Papali: Adult sepsis in a resource-constrained world

Clinical Pearls (Assisted by Dr. Deepak Kadiyala)

Abbreviations: RCSs – Resource-Constrained Settings, LICs – Low-Income Countries, LMIC – Low- to Middle-Income Countries, HICs – High-Income Countries

Sepsis Data

• 2.5 million people die from sepsis in HICs.
• No such data is available from LICs, as large studies did not include sepsis as a diagnosis in in itself and it is likely to be much larger.
  • Unlike ICU patients in HICs with refractory chronic illnesses, critically ill patients in RCSs are much younger and more likely to have one acute problem, from which they can recover.
• Surviving sepsis campaign and new sepsis 3 definitions are mostly written from HICs. 5.8 billion of 7.3 billion people from RCSs, are not represented in these guidelines.
  • Guidelines can’t be extrapolated from HICs due to resource limitations and different pathologies.

Sepsis avoidance

• Alleviating poverty, providing clean reliable water supply and hygiene are extremely important at a macroscopic level, to improve health in LICs.
• But as critical care trained physicians – we have much to offer to a critically ill person in RCSs. Supportive care alone can reduce mortality even in diseases like Ebola.

Human economics of illness

• Core elements of critical care are recognizing severity of illness and intervening in a time-sensitive manner.
• Critical care in a LIC is more human intensive and less resource intensive, as bells and whistles that are used in HICs can be scaled down/replaced with simpler equipment/physical exam.
• Cost effectiveness by WHO – intervention cost < value of GDP per capita per DALY (Childhood immunization 4 10 per DALY, Emergency surgery $10.93 – $223 per DALY, ART for AIDS $620 -$1200 per year of life).
  • No such data is available for sepsis. IV fluids/taking vital signs and early sepsis treatment should be very cost effective

Limitations in recognition/triage

• Nursing and physicians are in short supply in RCSs
• Equipment in short supply
  • Diagnostic – Xray/Sonography/Lactate/Blood count
  • Monitoring equipment – Blood pressure cuffs, Spo2 monitors
  • IV fluid /Drug infusing equipment
  • Equipment to assist with organ failure (ventilator/dialysis)
• Most of the equipment in LICs have are donated/basic. Even if the equipment is present, electricity/oxygen are in short supply

Resuscitation

• Fluid administration in setting of sepsis is vastly different in LMICS.
  • On an average,  1 liter versus 2.5-3 liters from various studies.
  • They may not even have the IV fluids and even if available, may not be warranted in similar quantities as HICs as evident in FEAST/SSSP trials.
• Different nutritionals status, genetics, microbiomes, environment and different infectious agents (Malaria, dengue, AIDS, TB) have a separate pathophysiology, limiting the extrapolation of HICs guidelines.

Monitoring and reassessment

• In the end it all boils down to training, staffing and equipment
  • Frequent vital sign monitoring as suggested in HICs cannot be extrapolated to LICs
  • For the future we need high quality studies in RCSs with geographic diversity, consideration for resource availability and involve practicing physicians for guideline development.
• An overseas experience for medical students/residents/fellows can make us better physicians and humanitarians.
• With increasing penetration of internet even in LICs, telemedicine can be implemented with a low cost, using donated equipment like iPads.