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Sepsis Management and Outcomes in a Rural Ugandan Hospital: A Prospective Observational

Cohort StudyKristina Rudd

18th June, 2013

+Outline

Introduction and Background Terminology Epidemiology Considerations for resource-limited settings

Bwindi Sepsis Study Goals, objectives, and hypothesis Logistics Methods Results Challenges and observations

+Introduction and Background

TerminologyEpidemiologyConsiderations for resource-limited settings

+Adult Sepsis Definition

Suspected infection PLUS

Systemic Inflammatory Response Syndrome (SIRS): 2 or more of the following:

Temp >38ºC or <36ºC HR >90 beats/min RR >20 breaths/min WBC >12,000 or <4000 cells/mm3, or >10% immature

(band) forms

+Pediatric Sepsis Definition

Suspected infection PLUS

Systemic Inflammatory Response Syndrome (SIRS): 2 or more of the following (MUST have abnormal temp or

WBC count): Core temp >38.5ºC or <36ºC WBC elevated or depressed for age, or >10% bands HR >2 SD above normal for age in absence of external

stimulus RR >2 SD above normal for age in absence of external

stimulus

+Epidemiology

Infectious diseases account for 4 of 5 top causes of death in Uganda HIV/AIDS, lower respiratory infections, diarrheal diseases,

malaria Similar to other low-income countries (LIC)

ischemic heart disease rather than stroke, different rank order

Account for about 40% of deaths in LIC

More than 3.6 million deaths in LIC annually due to severe infections

+Epidemiology

Unknown burden of sepsis in low- and middle-income countries (LMIC); extrapolate based on physiology and data from high-income countries (HIC)

Limited published data: Brazilian ICUs: 61.4% incidence, 34.7% mortality Zambian rural district hospital: 30% incidence

+Surviving Sepsis Campaign

Global program to improve sepsis-related mortality and morbidity

Early identification

Early antibiotics and cultures

Early goal-directed therapy for resuscitation

+Surviving Sepsis Campaign

+Resource-limited Settings

Mongolia (Baatar et al, 2010) Africa (Baelani et al, 2011)

Lactate measurement 13.2%, 23%

Blood Cultures 60.5%, 71%

Broad-spectrum antibiotics 65.8% 76.2%

Fluids for hypotension 92.1%, 90.7%

Central venous pressure monitoring 31.6%, 24.2% (combined elements)

ScvO2 monitoring 0%

Vasopressors 2.6%. 97.3%*

Oxygen 97.4% 93.8%*

X-ray 86.8% 90.8%*

+Resource-limited Settings

Several recent guidelines

Expert opinion, extrapolation

Need to be tested

+Resource-limited Settings

Ugandan sepsis studies – PRISM-U Study Group Urban

Kampala (Mulago) Masaka

Public Descriptive

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Bwindi Sepsis StudyGoals, objectives, and hypothesisLogisticsMethodsResultsChallenges and observations

+Bwindi Sepsis Study

Sepsis Management and Outcomes in a Rural Ugandan Hospital: A Prospective Observational Cohort Study

+Goals and Objectives

Describe the current presentation, management, and outcome of sepsis in adult and pediatric inpatients in a private, rural Ugandan hospital

Determine the correlates of in-hospital mortality and length of stay

Assess the frequency of acute lung injury based on SpO2-to-FiO2 ratio

Evaluate a modified SIRS/sepsis criteria excluding change in WBC to be used in low-resource settings

+Hypothesis

Adult and pediatric patients presenting to Bwindi Community Hospital with sepsis syndromes will have high in-hospital mortality rates and rates of hypoxemia and the major predictors of mortality will be AVPU Score, Glasgow Coma Score, and point-of-care venous lactate and glucose

Initial hypothesis based on mortality underpowered additional primary hypotheses based on length of stay Continuous outcome rather than binary

+Bwindi Community Hospital

112 beds

Inpatient, outpatient, surgery, maternity, HIV, nutrition

1 HDU bed (pediatric)

Oxygen, x-ray, ultrasound, limited lab, IV fluid, blood transfusion, antibiotics No ventilators, CT, central lines, cultures, cardiac monitors,

ECG, lactate

+Study Team

From Bwindi Community Hospital: Leonard Tutaryebwa, Head of Clinical Services Birungi Mutahunga, Medical Director

From the University of Washington: Kristina Rudd, Resident, Department of Medicine Eoin West, Assistant Professor, Division of Pulmonary

and Critical Care

+Logistics

Time: 2 months No more than 1 month away

Funding: International Respiratory and Severe Illness Center

(INTERSECT) INTERSECT – Ellison Fellowship

Ethics oversight: University of Washington Mbarara University of Science and Technology (MUST)

+Logistics

Language: Medical – English Patients – Rukiga Nurses, hospital staff as translators

Data collection One person, consecutive enrollment Chart screening – IRB waiver of consent

+Methods

Inclusion and exclusion criteria

Chart review

Primary data collection

+Inclusion and Exclusion Criteria

Inclusion: Consecutive enrollment Sepsis (including severe sepsis and septic shock) Inpatient admission

Exclusion: Surgical patient Pregnancy Neonate (less than 28 days)

+Chart Review

Timing Within 24hr of admission 24-48hr after admission Discharge

Content Demographics: age, gender, language, ethnic group Admit and discharge diagnoses and comorbidities Vital signs, labs, radiographic findings, IV fluids, O2,

antibiotics Disposition and complications

+Chart Review

+Primary Data Collection

Timing Initial assessment (within 24hr of admission) Follow-up assessment (24-48hr after admission)

Content AVPU, GCS SpO2 and FiO2 Point-of-care blood glucose, venous lactate

+Primary Data Collection

+Results

56 patients 1 missing data 3 erroneously included 6 qualified but not enrolled

1 declined 1 adolescent without parents to consent 1 died prior to enrollment 3 missed or no translator available

+Results

56 patients Vast majority pediatric Majority sepsis, not severe sepsis or shock Low mortality rate, relatively low length of stay Most common diagnoses malaria, respiratory tract

infections Low HIV prevalence among pediatrics, high among

adults

+Challenges and Observations

Confusion on sepsis definition and management

Reported findings first set of primary data potentially influenced follow-up data (many examples of changes in management)

Difficult to remain completely separate from clinical care

Paper charting

Higher severity of illness and mortality among patients who developed sepsis while inpatient – not included in study

Differences in consent Age Familial relationship

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Questions and Comments

+Thank You!

Eoin West, Mentor

Leonard Tutaryebwa, Research Collaborator

Medical leadership and staff of Bwindi Community Hospital

INTERSECT-Ellison Fellowship

Pediatric Sepsis Definition

AgeAge HRHR RRRR WBCWBC

1mo-1yr 90-180 <34 5-17.5

2-5yr <140 <22 6-15.5

6-12yr <130 <18 4.5-13.5

13-18yr <110 <14 4.5-11

+Additional Definitions

Severe sepsis: sepsis associated with hypotension, hypoperfusion, and/or end-organ dysfunction Examples of end-organ dysfunction: cardiac (ACS), renal

(decreased urine output), hepatic (shock liver), CNS (somnolence, decreased GCS not directly due to infection), hematological (DIC)

Septic shock: sepsis with hypotension despite adequate fluid resuscitation

+Overview of SIRS, Sepsis, Severe Sepsis, and Septic Shock

Infection SIRS

Severe sepsis

Septic shock

Sepsis

+FEAST Trial

FEAST = Fluid Expansion As Supportive Therapy Large RCT > 3000 children, severe febrile illness with

evidence of impaired perfusion or respiratory distress (but not severe hypotension)

Multiple sites in Kenya, Uganda, Tanzania 3 arms:

Immediate volume resuscitation with normal (0.9%) saline

Immediate volume expansion with 5% human albumin solution (HAS)

Control: no immediate volume expansion

Outcomes: Fluid boluses significantly increased mortality at 48hr