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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