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.
Key Points
- Sepsis Burden in LMICs: LMICs bear 85% of the global sepsis burden, with unique challenges like different etiologies, comorbidities, and limited healthcare infrastructure.
- Delphi Process: Four survey rounds achieved consensus on 94% of statements, resulting in 23 expert clinical practice guidelines tailored for resource-limited settings.
- Diagnosis and Monitoring: In the absence of serum lactate, parameters like capillary refill time, urine output, and altered mental status are effective alternatives.
- Antimicrobial Guidance: Empirical antibiotics should be administered without delay when sepsis is suspected, alongside antiparasitic agents in endemic areas.
- Fluid Resuscitation: Special considerations for tropical infections and the use of balanced salt solutions (e.g., Ringer’s lactate) are highlighted to avoid complications from fluid overload.
- Vasopressor Use: Epinephrine is an acceptable alternative to norepinephrine and vasopressin, and vasopressors can be safely initiated peripherally when central access is unavailable.
- Alternative Care Settings: Guidance on managing sepsis outside ICUs includes the use of telemedicine, basic imaging tools, and simplified monitoring protocols.
- Respiratory Support: Non-invasive ventilation (NIV) is recommended as an alternative to high-flow nasal oxygen (HFNO) when the latter is unavailable.
- Ethical and Socioeconomic Factors: Recommendations account for socioeconomic disparities, education levels, and access challenges common in LMICs.
- Research Priorities: The study identifies the need for context-specific research to refine antimicrobial regimens, fluid management strategies, and monitoring techniques.
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