Management of Adult Sepsis in Resource-Limited Settings: Global Expert Consensus Statements Using a Delphi Method

Author:

Thwaites Louise1,Nasa Prashant2,Abbenbroek Brett3,Dat Vu Quoc4,Finfer Simon3,Kwizera Arthur5,Ling Lowell6,Lobo Suzana M7,Sinto Robert8,Aditianingsih Dita8,Antonelli Massimo9,Arabi Yaseen M10,Argent Andrew11,Azevedo Luciano12,Bennett Elizabeth13,Chakrabarti Arunaloke14,De Asis Kevin15,De Waele Jan16,Divatia Jigeeshu Vasishtha17,Estenssoro Elisa18,Evans Laura19,Faiz Abul20,Hammond Naomi E3,Hashmi Madiha21,Herridge Margaret S22,Jacob Shevin T23,Jatsho Jimba24,Javeri Yash25,Khalid Karima26,Chen Lie Khie8,Levy Mitchell27,Lundeg Ganbold28,Machado Flavia R29,Mehta Yatin30,Mer Mervyn31,Son Do Ngoc32,Ospina-Tascón Gustavo A33,Ostermann Marlies34,Permpikul Chairat35,Prescott Hallie C36,Reinhart Konrad37,Vega Gloria Rodriguez38,S-Kabara Halima39,Shrestha Gentle S40,Siika Wangari41,Tan Toh Leong42,Todi Subhash43,Tripathy Swagata44,Venkatesh Bala3,Vincent Jean-Louis45,Myatra Sheila Nainan46ORCID

Affiliation:

1. Oxford University Clinical Research Unit

2. Royal Wolverhampton Hospitals NHS Trust

3. The George Institute for Global Health

4. Hanoi Medical University

5. Makerere University College of Health Sciences

6. The Chinese University of Hong Kong

7. FAMERP: Faculdade de Medicina de Sao Jose do Rio Preto

8. Hospital Dr Cipto Mangunkusumo: Rumah Sakit Dr Cipto Mangunkusumo

9. Fondazione Policlinico Universitario Agostino Gemelli IRCCS

10. King Saud bin Abdulaziz University for Health Sciences

11. University of Cape Town

12. Hospital Israelita Albert Einstein: Sociedade Beneficente Israelita Brasileira Albert Einstein

13. Fiji National University Library

14. Doodhadhari Burfani Hospital & Research Institute

15. Saint Luke's Medical Center

16. University Hospital Ghent: Universitair Ziekenhuis Gent

17. Tata Memorial Hospital,Homi Bhabha National Hospital

18. Health Ministry of Buenos Aires Province: Ministerio de Salud de la Provincia de Buenos Aires

19. University of Washington Seattle Campus: University of Washington

20. Toxicology Society of Bangladesh

21. Ziauddin Medical University: Ziauddin University

22. Toronto General Research Institute

23. Liverpool School of Tropical Medicine

24. National Medical Service

25. Regency Super Specialty Hospital

26. Muhimbili University College of Health Sciences: Muhimbili University of Health and Allied Sciences

27. Brown University Warren Alpert Medical School

28. Mongolian National University of Medical Sciences

29. Universidade Federal de Sao Paulo Escola Paulista de Medicina

30. Medanta The Medicity

31. Charlotte Maxeke Johannesberg Academic Hospital

32. Vietnam National University

33. Fundación de la Comunidad Valenciana Centro de Investigación Príncipe Felipe: Fundacion de la Comunidad Valenciana Centro de Investigacion Principe Felipe

34. King's College London Research Group of Renal Sciences: King's College London Centre for Nephrology Urology & Transplantation

35. Mahidol University

36. University of Michigan

37. Charite Universitatsmedizin Berlin Campus Charite Mitte: Charite Universitatsmedizin Berlin

38. HIMA-San Pablo Caguas

39. Bayero University

40. Tribhuvan University Institute of Medicine

41. Aga Khan University - Kenya

42. Universiti Kebangsaan Malaysia

43. Manipal Hospitals: Manipal Health Enterprises Pvt Ltd

44. AIIMS Bhubaneswar: All India Institute of Medical Sciences - Bhubaneswar

45. Erasme Hospital: Hopital Erasme

46. Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai

Abstract

Abstract

Purpose To generate consensus and provide expert clinical practice statements for the management of adult sepsis in resource-limited settings. Methods An international multidisciplinary Steering Committee with expertise in sepsis management and including a Delphi methodologist was convened by the Asia Pacific Sepsis Alliance (APSA). The committee selected an international panel of clinicians and researchers with expertise in sepsis management. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Results A stable consensus was achieved for 30 (94%) of the statements by 41 experts after four survey rounds. These include consensus on managing patients with sepsis outside a designated critical care area, triggers for escalating clinical management and criteria for safe transfer to another facility. The experts agreed on the following: in the absence of serum lactate, clinical parameters such as altered mental status, capillary refill time and urine output may be used to guide resuscitation; special considerations regarding the volume of fluid used for resuscitation, especially in tropical infections, including the use of simple tests to assess fluid responsiveness when facilities for advanced hemodynamic monitoring are limited; use of Ringer's lactate or Hartmann's solution as balanced salt solutions; epinephrine when norepinephrine or vasopressin are unavailable; and the administration of vasopressors via a peripheral vein if central venous access is unavailable or not feasible. Similarly, where facilities for investigation are unavailable, there was consensus for empirical antimicrobial administration without delay when sepsis was strongly suspected, as was the empirical use of antiparasitic agents in patients with suspicion of parasitic infections. Conclusion Using a Delphi method, international experts reached consensus to generate expert clinical practice statements providing guidance to clinicians worldwide on the management of sepsis in resource-limited settings. These statements complement existing guidelines where evidence is lacking and add relevant aspects of sepsis management that are not addressed by current international guidelines. Future studies are needed to assess the effects of these practice statements and address remaining uncertainties.

Publisher

Springer Science and Business Media LLC

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