Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines
Abstract Background Sepsis guidelines are widely used in high-income countries and intravenous fluids are an important supportive treatment modality. However, fluids have been harmful in intervention trials in low-income countries, most notably in sub-Saharan Africa. We assessed the relevance, quali...
| Main Authors: | , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2020-06-01
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| Series: | Critical Care |
| Subjects: | |
| Online Access: | http://link.springer.com/article/10.1186/s13054-020-02978-4 |
| _version_ | 1828759166093623296 |
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| author | Benjamin Silberberg Stephen Aston Selda Boztepe Shevin Jacob Jamie Rylance |
| author_facet | Benjamin Silberberg Stephen Aston Selda Boztepe Shevin Jacob Jamie Rylance |
| author_sort | Benjamin Silberberg |
| collection | DOAJ |
| description | Abstract Background Sepsis guidelines are widely used in high-income countries and intravenous fluids are an important supportive treatment modality. However, fluids have been harmful in intervention trials in low-income countries, most notably in sub-Saharan Africa. We assessed the relevance, quality and applicability of available guidelines for the fluid management of adult patients with sepsis in this region. Methods We identified sepsis guidelines by systematic review with broad search terms, duplicate screening and data extraction. We included peer-reviewed publications with explicit relevance to sepsis and fluid therapy. We excluded those designed exclusively for specific aetiologies of sepsis, for limited geographic locations, or for non-adult populations. We used the AGREE II tool to assess the quality of guideline development, performed a narrative synthesis and used theoretical case scenarios to assess practical applicability to everyday clinical practice in resource-constrained settings. Results Published sepsis guidelines are heterogeneous in sepsis definition and in quality: 8/10 guidelines had significant deficits in applicability, particularly with reference to resource considerations in low-income settings. Indications for intravenous fluid were hypotension (8/10), clinical markers of hypoperfusion (6/10) and lactataemia (3/10). Crystalloids were overwhelmingly recommended (9/10). Suggested volumes varied; 5/10 explicitly recommended “fluid challenges” with reassessment, totalling between 1 L and 4 L during initial resuscitation. Fluid balance, including later de-escalation of therapy, was not specifically described in any. Norepinephrine was the preferred initial vasopressor (5/10), specifically targeted to MAP > 65 mmHg (3/10), with higher values suggested in pre-existing hypertension (1/10). Recommendations for guidelines were almost universally derived from evidence in high-income countries. None of the guidelines suggested any refinement for patients with malnutrition. Conclusions Widely used international guidelines contain disparate recommendations on intravenous fluid use, lack specificity and are largely unattainable in low-income countries given available resources. A relative lack of high-quality evidence from sub-Saharan Africa increases reliance on recommendations which may not be relevant or implementable. |
| first_indexed | 2024-12-11T00:53:17Z |
| format | Article |
| id | doaj.art-fd8a17ff1c414da99348de61e4c65181 |
| institution | Directory Open Access Journal |
| issn | 1364-8535 |
| language | English |
| last_indexed | 2024-12-11T00:53:17Z |
| publishDate | 2020-06-01 |
| publisher | BMC |
| record_format | Article |
| series | Critical Care |
| spelling | doaj.art-fd8a17ff1c414da99348de61e4c651812022-12-22T01:26:33ZengBMCCritical Care1364-85352020-06-012411910.1186/s13054-020-02978-4Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelinesBenjamin Silberberg0Stephen Aston1Selda Boztepe2Shevin Jacob3Jamie Rylance4Aintree University Hospital, Liverpool University Hospitals NHS Foundation TrustAintree University Hospital, Liverpool University Hospitals NHS Foundation TrustUniversity Hospitals Bristol NHS Foundation TrustDepartment of Clinical Sciences, Liverpool School of Tropical MedicineDepartment of Clinical Sciences, Liverpool School of Tropical MedicineAbstract Background Sepsis guidelines are widely used in high-income countries and intravenous fluids are an important supportive treatment modality. However, fluids have been harmful in intervention trials in low-income countries, most notably in sub-Saharan Africa. We assessed the relevance, quality and applicability of available guidelines for the fluid management of adult patients with sepsis in this region. Methods We identified sepsis guidelines by systematic review with broad search terms, duplicate screening and data extraction. We included peer-reviewed publications with explicit relevance to sepsis and fluid therapy. We excluded those designed exclusively for specific aetiologies of sepsis, for limited geographic locations, or for non-adult populations. We used the AGREE II tool to assess the quality of guideline development, performed a narrative synthesis and used theoretical case scenarios to assess practical applicability to everyday clinical practice in resource-constrained settings. Results Published sepsis guidelines are heterogeneous in sepsis definition and in quality: 8/10 guidelines had significant deficits in applicability, particularly with reference to resource considerations in low-income settings. Indications for intravenous fluid were hypotension (8/10), clinical markers of hypoperfusion (6/10) and lactataemia (3/10). Crystalloids were overwhelmingly recommended (9/10). Suggested volumes varied; 5/10 explicitly recommended “fluid challenges” with reassessment, totalling between 1 L and 4 L during initial resuscitation. Fluid balance, including later de-escalation of therapy, was not specifically described in any. Norepinephrine was the preferred initial vasopressor (5/10), specifically targeted to MAP > 65 mmHg (3/10), with higher values suggested in pre-existing hypertension (1/10). Recommendations for guidelines were almost universally derived from evidence in high-income countries. None of the guidelines suggested any refinement for patients with malnutrition. Conclusions Widely used international guidelines contain disparate recommendations on intravenous fluid use, lack specificity and are largely unattainable in low-income countries given available resources. A relative lack of high-quality evidence from sub-Saharan Africa increases reliance on recommendations which may not be relevant or implementable.http://link.springer.com/article/10.1186/s13054-020-02978-4SepsisFluid therapyVasoconstrictor agentsAfrica south of the SaharaPractice guidelines as topicSystematic review |
| spellingShingle | Benjamin Silberberg Stephen Aston Selda Boztepe Shevin Jacob Jamie Rylance Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines Critical Care Sepsis Fluid therapy Vasoconstrictor agents Africa south of the Sahara Practice guidelines as topic Systematic review |
| title | Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines |
| title_full | Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines |
| title_fullStr | Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines |
| title_full_unstemmed | Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines |
| title_short | Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines |
| title_sort | recommendations for fluid management of adults with sepsis in sub saharan africa a systematic review of guidelines |
| topic | Sepsis Fluid therapy Vasoconstrictor agents Africa south of the Sahara Practice guidelines as topic Systematic review |
| url | http://link.springer.com/article/10.1186/s13054-020-02978-4 |
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