African Federation for Emergency Medicine. African Journal of Emergency Medicine.

Transcription

1 African Journal of Emergency Medicine (2012) 2, African Federation for Emergency Medicine African Journal of Emergency Medicine Reflections from a Canadian visiting South Africa: Advancing sepsis care in Africa with the development of local sepsis guidelines Réflexions d un Canadien lors d un se jour en Afrique du Sud: Faire progresser la prise en charge du sepsis graˆce a` l e laboration de directives locales sur le sepsis Robert S. Green *, on behalf of the Canadian Association of Emergency Physicians Critical Care Committee Department of Emergency Medicine, Department of Anesthesia, Division of Critical Care Medicine, Queen Elizabeth II Health Science Centre, Capital District Health Association, Canada Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada Received 16 January 2012; revised 18 March 2012; accepted 26 March 2012 Available online 20 April 2012 KEYWORDS Sepsis; Guidelines; Emergency medicine; Africa Abstract The objective of this article is to outline the key concepts in the care of the severely septic patient in the ED, and to provide lessons learned from an author of the Canadian Sepsis Guidelines. The goal for the African emergency physicians should be to develop local protocols and guidelines based on the resources and skill sets available in African communities in an attempt to provide timely and expert care for this patient population. ª 2012 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved. * Address: Department of Emergency Medicine, Department of Anesthesia, Division of Critical Care Medicine, Room 377 Bethune Building, 1276 South Park Street, Halifax, Nova Scotia, Canada B3H 2Y9. Tel.: address: Dr.Robert.Green@dal.ca X ª 2012 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of African Federation for Emergency Medicine. Production and hosting by Elsevier

2 Reflections from a Canadian visiting South Africa: Advancing sepsis care in Africa 91 KEYWORDS Sepsis; Guidelines; Emergency medicine; Africa Abstract L objectif de cet article est de décrire les concepts cle s de la prise en charge d un patient atteint de sepsis sévère par le service des urgences (SU), et de fournir les lec ons tirées d un auteur des Directives canadiennes sur le sepsis. L objectif des me decins urgentistes africains devrait être de développer des protocoles et directives locaux basés sur les ressources et compe tences disponibles dans les communaute s africaines afin de tenter de fournir une prise en charge opportune et professionnelle à cette population de patients. ª 2012 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved. African relevance Sepsis is a major cause of morbidity and mortality in all parts of the world, including Africa. A sepsis guideline that addresses the unique challenges in Africa would benefit both African patients and health care providers. The principles of early sepsis management have been outlined in other guidelines, including the Canadian Association of Emergency Medicine s Sepsis Guidelines. Lessons learned during the creation of other sepsis guidelines may be of use in the development of African-specific guidelines. What s new Early expert sepsis care can save lives. African-specific guidelines should be developed to address unique challenges within Africa. Other sepsis guidelines can serve as a resource for African Sepsis Guidelines. Introduction The management of patients with severe sepsis and septic shock is of paramount importance to emergency physicians from all over the world. 1 The burden of illness is extremely high, with mortality in western centres ranging from 30% to 50%. 1 4 The timeliness and expertise in the diagnosis and management of severe sepsis in the emergency centre (EC) phase of care have a significant impact on patient outcome. 5,6 Several guidelines are available for the management of the severely septic patient. 7 9 For the most part, these guidelines do not consider the important differences in medical systems and, specifically, the unique challenges relevant to emergency physicians practicing in Africa. 8,9 The Canadian Association of Emergency Physicians (CAEP) Critical Care Committee (C4) had developed a national guideline for the management of patients with severe sepsis/septic shock in Canadian emergency centres, with special consideration of unique factors in the Canadian medical system. 7 Although some of the key concepts in these and other guidelines may be relevant to the management of severe sepsis/septic shock in African emergency centres, adoption of guidelines not specifically developed for African countries without consideration of local issues in medical care would unlikely be successful However, lessons learned during the development of these guidelines may aid in the production of local protocols and guidelines to improve sepsis care in Africa. The goal of this article is to outline the key concepts in the care of the severely septic patient in the EC, and to provide lessons learned from an author of the Canadian Sepsis Guidelines. The goal for the African emergency physicians should be to develop local protocols and guidelines based on the resources and skill sets available in African communities in an attempt to provide timely and expert care for this patient population (see Table 1). 10 Patient identification The definition of sepsis is a combination of (1) the suspected presence of an infection and (2) two (P2) or more of the systemic inflammatory response syndrome (SIRS) criteria. 13 The SIRS criteria include elevated (>38 C) or low temperature (<36 C); tachycardia (>90 beats/min); increased respiratory rate (>20 breaths/min); or a white count that is either high or low (>12 or <4). In the EC, defining a suspected infection may be challenging, as patient presentation can range from non-specific complaints to system specific indicators of infection (ex: decreased level of consciousness and meningismus in meningitis, and shortness of breath, hypoxia, and sputum production with pneumonia). Clinicians should be aware that SIRS is the result of nonspecific physiologic responses to cytokine release and may result from many non-infectious disease processes such as trauma, emotional liability, exercise, and burns. 7 Although the definition of sepsis may be non-specific, it provides a framework for patient identification (see Table 2). Early administration of broad spectrum antimicrobials Immediate administration of broad spectrum intravenous antimicrobial medications to patients with severe sepsis/septic shock is a cornerstone in optimal sepsis resuscitation. 7,8 Data indicate the time sensitive importance of antimicrobial administration, with a mortality increase of 7.6% per hour when appropriate antimicrobials are delayed in North American patients with septic shock. 14 Antimicrobial regimes should be based on the presumed infected organ system (CNS, respiratory, abdominal, neurologic, cutaneous, etc.) and should also be based on local antimicrobial resistance patterns. It is important that all potential pathogens be susceptible to the antimicrobial administered, as insufficient or ineffective antimicrobial administration is

3 92 R.S. Green Table 1 Key issues in the management of the severely septic patient. 7 Principle Clinical points 1. Patient identification Use of sepsis definition: infection + 2 P SIRS (Table 2) 2. Early administration of broad spectrum antimicrobials Antimicrobials should be stored in an easily accessed area to assist in rapid intravenous administration within 1 h of the diagnosis of severe sepsis 3. Aggressive resuscitation Institute intravascular volume expansion with crystalloid fluids and vasopressor medications to minimize tissue hypoperfusion 4. Measurement of tissue hypoxia Serial measurements of either serum lactate or SVO 2. Improvement (normalization) indicates optimal resuscitation 5. Source control Identification and drainage of any infected collections Table 2 Definition of sepsis in the EC. 13 Criteria Presence of a known or suspected infection Systemic inflammatory response syndrome (SIRS) Clinical points Definitive confirmation of infection not required; suspicion of infection adequate Patient must have 2 or more (P2) of the following: 1. Heart rate P90 beats per minute 2. Respiratory rate P20 per minute or PCO mmhg 3. Temperature P38 C or636 C 4. WBC P12 or 64, or P10% bands associated with increased mortality. Specific antimicrobial regimes based on western guidelines would be inappropriate in African centres, as the microbes involved, drugs available, and resistance patterns differ substantially. Aggressive resuscitation Various resuscitation protocols and guidelines are available for severe sepsis/septic shock in the literature. 7 9,15 17 Aggressive resuscitation often requires the administration of intravenous fluids and vasopressor medications to reverse global tissue hypoxia secondary to vasodilatory shock and relative intravascular volume deficits. The choices of intravascular fluids available vary widely. In most circumstances, crystalloid resuscitation (0.9% saline or Ringer s lactate) is the appropriate first choice for patients with severe sepsis/septic shock. 7 The goal of intravascular volume resuscitation should be to stabilize hemodynamic derangements, with a mean arterial pressure (MAP) goal P60 mmhg and a central venous pressures 8 12 mmhg (as a measure of intravascular circulation volume). In studies of volume resuscitation in severe sepsis, it is not uncommon for patients to require 4 8 L of crystalloid in the first 6 h after presenting to the EC. 3 At present, there is little evidence to support the use of colloids (albumin or hydroxyl-ethyl starches) in the resuscitation of patients with severe sepsis/septic shock in the EC. 18 Contamination of sterile body tissues by micro-organisms causes a pro-inflammatory cytokine release resulting in vasoplegia and a vasodilatory shock state. 19 The use of vasopressor medications targeting vessel wall smooth muscle alpha-receptors reverse vasoplegia is required in the majority of patients with severe sepsis/septic shock. However, vasopressor medications should be administered through a central venous catheter so that ischaemic complications are minimized. Unfortunately, cannulation of central veins is often challenging for emergency physicians. Data from Canada indicate that this may be a significant barrier to expert resuscitation of severe sepsis. 20,21 Despite this, the reversal of hypotension and tissue hypoxia is paramount, and clinicians should rapidly administer a vasopressor medication if required. Recommended vasopressors include norepinephrine and/or dopamine. Measurement of tissue hypoxia It has become clear that the identification of tissue hypoxia is important in patients with severe sepsis/septic shock. Patients with ongoing tissue hypoxia after resuscitation have poorer outcomes than those who do not. In one study, the SVO 2 (saturation of the blood returning to the heart as measured from a central venous catheter located close to the right atrium) was utilized to measure tissue hypoxia, and treatment decisions were based on repeated measures in an attempt to rapidly reverse the shock state. 3 An alternative study utilized serum lactates in a similar manner. 22 It is unknown which marker of tissue hypoxia is optimal. However, the measurement of serum lactate holds a promise, as it does not require the cannulation of a central vein, as SCVO 2 measurement does. Serum lactates can be performed from a venous site with proper technique and the decay of the high lactate after resuscitation has been demonstrated to be associated with improved patient outcomes. Source control Antimicrobials are unlikely to successfully eradicate a mature focus of infection. The drainage of any accumulated infected body fluid is an important management principle in patients with severe sepsis/septic shock. Patients with empyema, intra-abdominal abscesses, cutaneous abscess, or an obstructed kidney should have the appropriate procedure performed as soon as it is feasible. The time to the invasive procedure being performed and drainage of the infected fluid may be important in patient outcome.

4 Reflections from a Canadian visiting South Africa: Advancing sepsis care in Africa 93 Lessons learned from the development of the Canadian Association of Emergency Physicians Guidelines and the Management of Severe Sepsis and Septic Shock in the Emergency Centre The identification of sepsis champions Engaged and dedicated personnel are required for the development of sepsis protocols and guidelines. The identification of opinion leaders and/or local champions for the development of sepsis guidelines is paramount. Sepsis guidelines need to balance optimal care in the face of practice variation and limitations in resources. Sepsis champions may include emergency physicians, nurses, paramedics, allied health or various specialists (among others) with a keen interest in the management of early septic shock. The engagement of these individuals to determine key points in the management of severe sepsis based on local issues will aid in the development and adoption of relevant and usable sepsis protocols and guidelines. Substantial resources are not required for the production of sepsis guidelines The development of sepsis protocols and guidelines do not require substantial financial support, other than the time required for dedicated sepsis champions. The CAEP sepsis guidelines were created with minimal cost. The most important cost is the time required to organize, produce and disseminate protocols and guidelines. The pertinent literature is available for free. Other guidelines should be used as a resource Although it is recommended that guidelines for severe sepsis/ septic shock in Africa be developed independently, other similar guidelines should be utilized as a resource. Guidelines need to be developed in conjunction with the realities of resource availability in the target user groups. Although the available guidelines may offer a basic outline and rationale for key sepsis management principles, they are unlikely to adequately address all relevant elements important in the African clinical environment. Determination of key issues in the management of septic shock, based on local factors Although some key points in the management of the severely septic patient are universal, such as early identification, early antimicrobial therapy, aggressive resuscitation and source control, other factors may be of equal importance. Issues such as the ability to determine a patient s white count in a timely manner, to determine lactate levels or SCVO 2 levels on an emergent basis, or access to vasopressor and antimicrobial medications is of importance in the development of guidelines. Various centres will have different issues, and developers of sepsis protocols/guidelines need to consider all factors when producing local protocols and guidelines. Consideration of local factors relevant to the provision of septic care Local factors, ranging from medical system related limitations, medication and equipment availability, and physician and nursing skill are need to be considered for protocols and guidelines to make a meaningful improvement in patient care. Medical system related factors, such as how patients arrive at hospital, how (and by whom) they are assessed and triaged, and the availability of skilled personnel to diagnosis and institute management in a rapid basis, vary widely. Antimicrobials, basic resuscitation equipment and time sensitive tests (serum lactates) may also differ substantially, and need to be considered. Physician and nursing skill and availability are vital considerations for any sepsis guidelines. Dissemination of guidelines Sepsis protocols and guidelines are only useful if they improve patient care and outcomes. The dissemination of sepsis guidelines to clinicians caring for this patient population should be considered during the planning phase of any sepsis guidelines. The publication of national guidelines or continent-specific guidelines is important for dissemination, and journals such as the African Journal of Emergency Medicine target the relevant clinician population. Conclusion Severe sepsis and septic shock are universal killers, not specific to North America or Europe. The continent of Africa has unique challenges and variable resources available for the management of this patient population. The development of severe sepsis/septic shock protocols and guidelines based on the local resources and other important factors is essential to improve sepsis care in Africa. Local champions should be engaged to develop clinically relevant guidelines to optimize patient outcomes in African patients with severe sepsis/septic shock. Financial support No financial support was received for the duration of this study. Conflict of interest The author declares no actual or potential conflicts of interest. Appendix A. Short answer questions Test your understanding of the contents of this paper (answers can be found at the end of the regular features section) 1. Patient identification in sepsis is based on the presence of an infection and at least 2 out of 4 criteria of what syndrome? a Multi-organ dysfunction syndrome b Acute respiratory distress syndrome c Cushing s syndrome d Systemic inflammatory response syndrome (SIRS) e Neuroleptic malignant syndrome 2. One of the most important management principles is severe sepsis is: a Insertion of a Foley catheter b Rapid administration of appropriate antimicrobials c Determining the white blood count

5 94 R.S. Green d Performing a lumbar puncture e Arranging admission to hospital 3. Sepsis guidelines should be developed for patients in Africa because a African health care provider face unique challenges which are not addressed in other sepsis guidelines b Authors of other guidelines do not want to share c Pharmaceutical companies think it would increase their profits d They are easy to produce References 1. Angus DC, Pereira CA, Silva E. Epidemiology of severe sepsis around the world. Endocr Metab Immune Disord Drug Targets 2006;6(2): Rivers E. The outcome of patients presenting to the emergency department with severe sepsis or septic shock. Crit Care 2006;10(4): Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345(19): Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29(7): Nee PA. Critical care in the emergency department: severe sepsis and septic shock. Emerg Med J 2006;23(9): Shapiro N, Howell MD, Bates DW, Angus DC, Ngo L, Talmor D. The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection. Ann Emerg Med 2006;48(5): Green RS, Djogovic D, Gray S, Howes D, Brindley PG, Stenstrom R, et al. Canadian association of emergency physicians sepsis guidelines: the optimal management of severe sepsis in Canadian emergency departments. CJEM 2008;10(5): Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med 2008;36(1): Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32(3): Jacob ST, West TE, Banura P. Fitting a square peg into a round hole: are the current surviving sepsis campaign guidelines feasible for Africa? Crit Care 2011;15(1): Bataar O, Lundeg G, Tsenddorj G, Jochberger S, Grander W, Baelani I, et al. Nationwide survey on resource availability for implementing current sepsis guidelines in Mongolia. Bull World Health Organ 2010;88(11): Baelani I, Jochberger S, Laimer T, Otieno D, Kabutu J, Wilson I, et al. Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self-reported, continentwide survey of anaesthesia providers. Crit Care 2011;15(1):R Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM consensus conference committee. American college of chest physicians/society of critical care medicine. Chest 1992;101(6): Kumar A, Haery C, Paladugu B, Kumar A, Symeoneides S, Taiberg L, et al. The duration of hypotension before the initiation of antibiotic treatment is a critical determinant of survival in a murine model of escherichia coli septic shock: association with serum lactate and inflammatory cytokine levels. J Infect Dis 2006;193(2): Green R. CAEP C4 sepsis guidelines. CJEM 2009;11(4): De Miguel-Yanes JM, Andueza-Lillo JA, Gonzalez-Ramallo VJ, Pastor L, Munoz J. Failure to implement evidence-based clinical guidelines for sepsis at the ED. Am J Emerg Med 2006;24(5): Nguyen HB, Corbett SW, Menes K, Cho T, Daugharthy J, Klein W, et al. Early goal-directed therapy, corticosteroid, and recombinant human activated protein C for the treatment of severe sepsis and septic shock in the emergency department. Acad Emerg Med 2006;13(1): Reinhart K, Bloos F, Engle C. Hydroxyethyl starch and ringer s lactate for fluid resuscitation in patients with severe sepsis results from the VISEP study. Intensive Care Med 2006;32(Suppl. 1):S Russell JA. Management of sepsis. N Engl J Med 2006;355(16): Green RS, MacIntyre JK. Critical care in the emergency department: an assessment of the length of stay and invasive procedures performed on critically ill ED patients. Scand J Trauma Resusc Emerg Med 2009;17: Green RS, McIntyre J. The provision of critical care in emergency departments at Canada. J Emerg Trauma Shock 2011;4(4): Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA 2010;303(8):