Rashan Haniffa

Recommendations for sepsis management in resource-limited settings

PurposeTo provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis.MethodsThe medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings.ResultsRecommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included.ConclusionOnly scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries.

Developing a clinically relevant classification to predict mortality in severe leptospirosis

Background: Severe leptospirosis requires critical care and has a high mortality. We reviewed the literature to identify factors predicting mortality, and such predictors were classified according to the predisposition, infection, response, organ dysfunction (PIRO) concept, which is a risk stratification model used in severe sepsis. Material and Methods: PUBMED was searched for all articles (English), with the key word leptospirosis in any field, within the last 20 years. Data were collected from 45 relevant papers and grouped into each component of the PIRO model. Results: The following correlated with increased mortality: predisposition – increasing age and chronic alcoholism; infection - leptospiraemic burden; response - hemodynamic disturbances, leukocytosis; organ dysfunction – multiple organ dysfunction syndrome, pulmonary involvement and acute renal failure. Conclusions: Further research is needed to identify the role of infecting serovars, clinical signs, inflammatory markers, cytokines and evidence of hepatic dysfunction as prognostic indicators. It is hoped that this paper will be an initiative to create a staging system for severity of leptospirosis based on the PIRO model with an added component for treatment-related predictors.

A cross-sectional survey of critical care services in Sri Lanka: A lower middle-income country

PURPOSE To describe the extent and variation of critical care services in Sri Lanka as a first step towards the development of a nationwide critical care unit (CCU) registry. MATERIALS AND METHODS A cross-sectional survey was conducted in all state CCUs by telephone or by visits to determine administration, infrastructure, equipment, staffing, and overall patient outcomes. RESULTS There were 99 CCUs with 2.5 CCU beds per 100000 population and 13 CCU beds per 1 000 hospital beds. The median number of beds per CCU was 5. The overall admissions were 194 per 100000 population per year. The overall bed turnover was 76.5 per unit per year, with CCU mortality being 17%. Most CCUs were headed by an anesthetist. There were a total of 790 doctors (1.6 per bed), 1,989 nurses (3.9 per bed), and 626 health care assistants (1.2 per bed). Majority (87.9%) had 1:1 nurse-to-patient ratio, although few (11.4%) nurses had received formal intensive care unit training. All CCUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (such as electronic monitoring and infusion pumps). CONCLUSION Sri Lanka, a lower middle-income country has an extensive network of critical care facilities but with inequalities in its distribution and facilities.

Critical care and severe sepsis in resource poor settings

There have been impressive gains in public health in low- and middle-income countries in recent decades, which are contributing to significant reductions in infant mortality, malaria attributable mortality and a general improvement in life expectancy in these countries. With basic public health needs better addressed, improvements in curative care, in particular for the critically ill, are becoming more important for saving lives. The recent and continuing outbreaks of severe acute respiratory infections due to emerging infections give further political and media attention to critical care. Increased awareness of the importance of critical care is reflected in an increase in availability of dedicated intensive care units (ICUs) in low-middle-income and middle-income countries. However, with the scarce data available, it appears that severity adjusted case fatality in ICUs in these settings remains much higher than in higher income countries.3,4 Improving these outcomes will require evaluation of setting specific factors adversely affecting performance and identification of investments and interventions to address them. In general, ICUs in low- and middle-income countries have to function with important limitations in material and human resources, although improving in some countries.1,2,5 Laboratory support is limited, supplies of consumables and medication can be unpredictable, and proper maintenance of crucial equipment for monitoring and treatment is often a challenge. Nevertheless, many of the basic principles of good critical care are as applicable (or are even more so) to resource poor settings, but are often not practiced. These include management and organizational aspects, such as regular ward rounds, empowerment of nurses, proper and frequent documentation of vital signs, structured handover to the next shift of doctors and nurses, admission and discharge policies, the use of both short-term and long-term treatment plans, and adherence to strict hygiene rules. The ‘Surviving Sepsis Campaign’ guidelines for severe sepsis and septic shock management6 have been implemented widely in ICUs in high-income countries and have, together with timely administration of essential therapies, contributed to improved survival. Part of these recommendations can be applied to more resource-limited settings at low or no extra costs. These include the use of low tidal volumes for mechanical ventilation, prompt start of appropriate empirical antibiotic treatment, restricted use of fluid therapy after the initial phase in septic shock and restricted use of sedation. From the limited data available, these practices are often not implemented.7 An important drawback of the ‘Surviving Sepsis Campaign’ guidelines is that the evidence for the recommendations has been mainly gathered from studies in high-income countries. Often this evidence cannot be directly translated to the resource-poor setting.8 The causes of severe sepsis are different in tropical countries and often require different approaches for their management. Examples are severe falciparum malaria and severe dengue, which require more restricted fluid therapy than recommended for bacterial sepsis.8,9 Also, some of the widely accepted recommendations for well-equipped ICUs can be dangerous in a resource-poor setting. An example is the early start of enteral feeding, including in sedated and comatose patients. In resource-poor settings, intubation for airway protection in patients with reduced consciousness is commonly not possible because of limited availability of mechanical ventilation. Early start of enteral feeding through a nasogastric tube in this group of patients results in aspiration pneumonia in an unacceptably large proportion of patients10 and should be reconsidered. Thus, many guidelines will require careful setting-adjusted re-evaluation. A basic requirement for improving critical care in resource-poor settings are tools for evaluation of baseline ICU facilities, practices and performance, which also facilitates assessment of improvement over time when changes are implemented. In rich countries, ICU registries have proven to be critical tools for monitoring ICU performance. These registries can be adjusted to the more resource-limited setting and can be implemented at relatively low costs.2 A limited number of low- and middle-income countries are using such registries, and a wider roll-out is clearly warranted. Such registries (local, national or regional across borders) will also enable inventorying existing ICUs and availability of equipment and other resources. Minimum standards for equipment, monitoring and treatment required for critical care adjusted to low- and middle-income countries have not been described and a registry can help make these recommendations. Monitoring of nosocomial infections and antimicrobial resistance patterns in the ICU could be an important part of the registry, but facilities for microbiology are unfortunately underdeveloped in these countries. Training of both doctors and nurses working in the ICU is another important area for sustained improvement of care. Collaboration between countries where ICU medicine has been established, and countries where critical care as a separate specialty is still at its early stages, can facilitate this. International networks and linked registries can help identify priority areas for improvement and training, develop communication channels and contribute to create a critical mass of critical care trainers. It is clear from the multitude of these issues, that research and quality improvement initiatives at different levels targeted towards critical care in resource-limited settings are warranted. The potential gains for the individual, families, ICU, hospital and healthcare systems are likely to be large and potentially of greater magnitude than is currently possible in high-income countries. Currently there is only a limited body of literature available on the topic and the usual funding schemes rarely focus on this important area. At the same time there is widespread interest on the topic of critical care as a global need, as witnessed by an increasing number of professional organizations with active working groups on the topic. We should capitalize on this development and make a concerted effort to make quality care for the critically ill patient a reachable goal for the entire globe.

Nursing intensive care skills training: A nurse led, short, structured, and practical training program, developed and tested in a resource-limited setting☆

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.

International Surviving Sepsis Campaign guidelines 2016: the perspective from low-income and middle-income countries

www.thelancet.com/infection Vol 17 September 2017 893 pro grammes re-affirms the power of a multidisciplinary approach. A winning team knows that teamwork is what makes the dream work; clinicians, infection prevention professionals, pharmacists, microbiologists, nurses, and an ever-expanding number of health-care professionals involved at the clinical interface form a whole that is greater than the sum of its parts. Only five of the 32 studies included in Baur and colleagues’ meta-analysis were from low-income or middle-income countries, where multidisciplinary teams are rarely found outside of central hospitals. In these settings, we need to re-examine our perception of what an antibiotic stewardship programme looks like. The success of pharmacist-led stewardship programmes highlights a model that builds stewardship teams around this key cadre of health professional. And what of stewardship programmes at the community level? We need to look to non-traditional stewards, such as community health workers and members of the public, in settings where health-care professionals are a scarce resource. Non-traditional stewards need to join us in a partnership that looks beyond what can be offered in high-resource settings. Decreasing antibiotic resistance while preserving the effectiveness of antibiotics is the dream and antibiotic stewardship is the team captain. Baur and colleagues have provided the ammunition to convey this important message to antibiotic stewardship naysayers, policy makers, and stakeholders. The results of Baur and colleagues’ meta-analysis are an important advocacy tool, and one that we should use in support of developing winning teams. If we get antibiotic stewardship right, the real winner will be the patient who avoids infection by a drug-resistant bacterium or C difficile, now and in the future, as we preserve antibiotics for the generations to come.

Applicability of the APACHE II model to a lower middle income country

Purpose: To determine the utility of APACHE II in a low‐and middle‐income (LMIC) setting and the implications of missing data. Materials and methods: Patients meeting APACHE II inclusion criteria admitted to 18 ICUs in Sri Lanka over three consecutive months had data necessary for the calculation of APACHE II, probabilities prospectively extracted from case notes. APACHE II physiology score (APS), probabilities, Standardised (ICU) Mortality Ratio (SMR), discrimination (AUROC), and calibration (C‐statistic) were calculated, both by imputing missing measurements with normal values and by Multiple Imputation using Chained Equations (MICE). Results: From a total of 995 patients admitted during the study period, 736 had APACHE II probabilities calculated. Data availability for APS calculation ranged from 70.6% to 88.4% for bedside observations and 18.7% to 63.4% for invasive measurements. SMR (95% CI) was 1.27 (1.17, 1.40) and 0.46 (0.44, 0.49), AUROC (95% CI) was 0.70 (0.65, 0.76) and 0.74 (0.68, 0.80), and C‐statistic was 68.8 and 156.6 for normal value imputation and MICE, respectively. Conclusions: An incomplete dataset confounds interpretation of prognostic model performance in LMICs, wherein imputation using normal values is not a suitable strategy. Improving data availability, researching imputation methods and developing setting‐adapted and simpler prognostic models are warranted. HighlightsAn incomplete dataset confounds interpretation of APACHE II performance in LMICs.Imputation of missing data with normal values is not appropriate for LMICs.Developing a setting‐adapted and simpler prognostic model for LMICs is warranted.

Impact of a structured ICU training programme in resource-limited settings in Asia

Objective To assess the impact on ICU performance of a modular training program in three resource-limited general adult ICUs in India, Bangladesh, and Nepal. Method A modular ICU training programme was evaluated using performance indicators from June 2009 to June 2012 using an interrupted time series design with an 8 to 15 month pre-intervention and 18 to 24 month post-intervention period. ICU physicians and nurses trained in Europe and the USA provided training for ICU doctors and nurses. The training program consisted of six modules on basic intensive care practices of 2–3 weeks each over 20 months. The performance indicators consisting of ICU mortality, time to ICU discharge, rate at which patients were discharged alive from the ICU, discontinuation of mechanical ventilation or vasoactive drugs and duration of antibiotic use were extracted. Stepwise changes and changes in trends associated with the intervention were analysed. Results Pre-Training ICU mortality in Rourkela (India), and Patan (Nepal) Chittagong (Bangladesh), was 28%, 41% and 62%, respectively, compared to 30%, 18% and 51% post-intervention. The intervention was associated with a stepwise reduction in cumulative incidence of in-ICU mortality in Chittagong (adjusted subdistribution hazard ratio [aSHR] (95% CI): 0.62 (0.40, 0.97), p = 0.03) and Patan (aSHR 0.16 (0.06, 0.41), p<0.001), but not in Rourkela (aSHR: 1.17 (0.75, 1.82), p = 0.49). The intervention was associated with earlier discontinuation of vasoactive drugs at Rourkela (adjusted hazard ratio for weekly change [aHR] 1.08 (1.03, 1.14), earlier discontinuation of mechanical ventilation in Chittagong (aHR 2.97 (1.24, 7.14), p = 0.02), and earlier ICU discharge in Patan (aHR 1.87 (1.02, 3.43), p = 0.04). Conclusion This structured training program was associated with a decrease in ICU mortality in two of three sites and improvement of other performance indicators. A larger cluster randomised study assessing process outcomes and longer-term indicators is warranted.

Association of the Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Score With Excess Hospital Mortality in Adults With Suspected Infection in Low- and Middle-Income Countries

Importance The quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score has not been well-evaluated in low- and middle-income countries (LMICs). Objective To assess the association of qSOFA with excess hospital death among patients with suspected infection in LMICs and to compare qSOFA with the systemic inflammatory response syndrome (SIRS) criteria. Design, Settings, and Participants Retrospective secondary analysis of 8 cohort studies and 1 randomized clinical trial from 2003 to 2017. This study included 6569 hospitalized adults with suspected infection in emergency departments, inpatient wards, and intensive care units of 17 hospitals in 10 LMICs across sub-Saharan Africa, Asia, and the Americas. Exposures Low (0), moderate (1), or high (≥2) qSOFA score (range, 0 [best] to 3 [worst]) or SIRS criteria (range, 0 [best] to 4 [worst]) within 24 hours of presentation to study hospital. Main Outcomes and Measures Predictive validity (measured as incremental hospital mortality beyond that predicted by baseline risk factors, as a marker of sepsis or analogous severe infectious course) of the qSOFA score (primary) and SIRS criteria (secondary). Results The cohorts were diverse in enrollment criteria, demographics (median ages, 29-54 years; males range, 36%-76%), HIV prevalence (range, 2%-43%), cause of infection, and hospital mortality (range, 1%-39%). Among 6218 patients with nonmissing outcome status in the combined cohort, 643 (10%) died. Compared with a low or moderate score, a high qSOFA score was associated with increased risk of death overall (19% vs 6%; difference, 13% [95% CI, 11%-14%]; odds ratio, 3.6 [95% CI, 3.0-4.2]) and across cohorts (P < .05 for 8 of 9 cohorts). Compared with a low qSOFA score, a moderate qSOFA score was also associated with increased risk of death overall (8% vs 3%; difference, 5% [95% CI, 4%-6%]; odds ratio, 2.8 [95% CI, 2.0-3.9]), but not in every cohort (P < .05 in 2 of 7 cohorts). High, vs low or moderate, SIRS criteria were associated with a smaller increase in risk of death overall (13% vs 8%; difference, 5% [95% CI, 3%-6%]; odds ratio, 1.7 [95% CI, 1.4-2.0]) and across cohorts (P < .05 for 4 of 9 cohorts). qSOFA discrimination (area under the receiver operating characteristic curve [AUROC], 0.70 [95% CI, 0.68-0.72]) was superior to that of both the baseline model (AUROC, 0.56 [95% CI, 0.53-0.58; P < .001) and SIRS (AUROC, 0.59 [95% CI, 0.57-0.62]; P < .001). Conclusions and Relevance When assessed among hospitalized adults with suspected infection in 9 LMIC cohorts, the qSOFA score identified infected patients at risk of death beyond that explained by baseline factors. However, the predictive validity varied among cohorts and settings, and further research is needed to better understand potential generalizability.

Capacity building for critical care training delivery: Development and evaluation of the Network for Improving Critical care Skills Training (NICST) programme in Sri Lanka

OBJECTIVES To deliver and evaluate a short critical care nurse training course whilst simultaneously building local training capacity. RESEARCH METHODOLOGY A multi-modal short course for critical care nursing skills was delivered in seven training blocks, from 06/2013-11/2014. Each training block included a Train the Trainer programme. The project was evaluated using Kirkpatricks Hierarchy of Learning. There was a graded hand over of responsibility for course delivery from overseas to local faculty between 2013 and 2014. SETTING Sri Lanka. MAIN OUTCOME MEASURES Participant learning assessed through pre/post course Multi-Choice Questionnaires. RESULTS A total of 584 nurses and 29 faculty were trained. Participant feedback was consistently positive and each course demonstrated a significant increase (p≤0.0001) in MCQ scores. There was no significant difference MCQ scores (p=0.186) between overseas faculty led and local faculty led courses. CONCLUSIONS In a relatively short period, training with good educational outcomes was delivered to nearly 25% of the critical care nursing population in Sri Lanka whilst simultaneously building a local faculty of trainers. Through use of a structured Train the Trainer programme, course outcomes were maintained following the handover of training responsibility to Sri Lankan faculty. The focus on local capacity building increases the possibility of long term course sustainability.