President’s Message - Sepsis and Pragmatism

2014 - 1 February – Critical Care in Underserved Areas
J. Christopher Farmer, MD, FCCM
High-income nations must help resource-limited countries address urgent critical care needs.

What is the difference between you could do it and you should do it?

Could is the simple past tense of can and implies possibility. Should is the simple past tense of shall, which implies obligation or compulsion arising from moral duty or simple expediency.(1) With these definitions in mind, consider this scenario:
A 21-year-old woman presents to a local hospital with confusion and lethargy. She is febrile and hypotensive. Little other history is available. The patient was transported over dirt roads by her family members via an animal-drawn cart, traveling for almost 24 hours before arriving at your facility. Your intensive care unit (ICU) supplies include oxygen, peripheral venous catheters, some intravenous fluids, and limited antibiotic selections. Which of the following actions should you take next?
a)  Measure the plasma lactate level
b)  Place a central venous catheter
c)  Obtain blood cultures
d)  Administer 30 mL/kg of intravenous fluids
In high-income nations, efforts such as the Surviving Sepsis Campaign have favorably impacted the recognition and management of sepsis and its outcomes for many patients and populations. These improvements are predicated on the high-reliability performance of standardized tasks that promote early recognition as well as early provision of standardized treatments (i.e., care bundle).
Over 75% of the global burden of infectious diseases, as assessed by mortality rates and disability-adjusted life years lost, occurs in resource-limited countries.(2,3) Infectious diseases make up six of the 10 most frequent causes of death in resource-limited countries.(4) While international guidelines have led to substantial improvements in sepsis mortality in Western countries, these guidelines cannot be practically implemented in many resource-limited countries for several reasons, only one of which is actually the lack of resources.
In resource-limited areas, recognition and treatment of sepsis differ significantly compared to well-supplied settings. First and foremost, resource availability is an issue and can be a major impediment. The Surviving Sepsis Campaign’s care bundle becomes less relevant when the means to accomplish specific bundle elements are lacking (e.g., serum lactate measurement, administration of necessary antibiotics, access to life support supplies such as central line catheters). Clearly, support of related organ system dysfunction is also beyond the scope of practice for many ICUs in these settings.
Second, prevailing infection control practices in resource-limited settings can adversely impact the proper care of patients with sepsis. For example, access to ICU medical supplies can be severely limited (e.g., central venous catheters, endotracheal tubes, ventilator circuits). These appliances are sometimes used for multiple patients, contributing to a high incidence of ICU nosocomial infection.
Third, access to ICU staff education is typically also limited. This is not simply “book knowledge” about sepsis, but also training in team behaviors, communications, and infection control.
Finally, owing to sociopolitical viewpoints and circumstances, care providers in emerging nations may not acknowledge sepsis as a reversible condition, possibly choosing not to treat some patients.  Addressing this problem requires public and governmental “buy-in” – that is, education of the nonmedical community regarding deficiencies, potential solutions, potentially available treatments, and expected outcomes.
Over the last year, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine have supported the fledgling development of a global task force to explore sepsis diagnosis and management in resource-limited countries. By necessity, the focus of this program is different than that of the Surviving Sepsis Campaign. This task force has developed a conceptual approach, the scan-teach-treat system. This approach has three steps:
• Scan the region of interest for key elements that influence sepsis detection, management, and outcome;
• Teach through public awareness and healthcare provider educational programs on sepsis;
• Treat by implementing a “sepsis first aid kit” into clinical practice.
Will this work? Will these efforts bear fruit? What defines success? What about process ownership, pragmatism, and reality? What is possible? Stay tuned. We have an amazing team assembled for an ambitious undertaking with no extramural budget – at least not yet!
These efforts focus on improving the diagnosis and management of sepsis, but they also can be applied to other critical care needs in resource-limited countries, including many efforts highlighted in this issue of Critical Connections. Learn about these efforts with a sense of purpose and commitment. 
So, why do we try? The critical care needs of resource-limited nations compel us to return to my brief language lesson: you could do it; you should do it.

1. English Language and Usage Stack Exchange. Accessed January 4, 2014.
2. Baelani I, Jochberger S, Laimer T, et al.  Identifying resource needs for sepsis care and guideline implementation in the Democratic Republic of the Congo: a cluster survey of 66 hospitals in four eastern provinces. Middle East J Anesthesiol. 2012;21(4):559-575.
3. Becker JU, Theodosis C, Jacob ST, Wira CR, Groce NA. Surviving sepsis in low-income and middle-income countries: new directions for care and research. Lancet Infect Dis. 2009;9:577-582.
4. World Health Organization.  Global health risks: mortality and burden of disease attributable to selected major risks. Published 2009. Accessed January 9, 2014.