strategy to improve morbidity and mortality in a variety of populations and settings. At Dhaka Hospital in Bangladesh, mortality from pediatric sepsis in high-risk children previously approached 60%, which prompted the implementation of an evidenced-based protocol in 2010. The clinical effectiveness of this protocol had not been measured. We hypothesized that implementation of a pediatric sepsis protocol improved clinical outcomes, including reducing mortality and length of hospital stay. MATERIALS AND METHODS This was a retrospective cohort study of children 1-59 months old with a diagnosis of sepsis, severe sepsis or septic shock admitted to Dhaka Hospital from 10/25/2009-10/25/2011. The primary outcome was inpatient mortality pre- and post-protocol implementation. Secondary outcomes included fluid overload, heart failure, respiratory insufficiency, length of hospital stay, and protocol compliance, as measured by antibiotic and fluid bolus administration within 60 minutes of hospital presentation. RESULTS 404 patients were identified by a key-word search of the electronic medical record; 328 patients with a primary diagnosis of sepsis, severe sepsis, or septic shock were included (143 pre- and185 post-protocol) in the analysis. Pre- and post-protocol mortality were similar and not statistically significant (32.17% vs. 34.59%, p = 0.72). The adjusted odds ratio (AOR) for post-protocol mortality was 1.55 (95% CI, 0.88-2.71). The odds for developing fluid overload were significantly higher post-protocol (AOR 3.45, 95% CI, 2.04-5.85), as were the odds of developing heart failure (AOR 4.52, 95% CI, 1.43-14.29) and having a longer median length of stay (AOR 1.81, 95% CI 1.10-2.96). There was no statistically significant difference in respiratory insufficiency (pre- 65.7% vs. post- 70.3%, p = 0.4) or antibiotic administration between the cohorts (pre- 16.08% vs. post- 12.43%, p = 0.42). CONCLUSIONS Implementation of a pediatric sepsis protocol did not improve all-cause mortality or length of stay and may have been associated with increased fluid overload and heart failure during the study period in a large, non-governmental hospital in Bangladesh. Similar rates of early antibiotic administration may indicate poor protocol compliance. Though evidenced-based protocols are a potential cost-effective strategy to improve outcomes, future studies should focus on optimal implementation of context-relevant sepsis protocols in limited resource settings.
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Mer M, Schultz MJ, Adhikari NK. Core elements of general supportive care for patients with sepsis and septic shock in resource-limited settings. Intensive Care Med 2017. [PMID: 28620804 PMCID: PMC5633616 DOI: 10.1007/s00134-017-4831-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Affiliation(s)
- Mervyn Mer
- Divisions of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. .,Wits-UQ Critical Care Infection Collaboration, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Neill K Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
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Papali A, Eoin West T, Verceles AC, Augustin ME, Nathalie Colas L, Jean-Francois CH, Patel DM, Todd NW, McCurdy MT. Treatment outcomes after implementation of an adapted WHO protocol for severe sepsis and septic shock in Haiti. J Crit Care 2017; 41:222-228. [PMID: 28591678 DOI: 10.1016/j.jcrc.2017.05.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/24/2017] [Accepted: 05/20/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE The World Health Organization (WHO) has developed a simplified algorithm specific to resource-limited settings for the treatment of severe sepsis emphasizing early fluids and antibiotics. However, this protocol's clinical effectiveness is unknown. We describe patient outcomes before and after implementation of an adapted WHO severe sepsis protocol at a community hospital in Haiti. MATERIALS AND METHODS Using a before-and-after study design, we retrospectively enrolled 99 adult Emergency Department patients with severe sepsis from January through March 2012. After protocol implementation in January 2014, we compared outcomes to 67 patients with severe sepsis retrospectively enrolled from February to April 2014. We defined sepsis according to the WHO's Integrated Management of Adult Illness guidelines and severe sepsis as sepsis plus organ dysfunction. RESULTS After protocol implementation, quantity of fluid administered increased and the physician's differential diagnoses more often included sepsis. Patients were more likely to have follow-up vital signs taken sooner, a radiograph performed, and a lactic acid tested. There were no improvements in mortality, time to fluids or antimicrobials. CONCLUSIONS Use of a simplified sepsis protocol based primarily on physiologic parameters allows for substantial improvements in process measures in the care of severely septic patients in a resource-constrained setting.
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Affiliation(s)
- Alfred Papali
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - T Eoin West
- Division of Pulmonary & Critical Care Medicine, University of Washington School of Medicine, Seattle, WA, USA; International Respiratory and Severe Illness Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Avelino C Verceles
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marc E Augustin
- Department of Medicine, St. Luke Family Hospital, Port-au-Prince, Haiti
| | - L Nathalie Colas
- Department of Medicine, St. Luke Family Hospital, Port-au-Prince, Haiti
| | | | - Devang M Patel
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nevins W Todd
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael T McCurdy
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future. Intensive Care Med 2017; 43:612-624. [PMID: 28349179 DOI: 10.1007/s00134-017-4750-z] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 02/27/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome. AIM To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU. FINDINGS Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources. CONCLUSIONS Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.
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Rudd KE, Tutaryebwa LK, West TE. Presentation, management, and outcomes of sepsis in adults and children admitted to a rural Ugandan hospital: A prospective observational cohort study. PLoS One 2017; 12:e0171422. [PMID: 28199348 PMCID: PMC5310912 DOI: 10.1371/journal.pone.0171422] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 01/20/2017] [Indexed: 12/29/2022] Open
Abstract
Objectives Limited data are available on sepsis in low-resource settings, particularly outside of urban referral centers. We conducted a prospective observational single-center cohort study in May 2013 to assess the presentation, management and outcomes of adult and pediatric patients admitted with sepsis to a community hospital in rural Uganda. Methods We consecutively screened all patients admitted to medical wards who met sepsis criteria. We evaluated eligible patients within 24 hours of presentation and 24–48 hours after admission, and followed them until hospital discharge. In addition to chart review, mental status evaluation, peripheral capillary oxygen saturation, and point-of-care venous whole blood lactate and glucose testing were performed. Results Of 56 eligible patients, we analyzed data on 51 (20 adults and 31 children). Median age was 8 years (IQR 2–23 years). Sepsis accounted for a quarter of all adult and pediatric medical ward admissions during the study period. HIV prevalence among adults was 30%. On enrollment, over half of patients had elevated point-of-care whole blood lactate, few were hypoglycemic or had altered mental status, and one third were hypoxic. Over 80% of patients received at least one antibiotic, all severely hypoxic patients received supplemental oxygen, and half of patients with elevated lactate received fluid resuscitation. The most common causes of sepsis were malaria and pneumonia. In-hospital mortality was 3.9%. Conclusions This study highlights the importance of sepsis among adult and pediatric patients admitted to a rural Ugandan hospital and underscores the need for continued research on sepsis in low resource settings.
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Affiliation(s)
- Kristina E. Rudd
- International Respiratory and Severe Illness Center, University of Washington, Seattle, Washington, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Leonard K. Tutaryebwa
- Department of Paediatrics and Child Health, Bwindi Community Hospital, Kanungu, Uganda
| | - T. Eoin West
- International Respiratory and Severe Illness Center, University of Washington, Seattle, Washington, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
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Meier B, Staton C. Sepsis Resuscitation in Resource-Limited Settings. Emerg Med Clin North Am 2017; 35:159-173. [DOI: 10.1016/j.emc.2016.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Kortz TB, Sawe HR, Murray B, Enanoria W, Matthay MA, Reynolds T. Clinical Presentation and Outcomes among Children with Sepsis Presenting to a Public Tertiary Hospital in Tanzania. Front Pediatr 2017; 5:278. [PMID: 29312910 PMCID: PMC5743673 DOI: 10.3389/fped.2017.00278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 12/06/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Pediatric sepsis causes significant global morbidity and mortality and low- and middle-income countries (LMICs) bear the bulk of the burden. International sepsis guidelines may not be relevant in LMICs, especially in sub-Saharan Africa (SSA), due to resource constraints and population differences. There is a critical lack of pediatric sepsis data from SSA, without which accurate risk stratification tools and context-appropriate, evidence-based protocols cannot be developed. The study's objectives were to characterize pediatric sepsis presentations, interventions, and outcomes in a public Emergency Medicine Department (EMD) in Tanzania. METHODS Prospective descriptive study of children (28 days to 14 years) with sepsis [suspected infection with ≥2 clinical systemic inflammatory response syndrome (SIRS) criteria] presenting to a tertiary EMD in Dar es Salaam, Tanzania (July 1 to September 30, 2016). Outcomes included: in-hospital mortality (primary), EMD mortality, and hospital length of stay. We report descriptive statistics using means and SDs, medians and interquartile ranges, and counts and percentages as appropriate. Predictive abilities of SIRS criteria, the Alert-Verbal-Painful-Unresponsive (AVPU) score and the Lambaréné Organ Dysfunction Score (LODS) for in-hospital, early and late mortality were tested. RESULTS Of the 2,232 children screened, 433 (19.4%) met inclusion criteria, and 405 were enrolled. There were 247 (61%) subjects referred from an outside facility. Approximately half (54.1%) received antibiotics in the EMD, and some form of microbiologic culture was collected in 35.8% (n = 145) of subjects. In-hospital and EMD mortality were 14.2 and 1.5%, respectively, median time to death was 3 days (IQR 1-6), and median length of stay was 6 days (IQR 1-12). SIRS criteria, the AVPU score, and the LODS had low positive (17-27.1, 33.3-43.9, 18.3-55.6%, respectively) and high negative predictive values (88.6-89.8, 86.5-91.2, 86.8-90.5%, respectively) for in-hospital mortality. CONCLUSION This pediatric sepsis cohort had high and early in-hospital mortality. Current criteria and tested clinical scores were inadequate for risk-stratification and mortality prediction in this population and setting. Pediatric sepsis management must take into account the local patient population, etiologies of sepsis, healthcare system, and resource availability. Only through studies such as this that generate regional data in LMICs can accurate risk stratification tools and context-appropriate, evidence-based guidelines be developed.
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Affiliation(s)
- Teresa Bleakly Kortz
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Hendry R Sawe
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Brittany Murray
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Wayne Enanoria
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Michael Anthony Matthay
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Teri Reynolds
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States
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65
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Leligdowicz A, Fischer WA, Uyeki TM, Fletcher TE, Adhikari NKJ, Portella G, Lamontagne F, Clement C, Jacob ST, Rubinson L, Vanderschuren A, Hajek J, Murthy S, Ferri M, Crozier I, Ibrahima E, Lamah MC, Schieffelin JS, Brett-Major D, Bausch DG, Shindo N, Chan AK, O'Dempsey T, Mishra S, Jacobs M, Dickson S, Lyon GM, Fowler RA. Ebola virus disease and critical illness. Crit Care 2016; 20:217. [PMID: 27468829 PMCID: PMC4965892 DOI: 10.1186/s13054-016-1325-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/26/2016] [Indexed: 12/26/2022] Open
Abstract
As of 20 May 2016 there have been 28,646 cases and 11,323 deaths resulting from the West African Ebola virus disease (EVD) outbreak reported to the World Health Organization. There continue to be sporadic flare-ups of EVD cases in West Africa.EVD presentation is nonspecific and characterized initially by onset of fatigue, myalgias, arthralgias, headache, and fever; this is followed several days later by anorexia, nausea, vomiting, diarrhea, and abdominal pain. Anorexia and gastrointestinal losses lead to dehydration, electrolyte abnormalities, and metabolic acidosis, and, in some patients, acute kidney injury. Hypoxia and ventilation failure occurs most often with severe illness and may be exacerbated by substantial fluid requirements for intravascular volume repletion and some degree of systemic capillary leak. Although minor bleeding manifestations are common, hypovolemic and septic shock complicated by multisystem organ dysfunction appear the most frequent causes of death.Males and females have been equally affected, with children (0-14 years of age) accounting for 19 %, young adults (15-44 years) 58 %, and older adults (≥45 years) 23 % of reported cases. While the current case fatality proportion in West Africa is approximately 40 %, it has varied substantially over time (highest near the outbreak onset) according to available resources (40-90 % mortality in West Africa compared to under 20 % in Western Europe and the USA), by age (near universal among neonates and high among older adults), and by Ebola viral load at admission.While there is no Ebola virus-specific therapy proven to be effective in clinical trials, mortality has been dramatically lower among EVD patients managed with supportive intensive care in highly resourced settings, allowing for the avoidance of hypovolemia, correction of electrolyte and metabolic abnormalities, and the provision of oxygen, ventilation, vasopressors, and dialysis when indicated. This experience emphasizes that, in addition to evaluating specific medical treatments, improving the global capacity to provide supportive critical care to patients with EVD may be the greatest opportunity to improve patient outcomes.
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Affiliation(s)
| | - William A Fischer
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy M Uyeki
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Thomas E Fletcher
- Defence Medical Services, Whittington Barracks, Lichfield, UK
- Liverpool School of Tropical Medicine, Liverpool, Merseyside, UK
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Shevin T Jacob
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Lewis Rubinson
- Department of Medicine, University of Maryland, Baltimore, MD, USA
| | - Abel Vanderschuren
- Centre de recherche de l'institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Jan Hajek
- Division of Infectious Diseases, University of British Columbia, Vancouver, BC, Canada
| | - Srinivas Murthy
- Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
| | | | - Ian Crozier
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elhadj Ibrahima
- Department of Infectious and Parasitic Diseases, Donka Hospital, Conakry, Guinea
| | - Marie-Claire Lamah
- Department of Infectious and Parasitic Diseases, Donka Hospital, Conakry, Guinea
| | - John S Schieffelin
- Department of Pediatrics, School of Medicine and School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - David Brett-Major
- Department of Preventive Medicine and Biometrics, Uniformed Services University, Bethesda, MD, USA
| | - Daniel G Bausch
- Department of Pandemic and Epidemic Diseases, World Health Organization, Geneva, Switzerland
| | - Nikki Shindo
- Department of Pandemic and Epidemic Diseases, World Health Organization, Geneva, Switzerland
| | - Adrienne K Chan
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Tim O'Dempsey
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Jacobs
- Department of Infection, Royal Free London NHS Foundation Trust, London, UK
| | - Stuart Dickson
- Acute Medicine and Intensive Care, Derriford Hospital, Plymouth, UK
| | - G Marshall Lyon
- Department of Infectious Diseases, Emory University Hospital, Atlanta, Georgia, USA
| | - Robert A Fowler
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Slusher T, Bjorklund A, Aanyu HT, Kiragu A, Philip C. The Assessment, Evaluation, and Management of the Critically Ill Child in Resource-Limited International Settings. J Pediatr Intensive Care 2016; 6:66-76. [PMID: 31073427 DOI: 10.1055/s-0036-1584677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 03/22/2016] [Indexed: 10/21/2022] Open
Abstract
Providing evidence-based care to the critically ill child including assessment, evaluation, and management in resource-limited settings provides unique challenges and limitless opportunities to significantly impact morbidity and mortality in these settings. Difficulties encountered include: determining which disease processes will benefit most from critical care in resource-limited settings, lack of triage tools and adjuncts to help with assessment, finite laboratory and radiological tests, limited understanding of key findings in critically ill/injured pediatric patients, (especially by those without pediatric focused training), and finally, lack of supplies, medicines, equipment, and training of health care providers to appropriately treat critically ill children in these resource-limited settings. In this review, the most common problems encountered and possible solutions to overcome these obstacles are discussed.
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Affiliation(s)
- Tina Slusher
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States.,Department of Pediatrics, Hennepin County Medical School, Minneapolis, Minnesota, United States
| | - Ashley Bjorklund
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Hellen T Aanyu
- Department of Pediatrics, Mulago National Referral Hospital, Kampala, Uganda
| | - Andrew Kiragu
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States.,Department of Pediatrics, Hennepin County Medical School, Minneapolis, Minnesota, United States
| | - Christo Philip
- Department of Emergency and Intensive Care, Duncan Hospital, Raxaul, Bihar, India
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Ulisubisya M, Jörnvall H, Irestedt L, Baker T. Establishing an Anaesthesia and Intensive Care partnership and aiming for national impact in Tanzania. Global Health 2016; 12:7. [PMID: 26993790 PMCID: PMC4799533 DOI: 10.1186/s12992-016-0144-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 03/09/2016] [Indexed: 01/09/2023] Open
Abstract
Anaesthesia and Intensive Care is a neglected specialty in low-income countries. There is an acute shortage of health workers – several low-income countries have less than 1 anaesthesia provider per 100,000 population. Only 1.5 % of hospitals in Africa have the intensive care resources needed for managing patients with sepsis. Health partnerships between institutions in high and low-income countries have been proposed as an effective way to strengthen health systems. The aim of this article is to describe the origin and conduct of a health partnership in Anaesthesia and Intensive Care between institutions in Tanzania and Sweden and how the partnership has expanded to have an impact at regional and national levels. The Muhimbili-Karolinska Anaesthesia and Intensive Care Collaboration was initiated in 2008 on the request of the Executive Director of Muhimbili National Hospital in Dar es Salaam. The partnership has conducted training courses, exchanges, research projects and introduced new equipment, routines and guidelines. The partnership has expanded to include all hospitals in Dar es Salaam. Through the newly formed Life Support Foundation, the partnership has had a national impact assisting the reanimation of the Society of Anaesthesiologists of Tanzania and has seen a marked increase of the number of young doctors choosing a residency in Anaesthesia and Intensive Care.
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Affiliation(s)
- Mpoki Ulisubisya
- Society of Anaesthesiologists of Tanzania, PO Box 65588, Dar es Salaam, Tanzania. .,Mbeya Zonal Referral Hospital, Mbeya, Tanzania.
| | - Henrik Jörnvall
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden
| | - Lars Irestedt
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden
| | - Tim Baker
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden.,Global Health - Health Systems and Policy, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
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68
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Modified Early Warning Score (MEWS) Identifies Critical Illness among Ward Patients in a Resource Restricted Setting in Kampala, Uganda: A Prospective Observational Study. PLoS One 2016; 11:e0151408. [PMID: 26986466 PMCID: PMC4795640 DOI: 10.1371/journal.pone.0151408] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 02/26/2016] [Indexed: 12/29/2022] Open
Abstract
Introduction Providing optimal critical care in developing countries is limited by lack of recognition of critical illness and lack of essential resources. The Modified Early Warning Score (MEWS), based on physiological parameters, is validated in adult medical and surgical patients as a predictor of mortality. The objective of this study performed in Uganda was to determine the prevalence of critical illness on the wards as defined by the MEWS, to evaluate the MEWS as a predictor of death, and to describe additional risk factors for mortality. Methods We conducted a prospective observational study at Mulago National Referral Teaching Hospital in Uganda. We included medical and surgical ward patients over 18 years old, excluding patients discharged the day of enrolment, obstetrical patients, and patients who self-discharged prior to study completion. Over a 72-hour study period, we collected demographic and vital signs, and calculated MEWS; at 7-days we measured outcomes. Patients discharged prior to 7 days were assumed to be alive at study completion. Descriptive and inferential statistical analyses were performed. Results Of 452 patients, the median age was 40.5 (IQR 29–54) years, 53.3% were male, 24.3% were HIV positive, and 45.1% had medical diagnoses. MEWS ranged from 0 to 9, with higher scores representing hemodynamic instability. The median MEWS was 2 [IQR 1–3] and the median length of hospital stay was 9 days [IQR 4–24]. In-hospital mortality at 7-days was 5.5%; 41.4% of patients were discharged and 53.1% remained on the ward. Mortality was independently associated with medical admission (OR: 7.17; 95% CI: 2.064–24.930; p = 0.002) and the MEWS ≥ 5 (OR: 5.82; 95% CI: 2.420–13.987; p<0.0001) in the multivariable analysis. Conclusion There is a significant burden of critical illness at Mulago Hospital, Uganda. Implementation of the MEWS could provide a useful triage tool to identify patients at greatest risk of death. Future research should include refinement of MEWS for low-resource settings, and development of appropriate interventions for patients identified to be at high risk of death based on early warning scores.
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69
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Affiliation(s)
- Arjen M Dondorp
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford, UK
| | - Rashan Haniffa
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford, UK National Intensive Care Surveillance, Ministry of Health, Sri Lanka Faculty of Medicine, University of Colombo
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Kwizera A, Festic E, Dünser MW. What's new in sepsis recognition in resource-limited settings? Intensive Care Med 2016; 42:2030-2033. [PMID: 26825954 PMCID: PMC5106488 DOI: 10.1007/s00134-016-4222-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/10/2016] [Indexed: 02/04/2023]
Affiliation(s)
- Arthur Kwizera
- Department of Anaesthesia, Makerere University College of Health Sciences, Mulago National Referral Hospital, Kampala, Uganda
| | - Emir Festic
- Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL USA
| | - Martin W. Dünser
- Interdisciplinary Intensive Care Units, Department of Anesthesiology, Perioperative and General Intensive Care Medicine, University Hospital Salzburg and Paracelsus Private Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
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71
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Turner EL, Nielsen KR, Jamal SM, von Saint André-von Arnim A, Musa NL. A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions. Front Pediatr 2016; 4:5. [PMID: 26925393 PMCID: PMC4757646 DOI: 10.3389/fped.2016.00005] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/22/2016] [Indexed: 01/09/2023] Open
Abstract
Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings.
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Affiliation(s)
- Erin L Turner
- Asante Rogue Regional Medical Center, Pediatric Hospital Medicine , Medford, OR , USA
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72
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Vital Signs Directed Therapy: Improving Care in an Intensive Care Unit in a Low-Income Country. PLoS One 2015; 10:e0144801. [PMID: 26693728 PMCID: PMC4687915 DOI: 10.1371/journal.pone.0144801] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 11/24/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Global Critical Care is attracting increasing attention. At several million deaths per year, the worldwide burden of critical illness is greater than generally appreciated. Low income countries (LICs) have a disproportionally greater share of critical illness, and yet critical care facilities are scarce in such settings. Routines utilizing abnormal vital signs to identify critical illness and trigger medical interventions have become common in high-income countries but have not been investigated in LICs. The aim of the study was to assess whether the introduction of a vital signs directed therapy protocol improved acute care and reduced mortality in an Intensive Care Unit (ICU) in Tanzania. METHODS AND FINDINGS Prospective, before-and-after interventional study in the ICU of a university hospital in Tanzania. A context-appropriate protocol that defined danger levels of severely abnormal vital signs and stipulated acute treatment responses was implemented in a four week period using sensitisation, training, job aids, supervision and feedback. Acute treatment of danger signs at admission and during care in the ICU and in-hospital mortality were compared pre and post-implementation using regression models. Danger signs from 447 patients were included: 269 pre-implementation and 178 post-implementation. Acute treatment of danger signs was higher post-implementation (at admission: 72.9% vs 23.1%, p<0.001; in ICU: 16.6% vs 2.9%, p<0.001). A danger sign was five times more likely to be treated post-implementation (Prevalence Ratio (PR) 4.9 (2.9-8.3)). Intravenous fluids were given in response to 35.0% of hypotensive episodes post-implementation, as compared to 4.1% pre-implementation (PR 6.4 (2.5-16.2)). In patients admitted with hypotension, mortality was lower post-implementation (69.2% vs 92.3% p = 0.02) giving a numbers-needed-to-treat of 4.3. Overall in-hospital mortality rates were unchanged (49.4% vs 49.8%, p = 0.94). CONCLUSION The introduction of a vital signs directed therapy protocol improved the acute treatment of abnormal vital signs in an ICU in a low-income country. Mortality rates were reduced for patients with hypotension at admission but not for all patients.
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Single Deranged Physiologic Parameters Are Associated With Mortality in a Low-Income Country. Crit Care Med 2015; 43:2171-9. [PMID: 26154933 DOI: 10.1097/ccm.0000000000001194] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate whether deranged physiologic parameters at admission to an ICU in Tanzania are associated with in-hospital mortality and compare single deranged physiologic parameters to a more complex scoring system. DESIGN Prospective, observational cohort study of patient notes and admission records. Data were collected on vital signs at admission to the ICU, patient characteristics, and outcomes. Cutoffs for deranged physiologic parameters were defined a priori and their association with in-hospital mortality was analyzed using multivariable logistic regression. SETTING ICU at Muhimbili National Hospital, Dar es Salaam, Tanzania. PATIENTS All adults admitted to the ICU in a 15-month period. MEASUREMENTS AND MAIN RESULTS Two hundred sixty-nine patients were included: 54% female, median age 35 years. In-hospital mortality was 50%. At admission, 69% of patients had one or more deranged physiologic parameter. Sixty-four percent of the patients with a deranged physiologic parameter died in hospital compared with 18% without (p < 0.001). The presence of a deranged physiologic parameter was associated with mortality (adjusted odds ratio, 4.64; 95% CI, 1.95-11.09). Mortality increased with increasing number of deranged physiologic parameters (odds ratio per deranged physiologic parameter, 2.24 [1.53-3.26]). Every individual deranged physiologic parameter was associated with mortality with unadjusted odds ratios between 1.92 and 16.16. A National Early Warning Score of greater than or equal to 7 had an association with mortality (odds ratio, 2.51 [1.23-5.14]). CONCLUSION Single deranged physiologic parameters at admission are associated with mortality in a critically ill population in a low-income country. As a measure of illness severity, single deranged physiologic parameters are as useful as a compound scoring system in this setting and could be termed "danger signs." Danger signs may be suitable for the basis of routines to identify and treat critically ill patients.
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Magaret A, Angus DC, Adhikari NKJ, Banura P, Kissoon N, Lawler JV, Jacob ST. Design of a multi-arm randomized clinical trial with no control arm. Contemp Clin Trials 2015; 46:12-17. [PMID: 26542388 DOI: 10.1016/j.cct.2015.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 10/30/2015] [Accepted: 11/01/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical trial designs that include multiple treatments are currently limited to those that perform pairwise comparisons of each investigational treatment to a single control. However, there are settings, such as the recent Ebola outbreak, in which no treatment has been demonstrated to be effective; and therefore, no standard of care exists which would serve as an appropriate control. METHODS/DESIGN For illustrative purposes, we focused on the care of patients presenting in austere settings with critically ill 'sepsis-like' syndromes. Our approach involves a novel algorithm for comparing mortality among arms without requiring a single fixed control. The algorithm allows poorly-performing arms to be dropped during interim analyses. Consequently, the study may be completed earlier than planned. We used simulation to determine operating characteristics for the trial and to estimate the required sample size. RESULTS We present a potential study design targeting a minimal effect size of a 23% relative reduction in mortality between any pair of arms. Using estimated power and spurious significance rates from the simulated scenarios, we show that such a trial would require 2550 participants. Over a range of scenarios, our study has 80 to 99% power to select the optimal treatment. Using a fixed control design, if the control arm is least efficacious, 640 subjects would be enrolled into the least efficacious arm, while our algorithm would enroll between 170 and 430. This simulation method can be easily extended to other settings or other binary outcomes. CONCLUSION Early dropping of arms is efficient and ethical when conducting clinical trials with multiple arms.
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Affiliation(s)
- Amalia Magaret
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA.
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Neill K J Adhikari
- Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Banura
- Austere environments Consortium for Enhanced Sepsis Outcomes, Frederick, MD, USA
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia's Children's Hospital and The University of British Columbia, Vancouver, BC, Canada; Department of Emergency Medicine, British Columbia's Children's Hospital and The University of British Columbia, Vancouver, BC, Canada
| | - James V Lawler
- Austere environments Consortium for Enhanced Sepsis Outcomes, Frederick, MD, USA; United States Naval Medical Research Center, Frederick, MD, USA
| | - Shevin T Jacob
- Austere environments Consortium for Enhanced Sepsis Outcomes, Frederick, MD, USA; Department of Medicine, University of Washington, Seattle, WA, USA; International Respiratory and Severe Illness Center (INTERSECT), University of Washington, Seattle, WA, USA
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75
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Chisti MJ, Salam MA, Bardhan PK, Faruque ASG, Shahid ASMSB, Shahunja KM, Das SK, Hossain MI, Ahmed T. Severe Sepsis in Severely Malnourished Young Bangladeshi Children with Pneumonia: A Retrospective Case Control Study. PLoS One 2015; 10:e0139966. [PMID: 26440279 PMCID: PMC4595075 DOI: 10.1371/journal.pone.0139966] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 09/18/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In developing countries, there is no published report on predicting factors of severe sepsis in severely acute malnourished (SAM) children having pneumonia and impact of fluid resuscitation in such children. Thus, we aimed to identify predicting factors for severe sepsis and assess the outcome of fluid resuscitation of such children. METHODS In this retrospective case-control study SAM children aged 0-59 months, admitted to the Intensive Care Unit (ICU) of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh from April 2011 through July 2012 with history of cough or difficult breathing and radiologic pneumonia, who were assessed for severe sepsis at admission constituted the study population. We compared the pneumonic SAM children with severe sepsis (cases = 50) with those without severe sepsis (controls = 354). Severe sepsis was defined with objective clinical criteria and managed with fluid resuscitation, in addition to antibiotic and other supportive therapy, following the standard hospital guideline, which is very similar to the WHO guideline. RESULTS The case-fatality-rate was significantly higher among the cases than the controls (40% vs. 4%; p<0.001). In logistic regression analysis after adjusting for potential confounders, lack of BCG vaccination, drowsiness, abdominal distension, acute kidney injury, and metabolic acidosis at admission remained as independent predicting factors for severe sepsis in pneumonic SAM children (p<0.05 for all comparisons). CONCLUSION AND SIGNIFICANCE We noted a much higher case fatality among under-five SAM children with pneumonia and severe sepsis who required fluid resuscitation in addition to standard antibiotic and other supportive therapy compared to those without severe sepsis. Independent risk factors and outcome of the management of severe sepsis in our study children highlight the importance for defining optimal fluid resuscitation therapy aiming at reducing the case fatality in such children.
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Affiliation(s)
- Mohammod Jobayer Chisti
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Dhaka Hospital, icddr,b, Dhaka, Bangladesh
- * E-mail:
| | - Mohammed Abdus Salam
- Research & Clinical Administration and Strategy (RCAS), icddr,b, Dhaka, Bangladesh
| | - Pradip Kumar Bardhan
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Dhaka Hospital, icddr,b, Dhaka, Bangladesh
| | - Abu S. G. Faruque
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu S. M. S. B. Shahid
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - K. M. Shahunja
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sumon Kumar Das
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Iqbal Hossain
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Dhaka Hospital, icddr,b, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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76
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Serpa Neto A, Schultz MJ, Festic E. Ventilatory support of patients with sepsis or septic shock in resource-limited settings. Intensive Care Med 2015; 42:100-3. [PMID: 26415679 PMCID: PMC4751193 DOI: 10.1007/s00134-015-4070-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 09/20/2015] [Indexed: 12/21/2022]
Affiliation(s)
- Ary Serpa Neto
- Medical Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.
- Program of Post-graduation, Research and Innovation, Faculdade de Medicina do ABC, São Paulo, Brazil.
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.
| | - Emir Festic
- Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA.
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77
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78
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Tupchong K, Koyfman A, Foran M. Sepsis, severe sepsis, and septic shock: A review of the literature. Afr J Emerg Med 2015. [DOI: 10.1016/j.afjem.2014.05.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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79
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Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, Baker T. Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC Res Notes 2015. [PMID: 26205670 PMCID: PMC5501369 DOI: 10.1186/s13104-015-1275-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Critical care saves lives of the young with reversible disease. Little is known about critical care services in low-income countries. In a setting with a shortage of doctors the actions of the nurse bedside are likely to have a major impact on the outcome of critically ill patients
with rapidly changing physiology. Identification of severely deranged vital signs and subsequent treatment modifications are the basis of modern routines in critical care, for example goal directed therapy and rapid response teams. This study assesses how often severely deranged vital signs trigger an acute treatment modification on an Intensive Care Unit (ICU) in Tanzania. Methods A medical records based, observational study. Vital signs (conscious level, respiratory rate, oxygen saturation, heart rate and systolic blood pressure) were collected as repeated point prevalences three times per day in a 1-month period for all adult patients on the ICU. Severely deranged vital signs were identified and treatment modifications within 1 h were noted. Results Of 615 vital signs studied, 126 (18%) were severely deranged. An acute treatment modification was in total indicated in 53 situations and was carried out three times (6%) (2/32 for hypotension, 0/8 for tachypnoea, 1/6 for tachycardia, 0/4 for unconsciousness and 0/3 for hypoxia). Conclusions This study suggests that severely deranged vital signs are common and infrequently lead to acute treatment modifications on an ICU in a low-income country. There may be potential to improve outcome if nurses are guided to administer acute treatment modifications by using a vital sign directed approach. A prospective study of a vital sign directed therapy protocol is underway.
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Affiliation(s)
- Carl Otto Schell
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden. .,Department of Internal Medicine, Medicinkliniken, Nyköping Hospital, Sörmland County Council, 61185, Nyköping, Sweden.
| | - Markus Castegren
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Edwin Lugazia
- Department of Anaesthesia and Intensive Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jonas Blixt
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Moses Mulungu
- Department of Anaesthesia and Intensive Care, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - David Konrad
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Tim Baker
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Global Health - Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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80
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Abstract
The context in which a sepsis guideline is to be used is important and to a large extent determines whether it will be implemented successfully. Factors such as lack of time and resources, lack of reimbursement and organizational constraints may also preclude adoption of guidelines. Thus, sepsis guidelines have been adapted to suit the resources in both resource rich and poor regions of the world. However, even when resources are present, physicians' may not follow guidelines due a myriad of reasons including a lack of agreement with the sepsis guideline or with guidelines in general, as well as lack of motivation and expectations of the desired outcomes. A holistic approach is necessary to address all issues that may be impediments to guideline adoption and adherence. This approach would include a rigorous transparent method to craft the guideline, which includes both clinicians and policy makers and addresses cultural and resource issues.
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Affiliation(s)
- Niranjan Kissoon
- BC Children's Hospital and Sunny Hill Health Centre for Children, University of British Columbia, Canada; Global Child Health, Department of Pediatrics and Emergency Medicine, University of British Columbia, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada.
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81
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Papali A, McCurdy MT, Calvello EJB. A "three delays" model for severe sepsis in resource-limited countries. J Crit Care 2015; 30:861.e9-14. [PMID: 25956595 DOI: 10.1016/j.jcrc.2015.04.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 04/08/2015] [Accepted: 04/14/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE The developing world carries the greatest burden of sepsis-related mortality, but success in managing severe sepsis in resource-limited countries (RLCs) remains challenging. A "three delays" model has been developed to describe factors influencing perinatal mortality in developing nations. This model has been validated across different World Health Organization regions and has provided the framework for policymakers to plan targeted interventions. Here, we propose a three delays model for severe sepsis in RLCs. MATERIALS AND METHODS A literature review was performed using the PubMed, Google Scholar, and Ovid databases. Additional sources were found after review of the reference lists from retrieved articles. RESULTS We propose a three delays model for severe sepsis in adults in RLCs. The model highlights limitations in the 3 basic pillars of sepsis management: (1) sepsis recognition and diagnosis at the time of triage, (2) initial focused resuscitation, and (3) postresuscitation clinical monitoring and reassessment. CONCLUSIONS Characterizing the major barriers to effective treatment of severe sepsis in RLCs frames the problem in a language common to global health circles, which may stimulate further research, streamline treatment, and reduce sepsis-related mortality in the developing world.
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Affiliation(s)
- Alfred Papali
- Division of Pulmonary/Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD.
| | - Michael T McCurdy
- Division of Pulmonary/Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Emilie J B Calvello
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
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82
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The Cauldron: Desert Island ICU: (Organised by the Trainee Committee). J Intensive Care Soc 2015; 16:8-15. [PMID: 28979362 PMCID: PMC5606493 DOI: 10.1177/1751143715577562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2023] Open
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83
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Geiling J, Burkle FM, Amundson D, Dominguez-Cherit G, Gomersall CD, Lim ML, Luyckx V, Sarani B, Uyeki TM, West TE, Christian MD, Devereaux AV, Dichter JR, Kissoon N. Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2015; 146:e156S-67S. [PMID: 25144337 DOI: 10.1378/chest.14-0744] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Planning for mass critical care (MCC) in resource-poor or constrained settings has been largely ignored, despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing MCC in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas. METHODS The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. RESULTS The five key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part 1, Infrastructure/Capacity in this article, and part 2, Response/Recovery/Research in the accompanying article. CONCLUSIONS Lack of, or presence of, rudimentary ICU resources and limited capacity to enhance services further challenge resource-poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.
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84
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Temsah MH. Beyond the guidelines of paediatric septic shock: A focused review. Sudan J Paediatr 2015; 15:16-22. [PMID: 27493431 PMCID: PMC4958657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Severe sepsis and septic shock continue to cause major morbidity and mortality among children, especially in the resource-limited areas. Guidelines that focus on these entities, such as "Surviving Sepsis" and "Paediatric Advanced Life Support" guidelines, are revised and updated on regular basis to incorporate new evidence based medicine. There is ongoing need to review these updated guidelines, and address potentially best available solutions for adapting them into suitable practical steps for paediatricians worldwide, especially those working in resource-limited areas. The available recommendations may help to improve sepsis management in middle- and low-income countries; however, guidelines must be wisely implemented according to the available resources, with follow up auditing to ensure appropriate implementation.
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Affiliation(s)
- Mohamad-Hani Temsah
- Paediatric Intensive Care Unit, King Saud University Medical City, Riyadh, Saudi Arabia
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85
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86
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Abstract
OBJECTIVE To determine the prevalence, treatment, and outcomes of sepsis at regional hospitals in Huai'an, Jiangsu, China. DESIGN Prospective data registry using a descriptive clinical epidemiologic approach through a collaborative network. SETTING Pediatric departments in 11 regional city and county referral hospitals serving 843,000 children (exclusive of neonates). SUBJECTS All admissions (n = 27,836) of patients from 28 days to 15 years old from September 1, 2010, to August 31, 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,530 patients met the 2005 international consensus definition of sepsis, corresponding to an estimated incidence of 181/100,000 children, with 80% under 5 years old, and in 10% (153), severe sepsis or septic shock developed. The overall case fatality rate for sepsis was 3.5% (53/1,530) or 34.6% (53/153) in those in whom severe sepsis or septic shock developed. Treatment varied widely and in many instances did not conform to international guidelines as reflected by inadequate use of antibiotics, corticosteroids, vasoactive agents, and inotropes. CONCLUSIONS We first report the prevalence and outcome of pediatric sepsis based on a regional hospital network in China. The diverse treatment approaches and practice at low-level clinics suggest the need for clinical implementation of internationally recognized strategy to improve the care standard in resource-limited regional hospitals.
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Affiliation(s)
- Vanessa B Kerry
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Center for Global Health, Massachusetts General Hospital, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Seed Global Health, Boston, MA, USA.
| | - Sadath Sayeed
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Seed Global Health, Boston, MA, USA; Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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88
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Bhagwanjee S, Ugarte S. Sepsis in vulnerable populations. Glob Heart 2014; 9:281-8. [PMID: 25667179 DOI: 10.1016/j.gheart.2014.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/18/2014] [Indexed: 12/29/2022] Open
Abstract
Despite the acquisition of a large body of evidence, there are many unanswered questions about sepsis. The definition of this disease is plagued by the lack of a simple pathophysiological description linking cause to effect and the activation of host immune responses that hinders disease progression at the same time producing multiorgan dysfunction. A plethora of inconsistent clinical features has served to obfuscate rather than illuminate. The Surviving Sepsis Guidelines (SSG) are a major advance because it comprehensively interrogates all aspects of care for the critically ill. For vulnerable populations living in low- and middle-income countries, this guideline is ineffectual because of the lack of region-specific data, differences in etiology of sepsis and burden of disease, limited human capacity and infrastructure, as well as socioeconomic realities. Appropriate care must be guided by common sense guidelines that are sensitive to local realities and adapted as relevant data are acquired.
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Affiliation(s)
- Satish Bhagwanjee
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA.
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89
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Stafford RE, Morrison CA, Godfrey G, Mahalu W. Challenges to the provision of emergency services and critical care in resource-constrained settings. Glob Heart 2014; 9:319-23. [PMID: 25667183 DOI: 10.1016/j.gheart.2014.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 08/07/2014] [Accepted: 08/08/2014] [Indexed: 11/29/2022] Open
Abstract
The practice of intensive care unit (ICU) care in Sub-Saharan Africa is challenging and can have a significant impact on the lives of people in the region. Sub-Saharan Africa bears a disproportionate global burden of disease compared with the rest of the world. Inadequate emergency care services and transportation infrastructure; long lead times to hospital admission, evaluation, treatment and transfer to ICU; inadequate ICU and hospital infrastructure and, unreliable consumable and medical equipment supply chains all present significant challenges to the provision of ICU care in Sub-Saharan Africa. These challenges, coupled with an inadequate supply of trained healthcare workers and biomedical technicians and a lack of formal ICU-related research in Sub-Saharan Africa, would seem to be insurmountable. However, ICU care is being provided in district and regional hospitals throughout the region. We describe some of the challenges to the provision of emergency services and critical care in Tanzania.
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Affiliation(s)
- Renae E Stafford
- Catholic University of Health and Allied Sciences, Wurzburg Road, Mwanza, Tanzania; Sengerema Designated District Hospital, Sengerema, Tanzania; Touch Foundation, Mwanza, Tanzania.
| | - Catherine A Morrison
- Catholic University of Health and Allied Sciences, Wurzburg Road, Mwanza, Tanzania; Sengerema Designated District Hospital, Sengerema, Tanzania; Touch Foundation, Mwanza, Tanzania
| | - Godwin Godfrey
- Catholic University of Health and Allied Sciences, Wurzburg Road, Mwanza, Tanzania
| | - William Mahalu
- Catholic University of Health and Allied Sciences, Wurzburg Road, Mwanza, Tanzania
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90
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De Silva AP, Stephens T, Welch J, Sigera C, De Alwis S, Athapattu P, Dharmagunawardene D, Olupeliyawa A, de Abrew A, Peiris L, Siriwardana S, Karunathilake I, Dondorp A, Haniffa R. Nursing intensive care skills training: a nurse led, short, structured, and practical training program, developed and tested in a resource-limited setting. J Crit Care 2014; 30:438.e7-11. [PMID: 25466312 DOI: 10.1016/j.jcrc.2014.10.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 10/21/2014] [Accepted: 10/26/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To assess the impact of a nurse-led, short, structured training program for intensive care unit (ICU) nurses in a resource-limited setting. METHODS A training program using a structured approach to patient assessment and management for ICU nurses was designed and delivered by local nurse tutors in partnership with overseas nurse trainers. The impact of the course was assessed using the following: pre-course and post-course self-assessment, a pre-course and post-course Multiple Choice Questionnaire (MCQ), a post-course Objective Structured Clinical Assessment station, 2 post-course Short Oral Exam (SOE) stations, and post-course feedback questionnaires. RESULTS In total, 117 ICU nurses were trained. Post-MCQ scores were significantly higher when compared with pre-MCQ (P < .0001). More than 95% passed the post-course Objective Structured Clinical Assessment (patient assessment) and SOE 1 (arterial blood gas analysis), whereas 76.9% passed SOE 2 (3-lead electrocardiogram analysis). The course was highly rated by participants, with 98% believing that this was a useful experience. CONCLUSIONS Nursing Intensive Care Skills Training was highly rated by participants and was effective in improving the knowledge of the participants. This sustainable short course model may be adaptable to other resource-limited settings.
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Affiliation(s)
- A Pubudu De Silva
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo, Sri Lanka; Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Tim Stephens
- Simulation and Essential Clinical Skills Department, Barts Health NHS Trust, London, United Kingdom
| | - John Welch
- Critical Care Department, University College Hospitals Foundation Trust, London, United Kingdom
| | - Chathurani Sigera
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo, Sri Lanka
| | - Sunil De Alwis
- Office of Deputy Director General (Education, Training and Research), Ministry of Health, Colombo, Sri Lanka
| | - Priyantha Athapattu
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo, Sri Lanka; Office of Director Tertiary Care Health, Ministry of Health, Colombo, Sri Lanka
| | - Dilantha Dharmagunawardene
- Office of Deputy Director General (Education, Training and Research), Ministry of Health, Colombo, Sri Lanka
| | - Asela Olupeliyawa
- Medical Education Development and Research Centre, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Ashwini de Abrew
- Medical Education Development and Research Centre, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Lalitha Peiris
- Post Basic College of Nursing, Ministry of Health, Colombo, Sri Lanka
| | - Somalatha Siriwardana
- Office of Deputy Director General (Education, Training and Research), Ministry of Health, Colombo, Sri Lanka
| | - Indika Karunathilake
- Medical Education Development and Research Centre, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Arjen Dondorp
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand
| | - Rashan Haniffa
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo, Sri Lanka; Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand; Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
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91
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Systems for Paediatric Sepsis: A Global Survey. W INDIAN MED J 2014; 63:703-10. [PMID: 25867557 DOI: 10.7727/wimj.2013.326] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 01/21/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To evaluate the resources available for early diagnosis and treatment of paediatric sepsis at hospitals in developing and developed countries. METHODS This was a voluntary online survey involving 101 hospitals from 41 countries solicited through the World Federation of Pediatric Intensive and Critical Care Societies contact list and website. The survey was designed to assess the spectrum of sepsis epidemiology, patterns of applied therapies, availability of resources and barriers to optimal sepsis treatment. RESULTS Ninety per cent of respondents represented a tertiary or general hospital with paediatric intensive care facilities, including 63% from developed countries. Adequate triage services were absent in more than 20% of centres. Insufficiently trained personnel and lack of a sepsis protocol was reported in 40% of all sites. While there were specific guidelines for sepsis management in 78% of centres (n = 100), protocols for assessing sepsis patients were not applied in nearly 70% of centres. Lack of parental recognition of sepsis and failure of referring centres to diagnose sepsis were identified as major barriers by more than 50% of respondents. CONCLUSIONS Even among centres with no significant resource constraints and advanced medical systems, significant deficits in sepsis care exist. Early recognition and management remain a key issue and may be addressed through improved triage, augmented support for referring centres and public awareness. Focussed research is necessary at the institutional level to identify and address specific barriers.
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92
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Sarmin M, Ahmed T, Bardhan PK, Chisti MJ. Specialist hospital study shows that septic shock and drowsiness predict mortality in children under five with diarrhoea. Acta Paediatr 2014; 103:e306-11. [PMID: 24661049 DOI: 10.1111/apa.12640] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/13/2014] [Accepted: 03/19/2014] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the clinical characteristics and outcome in children hospitalised with diarrhoea, comparing those developed septic shock with those who did not. METHODS We carried out a retrospective chart review on children aged 0-59 months admitted to the Dhaka Hospital, International Centre for Diarrhoeal Diseases Research, Bangladesh, with diarrhoea between October 2010 and September 2011. They were included if they had severe sepsis defined as tachycardia plus hyperthermia or hypothermia or an abnormal white blood cell count plus poor peripheral perfusion in absence of dehydration. Patients unresponsive to fluid and boluses, who required inotropes, were categorised as having septic shock (n = 88). The controls were those without septic shock (n = 116). RESULTS Death was significantly higher among the children with septic shock (67%) than the controls (14%) (p < 0.001). A logistic regression analysis, adjusted for potential confounders, found that children with septic shock were more likely to be drowsy on admission and received blood transfusions and mechanical ventilation (all p < 0.05). CONCLUSION Children hospitalised for diarrhoea with septic shock were more likely to die, be drowsy on admission and receive blood transfusions and mechanical ventilation. A randomised clinical trial on inotropes in children with diarrhoea, severe sepsis and drowsiness may expedite their use and prevent mechanical ventilation and deaths.
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Affiliation(s)
- Monira Sarmin
- Clinical Service (CS); International Centre for Diarrhoeal Disease Research; Bangladesh (icddr,b); Dhaka Bangladesh
| | - Tahmeed Ahmed
- Centre for Nutrition & Food Security; International Centre for Diarrhoeal Disease Research; Bangladesh (icddr,b); Dhaka Bangladesh
| | - Pradip K. Bardhan
- Clinical Service (CS); International Centre for Diarrhoeal Disease Research; Bangladesh (icddr,b); Dhaka Bangladesh
- Centre for Nutrition & Food Security; International Centre for Diarrhoeal Disease Research; Bangladesh (icddr,b); Dhaka Bangladesh
| | - Mohammod J. Chisti
- Clinical Service (CS); International Centre for Diarrhoeal Disease Research; Bangladesh (icddr,b); Dhaka Bangladesh
- Centre for Nutrition & Food Security; International Centre for Diarrhoeal Disease Research; Bangladesh (icddr,b); Dhaka Bangladesh
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93
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Abstract
The care of the critically ill patient in low-resource settings is challenging because of many factors, including limitations in the existing infrastructure, lack of disposables, and low numbers of trained healthcare workers. Although cost constraints in low-resource settings have traditionally caused critical care to be relegated to a low priority, ethical issues and the potential for mitigation of the lethal effects of often reversible acute conditions, such as sepsis and traumatic hemorrhage, argue for prudent deployment of critical care resources. Given these challenges, issues that require prioritization include timely and reliable delivery of evidence-based or generally accepted interventions to acutely ill patients before the development of organ failure, context-specific adaptation and evaluation of clinical evidence, and sustained investments in quality improvement and health systems strengthening. Specific examples include fluid resuscitation algorithms for patients with sepsis and reliable, low-cost, high-flow oxygen concentrators for patients with pneumonia. The lessons from new research on clinical management and sustainable education and quality improvement approaches will likely improve the care of critically ill patients worldwide.
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94
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Ortiz JR, Jacob ST, West TE. Clinical care for severe influenza and other severe illness in resource-limited settings: the need for evidence and guidelines. Influenza Other Respir Viruses 2014; 7 Suppl 2:87-92. [PMID: 24034491 PMCID: PMC5909399 DOI: 10.1111/irv.12086] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The 2009 influenza A (H1N1) pandemic highlighted the importance of quality hospital care of the severely ill, yet there is evidence that the impact of the 2009 pandemic was highest in low‐ and middle‐income countries with fewer resources. Recent data indicate that death and suffering from seasonal influenza and severe illness in general are increased in resource‐limited settings. However, there are limited clinical data and guidelines for the management of influenza and other severe illness in these settings. Life‐saving supportive care through syndromic case management is used successfully in high‐resource intensive care units and in global programs such as the Integrated Management of Childhood Illness (IMCI). While there are a variety of challenges to the management of the severely ill in resource‐limited settings, several new international initiatives have begun to develop syndromic management strategies for these environments, including the World Health Organization's Integrated Management of Adult and Adolescent Illness Program. These standardized clinical guidelines emphasize syndromic case management and do not require high‐resource intensive care units. These efforts must be enhanced by quality clinical research to provide missing evidence and to refine recommendations, which must be carefully integrated into existing healthcare systems. Realizing a sustainable, global impact on death and suffering due to severe influenza and other severe illness necessitates an ongoing and concerted international effort to iteratively generate, implement, and evaluate best‐practice management guidelines for use in resource‐limited settings.
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Affiliation(s)
- Justin R Ortiz
- International Respiratory and Severe Illness Center (INTERSECT), University of Washington, Seattle, WA, USA
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95
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Kissoon N. Sepsis guideline implementation: benefits, pitfalls and possible solutions. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:207. [PMID: 25028802 PMCID: PMC4055980 DOI: 10.1186/cc13774] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Kiguli S, Akech SO, Mtove G, Opoka RO, Engoru C, Olupot-Olupot P, Nyeko R, Evans J, Crawley J, Prevatt N, Reyburn H, Levin M, George EC, South A, Babiker AG, Gibb DM, Maitland K. WHO guidelines on fluid resuscitation in children: missing the FEAST data. BMJ 2014; 348:f7003. [PMID: 24423891 PMCID: PMC5693317 DOI: 10.1136/bmj.f7003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Sarah Kiguli
- Department of Paediatrics, Mulago Hospital, Makerere University, Kampala, Uganda
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Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 2013; 40:182-191. [PMID: 24146003 DOI: 10.1007/s00134-013-3131-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/04/2013] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting. METHODS This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. The program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. The network administration and an external consultant provided performance feedback and benchmarking within the network. The primary outcome was compliance with the resuscitation bundle. The secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness. RESULTS The proportion of patients who received all the required items for the resuscitation bundle improved from 13% [95% confidence interval (CI) 8-18%] at baseline to 62% (95% CI 54-69%) in the last trimester (p < 0.001). Hospital mortality decreased from 55% (95% CI 48-62%) to 26% (95% CI 19-32%, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95% CI 0.56-0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95% CI 23.9-35.4) to 17.5 (95% CI 14.3-21.1) thousand US dollars from baseline to the last 3 months (mean difference -11,815; 95% CI -18,604 to -5,338). The mean QALY increased from 2.63 (95% CI 2.15-3.14) to 4.06 (95% CI 3.58-4.57). For each QALY, the full compliance saves US$5,383. CONCLUSIONS A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. The intervention was cost-effective and associated with a reduction in mortality.
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Adhikari NKJ. Patient safety without borders: measuring the global burden of adverse events. BMJ Qual Saf 2013; 22:798-801. [PMID: 23996095 DOI: 10.1136/bmjqs-2013-002396] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Neill K J Adhikari
- Interdepartmental Division of Critical Care, University of Toronto, , Toronto, Canada
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Preventing intensive care admissions for sepsis in tropical Africa (PICASTA): an extension of the international pediatric global sepsis initiative: an African perspective. Pediatr Crit Care Med 2013; 14:561-70. [PMID: 23823191 DOI: 10.1097/pcc.0b013e318291774b] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Global Sepsis Initiative recommends prevention of sepsis through immunizations, vitamins, breast feeding, and other important interventions. In our study, we consider a second set of proposals for preventing intensive care admissions for sepsis in tropical Africa, which have been specifically designed to further prevent ICU admissions for sepsis in the group A nation hospital setting. OBJECTIVES To reduce admissions with severe sepsis in an ICU of a group A nation through the identification of challenges leading to preventable, foreseeable, or nosocomial sepsis specific to our setting. METHODS Malawi is one of the poorest countries in the world. Lacking the ability to comply with standard sepsis treatment, we conducted over 4 years several studies, audits, and surveys to identify challenges leading to preventable pediatric sepsis in our setting. We developed a method to identify malnourished children through a "gatekeeper" in the theaters without any equipment, tried to implement the World Health Organization's Safe Surgery Campaign checklist, evaluated our educational courses for the districts to improve the quality of referrals, looked into the extreme fasting times discovered in our hospital, trained different cadres in the districts to deal with peripartal and posttraumatic sepsis, and identified the needs in human resources to deal with pediatric sepsis in our setting. RESULTS Six foci were identified as promising to work on in future. Focus 1: Preventing elective operations and procedures in malnourished children in the hospital and in the district: 134 of 145 nurses (92.4%) and even 25 of 31 African laymen (80.6%) were able to identify malnourished children with their own fingers. Focus 2: Preventing sepsis-related problems in emergencies through the implementation of the Safe Surgery Campaign checklist: only 100 of 689 forms (14.5%) were filled in due to challenges in ownership, communication responsibility, and time constraints. Focus 3: Preventing sepsis through the reduction of unwise referrals: our courses toward this topic reached 82-100% satisfaction of the 391 participants for relevance, presentation applicability, content, and teaching technique. Focus 4: Preventing sepsis-related problems through reduction of excessive fasting times in our hospital: necessity for action was documented by a mean fasting time of 10.2 hours (SD, 4.4 hr). Focus 5: Concentration on two extremely sepsis-relevant health challenges for children in Malawian districts, trauma and peripartal complications: numbers after our courses in the trained two districts showed a reduction in the maternal mortality rate (from 150.3 to 55 and 234.2 to 75.2), an inconclusive result for posttraumatic deaths and the identification of 44 future instructors. Focus 6: Implementation of a Master in Medicine (anesthesia and intensive care) and improvement of training in anesthesia for all cadres resulted in the first five anesthetic registrars in training and enhanced numbers in all other cadres in anesthesia dealing in own responsibility with pediatric sepsis. CONCLUSIONS Every hospital can try to improve sepsis prevention on a local level by the Preventing Intensive Care Admissions for Sepsis in Tropical Africa approach. This will help support the promotion of the regionally adjusted Global Sepsis Initiative guidelines and the future global implementation of feasible bundles as a gold standard for resource-poor countries.
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