Hemodynamic Assessment and Support in Sepsis and Septic Shock in Resource-Limited Settings

Abstract

Recommendations for hemodynamic assessment and support in sepsis and septic shock in resource-limited settings are largely lacking. In this chapter, we reviewed the literature and provided recommendations regarding hemodynamic assessment and support, taking into consideration aspects of efficacy and effectiveness, availability and feasibility, and affordability and safety. We suggest using capillary refill time, skin mottling scores, and skin temperature gradients and suggest passive leg raise test to guide fluid resuscitation. We recommend crystalloid solutions as the initial fluid of choice and recommend initial fluid resuscitation with 30 ml/kg in the first 3 h but with extreme caution in settings where there is lack of mechanical ventilation. Patients with severe malaria or severe dengue without hypotension should not receive fluid bolus therapy. We recommend against early start of vasopressors and suggest starting a vasopressor in patients with persistent hypotension after initial fluid resuscitation with at least 30 ml/kg, but earlier when there is lack of access to mechanical ventilation, and recommend using norepinephrine (noradrenaline) as first-line vasopressor. We suggest in patients with suspected bacterial sepsis starting an inotrope with persistence of plasma lactate >2 mmol/l or persistence of skin mottling or prolonged capillary refill time when plasma lactate cannot be measured and only after initial fluid resuscitation. We suggest the use of dobutamine as first-line inotrope, recommend administering vasopressors through a central venous line, and suggest administering vasopressors and inotropes via a central venous line using a syringe or infusion pump when available.