Core elements of general supportive care for patients with sepsis and septic shock in resource-limited settings

Abstract

In this chapter, we outline important elements for the general supportive care for patients with sepsis in resource-limited settings. We discuss the use of corticosteroids, sedation, neuromuscular blocking agents, deep venous thrombosis (DVT) prophylaxis, gastric ulcer prevention, glucose control, enteral feeding, renal replacement therapy, and initial fluid resuscitation. Low-dose corticosteroids are recommended in septic patients with refractory shock, pending completion of current trials. Important issues around sedation include the availability of selected opiates and benzodiazepines, ways of administration, and availability of expertise and (human) resources essential for dosing and monitoring of sedation to care for mechanically ventilated patients with sepsis. Venous thromboembolism prophylaxis with proton-pump inhibitors and histamine-2 receptor antagonists is generally available for stress ulcer prophylaxis in resource-limited ICUs and can be delivered feasibly and safely. Critical illness-associated hyperglycemia is common, and short-acting insulin is widely available and inexpensive. However, stringent blood glucose control is not recommended, since this is dangerous in settings where continuous intravenous insulin with frequent monitoring is not feasible. Enteral feeding can be with hospital-prepared foods where commercial feeds are not available or expensive. Risk of aspiration pneumonia starts early in comatose non-intubated patients. Although not as effective as hemodialysis or hemofiltration methods, peritoneal dialysis is a feasible and cost-effective alternative for renal replacement therapy in very resource-limited settings. Initial fluid resuscitation in severe sepsis or septic shock should be more conservative in resource-limited settings where positive-pressure mechanical ventilation is not readily available.