| dc.description.abstract | Background
Severe sepsis and septic shock is a major contributor of morbidity and mortality worldwide. Kenyatta National Hospital is the main referral hospital with the largest critical care unit in Kenya. In 2009, severe sepsis and septic shock contributed 8% of admissions to the critical care unit, with a mortality of
1 up to 70%.
Objectives
There have been efforts worldwide aimed at reducing mortality from severe sepsis and septic shock. The objective of the study was to review the current management practices of patients with severe sepsis and septic shock by the anaesthesia and critical care practitioners, comparing it with the surviving sepsis campaign guidelines, and to identify the challenges faced in managing these patients.
Methodology
The study was a cross sectional descriptive survey of anaesthesia practitioners at the Kenyatta National Hospital Critical Care Unit. The study population included physician anaesthesiologists and senior post-graduate students in the anaesthesia program. Data was collected by use of a self administered questionnaire to the anaesthesia practitioners. Data collected was analyzed by use of Statistical Package for Social Sciences Version 17 and Microsoft Excel
spreadsheet.
Results
Forty five anaesthesia practitioners were surveyed. 58% were consultant anaesthesiologists and 42% were part two post-graduate anaesthesia students. The lungs were stated as the most common site of infection leading to sepsis by 31% of respondents. 51% correctly indicated the lactic acid level above which would indicate tissue hypoxia in sepsis. The monitoring parameters which were ranked as the most important in sepsis by the respondents were CVP {93.3%}, NIBP {91.1%}, Foley catheter {91.1%} and oxygen, saturation {88.9%}. Over half the respondents used normal saline (91.1%), Ringers lactate {66.6%} and hemacael {61.0%} 'often' or 'always' for early fluid resuscitation. The four most cited resuscitation end points were urine output (93.3%), CVP (93.3%), peripheral perfusion (93.3%) and blood pressure (91.1%). Only 37.8% of the respondents felt that the target CVP in a mechanically ventilated patient
during initial fluid resuscitation should be 14cmH20. 82.2% of the respondents would consider transfusion of packed red cells if ~tiie SCV02 of 70% is not achieved after fluid resuscitation to target CVP with all the respondents stating they would start an inotropic agent to further increase oxygen delivery if the SCV02 was still below the set goal. 24.4% of the respondents recommended dobutamine as the 15t inotropic agent of choice. 42.2% of the respondents would use a haemoglobin transfusion trigger of 7g/dl to adrntnlstena red blood cell transfusion. All the anaesthesia practitioners sampled would start empirical intravenous combination antibiotic therapy within the 15t hour of recognition of septic shock or severe sepsis. All recommended de-escalation to the most appropriate single therapy after susceptibility profile is known. The 15t choice vasopressor agent for correction of hypotension tn septic shock is norepinephrine from the responses sampled. 64% of the respondents recommended a conservative fluid strategy for patients with established ALI/ ARDS. Key challenges in patient care revealed many resource limitations with limited CCU bed space and delay in surgical intervention standing out.
Recommendations
KNH should come up with a protocol to guide in management of severe sepsis and septic shock. Continuous medical education to the members of the care team on the current recommended practice is needed. | en_US |
