Point of care ultrasound for sepsis management in resource-limited settings: time for a new paradigm for global health care

Abstract

Dear Editor, We applaud the ESICM Global Intensive Care Working Group for its pivotal contribution to the improvement of sepsis management in developing countries [1]. Dunser et al. acknowledge that health-care practices of industrialized nations are not available to the majority of humanity. On the basis of this current reality the authors offer guidelines regarding approaches to the management of sepsis in limited-resource settings. Surprisingly, we found no mention of the use of point-of-care ultrasound (POC-US) [2] beyond a generic recommendation to ‘‘use imaging techniques when available’’ [1]. Since 1985 ultrasonography has been recommended for developing countries by the World Health Organization (WHO) [3], as an inexpensive, rapidly deployable, and portable tool with minimal side effects. This is true today more than ever. Notwithstanding the lack of randomized, controlled trials on POC-US use in the specific setting of sepsis, increasing scientific evidence suggests tremendous potential for this tool in managing critical patients with infectious diseases. POC-US can be of great aid in the diagnosis of infectious diseases in rural areas [4], and generically in the detection of septic foci in febrile states [5]. It has a significant impact on mitigating diagnostic uncertainty in undifferentiated shock, narrowing differential diagnosis [6], and improving the specificity of early recognition of hypovolemia [7] and septic shock cardiovascular patterns [8]. Lung ultrasound has indeed a broad spectrum of established applications in the diagnosis and management of respiratory infectious diseases [9]—the leading cause of childhood mortality in developing countries [10]. The potential of POCUS in sepsis management is wide [11], and includes procedure-guidance applications that are increasingly acknowledged as best practice [12, 13]. With regards to education, innovative ultrasound curricula have been shaped for non-imaging specialists [14]. Short-term POC-US training programs are proven to deliver adequate knowledge and skills to novices [15]. And proof-of-concept studies have been conducted in the screening for infection sources in resource-limited settings of tropical countries [16]. Furthermore, low-cost technology can now provide minimally POC-UStrained operators (paramedics, midwives) with tele-mentoring and second-opinion facilities [17], mitigating the impracticable availability of ‘‘experienced practitioners’’ in all settings. This is of paramount importance for sustainable healthcare delivery where the patient-tophysician ratio is dramatically high. The use of POC-US represents a paradigm shift for improving health-