Silberberg, Benjamin, Aston, Stephen 
ORCID: 0000-0002-0701-8364, Boztepe, Selda, Jacob, Shevin and Rylance, Jamie
(2020)
Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines.
CRITICAL CARE, 24 (1).
286-.
Abstract
<h4>Background</h4>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.<h4>Methods</h4>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.<h4>Results</h4>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.<h4>Conclusions</h4>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.
| Item Type: | Article |
|---|---|
| Uncontrolled Keywords: | Sepsis, Fluid therapy, Vasoconstrictor agents, Africa south of the Sahara, Practice guidelines as topic, Systematic review |
| Divisions: | Faculty of Health and Life Sciences Faculty of Health and Life Sciences > Institute of Infection, Veterinary and Ecological Sciences |
| Depositing User: | Symplectic Admin |
| Date Deposited: | 09 Jun 2021 10:22 |
| Last Modified: | 18 Jan 2023 22:35 |
| DOI: | 10.1186/s13054-020-02978-4 |
| Open Access URL: | http://doi.org/10.1186/s13054-020-02978-4 |
| Related URLs: | |
| URI: | https://livrepository.liverpool.ac.uk/id/eprint/3125712 |
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