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Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self-reported, continent-wide survey of anaesthesia providers

Availability of critical care resources to treat patients with severe sepsis or septic shock in... Introduction: It is unknown whether resources necessary to implement the Surviving Sepsis Campaign guidelines and sepsis bundles are available in Africa. This self-reported, continent-wide survey compared the availability of these resources between African and high-income countries, and between two African regions (Sub-Sahara Africa vs. South Africa, Mauritius and the Northern African countries). Methods: The study was conducted as an anonymous questionnaire-based, cross-sectional survey among anaesthesia providers attending a transcontinental congress. Based on the respondents’ country of practice, returned questionnaires were grouped into African and high-income countries. The questionnaire contained 74 items and evaluated all material resources required to implement the most recent Surviving Sepsis Campaign guidelines. Group comparisons were performed with the Chi , Fisher’s Exact or Mann Whitney U test, as appropriate. Results: The overall response rate was 74.3% (318/428). Three-hundred-seven questionnaires were analysed (African countries, n = 263; high-income countries, n = 44). Respondents from African hospitals were less likely to have an emergency room (85.5 vs. 97.7%, P = 0.03) or intensive care unit (73.8 vs. 100%, P < 0.001) than respondents from high-income countries. Drugs, equipment, and disposable materials required to implement the Surviving Sepsis Campaign guidelines or sepsis bundles were less frequently available in African than high-income countries. Of all African and Sub-Saharan African countries, 1.5% (4/263) and 1.2% (3/248) of respondents had the resources available to implement the Surviving Sepsis Campaign guidelines in entirety. The percentage of implementable recommendations was lower in African than in high-income countries (72.6 (57.7 to 87.7)% vs. 100 (100 to 100)%, P < 0.001) and lower in Sub-Saharan African countries than South Africa, Mauritius, and the Northern African countries (72.6 (56.2 to 86.3)% vs. 90.4 (71.2 to 94.5)%, P = 0.02). Conclusions: The results of this self-reported survey strongly suggest that the most recent Surviving Sepsis guidelines cannot be implemented in Africa, particularly not in Sub-Saharan Africa, due to a shortage of required hospital facilities, equipment, drugs and disposable materials. However, availability of resources to implement the majority of strong Surviving Sepsis Campaign recommendations and the sepsis bundles may allow modification of current sepsis guidelines based on available resources and implementation of a substantial number of life-saving interventions into sepsis care in Africa. * Correspondence: [email protected] † Contributed equally Department of Anaesthesiology, Perioperative and Intensive Care Medicine, Salzburg General Hospital and Paracelsus Private Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria Full list of author information is available at the end of the article © 2011 Baelani et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Baelani et al. Critical Care 2011, 15:R10 Page 2 of 12 http://ccforum.com/content/15/1/R10 th providers attending the 4 All Africa Anaesthesia Con- Introduction gress held in Nairobi/Kenya from 12 to 16 September The annual incidence of sepsis is 750,000 cases in the 2009. During the opening plenary session of the con- United States and is increasing by 9% each year [1]. Sep- gress, all attendants were informed about the purpose sis is a major burden on the US healthcare system and anonymous design of the study together with the resulting in annual costs of $16.7 billion [2]. In fact that its results would be published in a scientific Germany, an annual sepsis case load of 76 to 110 per journal. Considering that participation in the survey and 100,000 inhabitants has been estimated and held respon- information disclosure were voluntary, the study proto- sible for approximately 60,000 deaths per year [3]. Despite these startling figures from high-income coun- col did not undergo review by an Ethics Committee. tries, the largest part of the global burden of sepsis still Participants occurs unrecognized by the Western medical commu- On thefirst twodaysofthe congress,questionnaires nity. Given that approximately 80% of the world’s popu- were haphazardly distributed to anaesthesia providers lation live in low- or middle-income countries [4], it can (both physicians and non-physicians) attending the con- be assumed that most sepsis cases occur outside the gress. No incentives to complete the survey were more economically developed world. While few reports offered. Throughout the congress, seven investigators on the outcome of sepsis in these countries exist, low were on site to collect the completed questionnaire hygienic standards, widespread malnutrition and a high responses and to be available for assistance in complet- incidence of bacterial, parasitic and HIV infection sug- ing the form. Questionnaires retrieved from respondents gest a disproportionally high morbidity and mortality practicing in an African (Table S1 in Additional file 1) from sepsis in low- and middle-income countries [5]. or high-income country were eligible for study inclusion. Indeed, the latest global burden of disease report of the High-income countries were defined according to the World Health Organization found that three infectious latest World Bank report [4]. Questionnaires completed diseases (lower respiratory tract infection, diarrhoeal dis- by non-healthcare providers or those from non-African eases, HIV/AIDS) range among the four most frequent low- or middle-income countries were excluded. causes of death in low-income countries [6]. During recent years, sepsis care in high-income coun- Survey instrument and data collection tries has substantially improved due to extensive The questionnaire was designed by all investigators research efforts allowing novel insights into the patho- based on the latest SSC guidelines. It was anonymous, physiology and treatment of sepsis [7]. Current scientific evidence to improve the care of severe sepsis or septic contained 74 items grouped into seven main categories shockpatientsissummarizedinthe SurvivingSepsis (general information, hospital facilities, drugs, patient monitoring, laboratory, equipment, disposables) and can Campaign (SSC) guidelines [8,9], which are considered be downloaded from the Additional file 1. Responses the gold standard of care in many countries. As repeat- were classified as ‘yes’, ‘no’, ‘don’t know’ for the category edly shown [10,11], implementation of the SSC guide- ‘hospital facilities’,and ‘always’, ‘sometimes’, ‘never’, lines into routine care can improve outcome from ‘don’tknow’ for the remaining categories. The ‘general severe sepsis and septic shock. However, the possibility information’ category optionally required two open- to implement the SSC guidelines in low- and middle- ended text responses (’other hospital type’ and ‘other income countries has been questioned [5,12,13]. medical grade’) which were retrospectively coded by two The aim of this survey was to compare availability of study investigators. The study questionnaire was written resources required to implement the SSC guidelines and in English, underwent pre-testing by the investigators sepsis bundles between anaesthesia providers from and subsequently pilot testing by 10 anaesthesia provi- African and high-income countries as well as bet- ders in two African countries (Hospital of Kisumu/ ween anaesthesia providers from two African regions Kenya, n = 5; Muhimbili Hospital, Dar-Es-Salaam/ (Sub-Sahara Africa vs. South Africa, Mauritius and the Tanzania, n = 5). For the pilot test, anaesthesia provi- Northern African countries). Based on personal experience ders were asked to complete and examine the question- and recent data, we hypothesized that the SSC guidelines naire with regard to its flow, salience, acceptability and could not effectively be implemented by African anaesthe- administrative ease. Inter-rater reliability was assessed sia providers due to a lack of necessary hospital facilities, for all five respondents from each hospital and yielded a equipment, drugs and disposable materials. Cohen’s Kappa of 0.71. Based on the results of the pilot testing and individual feedback, the questionnaire was Materials and methods modified. Finally, it was again reviewed and approved by This study was conducted as a self-reported, question- naire-based, cross-sectional survey among anaesthesia all investigators. Baelani et al. Critical Care 2011, 15:R10 Page 3 of 12 http://ccforum.com/content/15/1/R10 Study variables ranges. Categorical and non-continuous variables were The main study variable was availability of resources compared between groups using the Chi -or Fisher’s necessary to implement the latest SSC guidelines and Exact test, as appropriate. For comparisons of resource their sepsis resuscitation/management bundles [9]. Prior availability, only ‘always’, ‘sometimes’ and ‘never’ choices to the survey, hospital facilities, equipment, drugs and were statistically evaluated. Group comparisons of con- disposable materials required to implement individual tinuous data were performed with the Mann Whitney U SSC recommendations and sepsis bundles were defined test. P-values < 0.05 were considered to indicate statisti- by consensus of the investigators (Table S2 in Addi- cal significance. tional file 1). In order to consistently implement the SSC guidelines, resources had to be ‘always’ available. Results Resources ‘sometimes’ or ‘never’ available, as well as Questionnaires were randomly distributed to 428 of 832 those respondents who did not know whether they were congress attendants. A total of 318 questionnaires were available at their hospital were considered insufficient returned (overall response rate, 74.3%). Eleven question- to implement the SSC guidelines. Furthermore, the naires had to be excluded because respondents practi- percentage of implementable recommendations of cing in non-African middle-income countries (India, n = the SSC guidelines was calculated for each returned 5; Romania, n = 2), were returned blank (n =3), or questionnaire. were completed by non-healthcare providers (n =1). Finally, 307 questionnaires were statistically analysed Study cohorts and survey goals (African countries, n = 263; high-income countries, n = Based on the respondents’ countries of practice, ques- 44). Respondents from 185 hospitals located in 14 high- tionnaires were grouped into African and high-income income and 24 African countries (45.3% of all 53 Afri- countries. Furthermore, African countries were sub- can countries) were included (Sub-Saharan African grouped into two regions: 1) Sub-Saharan African coun- countries, n = 248; South Africa, Mauritius, and the tries generally representing low-income countries, and Northern African countries, n = 15) (Figure 1). The 2) South Africa, Mauritius, and the Northern African median (interquartile range) number of respondents per countries rated as middle-income countries according to hospital, respondents per country, and respondents’ hos- the World Bank [4]. With few exceptions, this econ- pitals per country was 1 (1 to 1), 2 (1 to 5), and 2 (1 to omy-based country classification by the World Bank 4), respectively. One hundred-nine questionnaires correlates well with the quality and development of the (35.5%) were partially incomplete. The median number national health care systems [4]. of missing responses per incomplete questionnaire was The primary goal of our survey was to compare the 1 (interquartile range, 1 to 3). availability of each resource to implement the SSC Characteristics of respondents and their hospitals are guidelines, the percentage of implementable guidelines, summarized in Table 1. Significant differences between and the possibility to implement the SSC guidelines respondents from African and high-income countries (Grade 1 and 2 recommendations) and their associated were observed in regards to the respondent’s specialty, sepsis bundles (resuscitation and management bundles) hospital type and size, as well as the availability of an between respondents and hospitals from African and emergency room and an intensive care unit. Differences high-income countries. Comparison of the same vari- in the availability of an intensive care unit were ables between respondents from Sub-Saharan African observed between Sub-Saharan African countries and countries and South Africa, Mauritius, and the Nor- South Africa, Mauritius, and the Northern African thern African countries was considered the secondary countries (Table S3 in Additional file 1). survey goal. Respondents from African countries reported to have drugs (Table 2), equipment (Table 3), and disposable Data processing and statistical analysis materials (Table 4) required to implement the SSC Questionnaires were manually entered into a centralized guidelines less frequently available than respondents database. After random cross-checking, the database was from high-income countries. Certain drugs, equipment, re-checked by calculating minimum and maximum and disposable materials (Table S4-6 in Additional file values of each question in order to detect entry errors. 1) were less frequently available for respondents from The SPSS software package (SPSS 13.0.1; SPSS Inc., Sub-Saharan African countries compared to those from Chicago, IL, USA) was used for statistical analysis. Fre- South Africa, Mauritius, and the Northern African quencies based on the number of completed questions countries. The possibility to perform thick drop analysis (some questions were not completed by all respondents) to diagnose malaria was the single resource more fre- were calculated for all categorical data. Continuous vari- quently available for respondents from African countries ables are presented as median values with interquartile compared to high-income countries and for respondents Baelani et al. Critical Care 2011, 15:R10 Page 4 of 12 http://ccforum.com/content/15/1/R10 African countries (n=263) High-income countries (n=44) � Australia � Austria � Belgium � Canada � France � Germany � Ireland � Netherlands � New Zealand � Norway � Sweden � Switzerland � United Kingdom � United States of America Figure 1 Countries of practice of survey participants. Sub-Saharan African countries (n = 248) are marked in dark grey. South Africa, Mauritius and the Northern African countries (n = 15) are marked in light grey. from Sub-Saharan African countries compared to South or any of their sepsis resuscitation and management Africa, Mauritius, and the Northern African countries. bundles (Tables 5 and 6). Respondents and hospitals Of all African respondents and hospitals, four (1.5%) from African countries less frequently had all resources and two (1.4%), respectively, stated to have the resources available to implement the SSC guidelines (Grade 1 and available to consistently implement the SSC guidelines 2 recommendations) than respondents from high- Baelani et al. Critical Care 2011, 15:R10 Page 5 of 12 http://ccforum.com/content/15/1/R10 Table 1 Characteristics of respondents and their hospitals African countries High-income countries P-value n 263 44 Specialty of respondent n (%) 0.002* Physician anaesthetist 150 (57) 35 (81.8) Non-physician anaesthetist 92 (35) 5 (11.4) Other physician 6 (2.3) 3 (6.8) Other 15 (5.7) 0 Type of hospital n (%) 0.01* University teaching 117 (44.5) 19 (43.2) Regional/Provincial 30 (11.4) 11 (25) District 34 (12.9) 9 (20.5) Private 61 (23.2) 3 (6.8) Other 21 (8) 2 (4.6) Size of hospital (beds) 350 (200 to 1,000) 600 (388 to 800) 0.03* Availability of hospital facilities n (%) Emergency room 225 (85.6) 43 (97.7) 0.03* Operation theatre 260 (98.9) 44 (100) 1 Intensive care unit 194 (73.8) 44 (100) <0.001* *, significant group difference. Data are given as median values with interquartile ranges, if not otherwise indicated. Comparisons were made with a Fisher’s Exact or a Mann Whitney U test (size of hospital). income countries. The percentage of implementable individual SSC recommendations. These results are grade 1 and 2 recommendations was lower in respon- important for the future management of sepsis care in Africa. dents and hospitals from African compared to high- income countries (Tables 5 and 6). The percentage of The finding that only 1.5% of African respondents and implementable SSC guidelines was different between even less from Sub-Sahara Africa (1.2%) reported to African respondents working in hospital of different have the resources constantly available to treat sepsis types (<0.01 for all comparisons; data not shown). patients according to the latest SSC guidelines in Resources to implement the SSC guidelines (grade 1 entirety is striking on the first sight. However, almost and 2 recommendations) tended to be less frequently three-quarters of individual SSC recommendations and available for respondents from Sub-Saharan African sepsis resuscitation/management bundles could be countries than those from South Africa, Mauritius, and implemented by African respondents. The interquartile the Northern African countries (Table 7). range of implementable guidelines (57.5 to 87.7%) was wide, suggesting considerable heterogeneity among Discussion respondents. When interpreting these figures, it needs The results of this continent-wide, cross-sectional, self- to be taken into account that 16 of the 73 (21.9%) reported, questionnaire-based survey indicate that while recommendations of the SSC guidelines are either pas- almost all respondents from high-income countries sive (’do not use’)orrequire no resourcesatall.These reported to be able to implement the latest SSC guide- results underline earlier criticism that SSC guidelines lines, only a small percentage of African respondents may not be feasible in low- or middle-income countries stated to have the required facilities, equipment, drugs [5,12,13]. Our finding that not even all respondents of and disposable materials consistently available to imple- high-income countries reported to have resources avail- ment the SSC in entirety. These results remained able to implement the SSC guidelines was unexpected. unchanged when comparisons were made between hos- However, this was due to the lack of selected resources pitals instead of respondents. Supporting our hypothesis, (for example, vasopressin or activated protein C). The median percentage of implementable SSC recommenda- these data imply that the SSC guidelines cannot be implemented in entirety by African, particularly not by tions reported by respondents from high-income coun- Sub-Saharan African, respondents due to a lack of tries was 100%. necessary resources. However, with a wide variability Lack of resources required to implement the SSC among African respondents, resources appear to be guidelines and sepsis bundles by African anaesthesia available to implement approximately three-quarter of providers was not confined to specific materials but Baelani et al. Critical Care 2011, 15:R10 Page 6 of 12 http://ccforum.com/content/15/1/R10 Table 2 Availability of drugs to implement the surviving sepsis campaign guidelines African countries High-income countries P-value N = 263 N =44 Always Some-times Never Don’t know Always Some-times Never Don’t know Oxygen 243 (93.8) 15 (5.8) 1 (0.4) 0 44 (100) 0 0 0 0.24 Antibiotics Ampicilline 201 (78.5) 47 (18.4) 5 (2) 3 (1.2) 44 (100) 0 0 0 0.004* Gentamycine 243 (92.4) 19 (7.2) 0 1 (0.4) 44 (100) 0 0 0 0.07 rd th 3 /4 Gen Cephalosporine 203 (77.5) 57 (21.8) 1 (0.4) 1 (0.4) 44 (100) 0 0 0 0.002* Piperacilline 65 (26.4) 40 (16.3) 83 (33.7) 58 (23.6) 43 (97.7) 0 0 1 (2.3) <0.001* Carbapenem 79 (32.1) 46 (18.7) 68 (27.6) 53 (21.5) 43 (97.7) 0 0 1 (2.3) <0.001* IV fluids Crystalloids 254 (96.6) 9 (3.4) 0 0 44 (100) 0 0 0 0.21 Colloids 158 (60.8) 81 (31.2) 16 (6.2) 5 (1.9) 44 (100) 0 0 0 <0.001* Blood products Red blood cells 206 (79.5) 51 (19.7) 1 (0.4) 1 (0.4) 44 (100) 0 0 0 0.005* Fresh frozen plasma 109 (42.6) 81 (31.6) 59 (23) 7 (2.7) 44 (100) 0 0 0 <0.001* Platelets 69 (27.2) 93 (36.6) 79 (31.1) 13 (5.1) 44 (100) 0 0 0 <0.001* Cardiovascular drugs Noradrenaline 119 (46.7) 60 (23.5) 67 (26.3) 9 (3.5) 44 (100) 0 0 0 <0.001* Dopamine 133 (51.4) 68 (26.3) 52 (20.1) 6 (2.3) 44 (100) 0 0 0 <0.001* Dobutamine 94 (37.2) 67 (26.5) 77 (30.4) 15 (5.9) 44 (100) 0 0 0 <0.001* Adrenaline 255 (97.3) 7 (2.7) 0 0 44 (100) 0 0 0 0.27 Hydrocortisone 252 (96.2) 9 (3.4) 0 1 (0.4) 44 (100) 0 0 0 0.21 Vasopressin 76 (29.8) 66 (25.9) 93 (36.5) 20 (7.8) 43 (97.7) 0 0 1 (2.3) <0.001* Anesthetic/sedative drugs Thiopentone 243 (93.1) 11 (4.2) 7 (2.7) 0 43 (97.7) 1 (2.3) 0 0 0.44 Propofol 154 (59) 71 (27.2) 36 (13.8) 0 43 (97.7) 1 (2.3) 0 0 <0.001* Succinylcholine 242 (93.4) 9 (3.5) 7 (2.7) 1 (0.4) 44 (100) 0 0 0 0.24 ND Muscle Relaxant 185 (70.6) 59 (22.5) 18 (6.9) 0 44 (100) 0 0 0 <0.001* IV opiate/opioide 208 (79.7) 50 (19.2) 3 (1.1) 0 44 (100) 0 0 0 0.004* Diazepam 251 (95.8) 11 (4.2) 0 0 44 (100) 0 0 0 0.17 Midazolam 138 (52.9) 72 (27.6) 48 (18.4) 3 (1.1) 44 (100) 0 0 0 <0.001* Others Insulin 232 (89.2) 27 (10.4) 1 (0.4) 0 44 (100) 0 0 0 0.07 Heparin or LMWH 174 (67.7) 56 (21.8) 21 (8.2) 6 (2.3) 44 (100) 0 0 0 <0.001* H2-Blockers 182 (70.3) 64 (24.7) 9 (3.5) 4 (1.5) 44 (100) 0 0 0 <0.001* Proton pump inhibitor 145 (55.1) 82 (31.2) 18 (7.1) 10 (3.9) 42 (95.5) 0 0 2 (4.5) <0.001* Activated protein C 15 (6.1) 32 (13) 139 (56.3) 61 (24.7) 39 (88.6) 1 (2.3) 2 (4.5) 2 (4.5) <0.001* *, significant group difference (’don’t know’ choices were not included in statistical comparisons); H2, histamine receptor 2; IV, intravenous; LMWH, low molecular weight heparin; ND, non-depolarizing. All data are given as absolute values and percentages of completed responses. appears multi-faceted. For example, 25% of respondents disposables and monitoring equipment reported by stated that their hospital did not have an intensive care some respondents. As suggested before [16,17], the lack unit. Similarly, an emergency room, a key hospital facil- of resources was especially pronounced for respondents ity to timely recognize, triage and treat sepsis patients practicing in Sub-Sahara Africa. [14,15], was not available in the hospitals of 15% of Although our survey did not specifically ask whether respondents. Nearly all materials necessary to imple- respondents routinely care for sepsis patients, several ment the SSC guidelines were less frequently available earlier studies reported that anaesthetists are crucially for African respondents compared to those from high- involved in intensive care medicine and in the care of income countries. Particularly shocking is the inconsis- critically ill sepsis patients in Africa [16,18-22]. None- tent supply or lack of basic resources such as oxygen, theless, it is notable that a relevant number of respon- fluids and broad-spectrum antibiotics or essential dents stated that they did not know whether certain Baelani et al. Critical Care 2011, 15:R10 Page 7 of 12 http://ccforum.com/content/15/1/R10 Table 3 Availability of equipment to implement the surviving sepsis campaign guidelines African countries High-income countries P-value N = 263 N =44 Always Some-times Never Don’t know Always Some-times Never Don’t know Diagnostic equipment X-ray 236 (90.8) 14 (5.4) 10 (3.8) 0 44 (100) 0 0 0 0.11 Sonography 216 (83.4) 17 (6.6) 25 (9.7) 1 (0.4) 43 (97.7) 1 (2.3) 0 0 0.04* Echocardiography 152 (60.6) 30 (12) 61 (24.3) 8 (3.2) 40 (90.9) 4 (9.1) 0 0 <0.001* Laboratory investigations Thick drop 251 (96.5) 4 (1.5) 3 (1.2) 2 (0.8) 35 (79.5) 3 (6.8) 5 (11.4) 1 (2.3) <0.001* Gram stain 238 (92.2) 18 (7) 2 (0.8) 0 43 (97.7) 1 (2.3) 0 0 0.41 Microbiological cultures 193 (75.1) 44 (17.1) 19 (7.4) 1 (0.4) 44 (100) 0 0 0 0.001* Antibiogram 181 (70.4) 51 (19.8) 21 (8.2) 4 (1.6) 44 (100) 0 0 0 <0.001* Blood sugar 242 (93.1) 17 (6.5) 1 (0.4) 0 44 (100) 0 0 0 0.2 Blood gas analysis 110 (43.5) 48 (19) 89 (35.2) 6 (2.4) 44 (100) 0 0 0 <0.001* Lactate 64 (25.7) 60 (24.1) 92 (36.9) 33 (13.3) 43 (97.7) 1 (2.3) 0 0 <0.001* Blood count 227 (87.6) 27 (10.4) 4 (1.5) 1 (0.4) 44 (100) 0 0 0 0.05 Creatinine 201 (78.2) 40 (15.6) 15 (5.8) 1 (0.4) 44 (100) 0 0 0 0.003* Bilirubin 194 (74.6) 46 (17.7) 18 (6.9) 2 (0.8) 44 (100) 0 0 0 0.001* Prothrombin time/INR 176 (68.5) 39 (15.2) 36 (14) 6 (2.3) 44 (100) 0 0 0 <0.001* Other coagulation tests 149 (60.1) 59 (23.8) 29 (11.7) 11 (4.4) 44 (100) 0 0 0 <0.001* Monitoring equipment Body temperature 205 (79.2) 50 (19.3) 2 (0.8) 2 (0.8) 42 (95.5) 2 (4.5) 0 0 0.04* Non-invasive blood pressure 241 (93.8) 11 (4.3) 5 (1.9) 0 43 (97.7) 1 (2.3) 0 0 0.52 Invasive blood pressure 58 (23.1) 84 (33.5) 102 (40.6) 7 (2.8) 41 (93.2) 3 (6.8) 0 0 <0.001* Oxygen saturation 199 (76.8) 42 (16.2) 18 (6.9) 0 44 (100) 0 0 0 <0.001* Central venous pressure 87 (33.9) 78 (30.4) 90 (35) 2 (0.8) 41 (93.2) 3 (6.8) 0 0 <0.001* Cardiac output 30 (12) 62 (24.8) 146 (58.4) 12 (4.8) 37 (84.1) 5 (11.4) 2 (4.5) 0 <0.001* Pulmonary arterial pressure 22 (8.6) 45 (17.6) 174 (68) 15 (5.9) 34 (77.3) 8 (18.2) 2 (4.5) 0 <0.001* Endtidal carbon dioxyde 99 (38.2) 78 (30.1) 78 (30.1) 4 (1.5) 43 (97.7) 1 (2.3) 0 0 <0.001* Other equipment Mechanical ventilator 184 (71.9) 38 (14.8) 34 (13.3) 34 (13.3) 44 (100) 0 0 0 <0.001* Syringe pump 138 (53.9) 53 (20.7) 61 (23.8) 4 (1.6) 44 (100) 0 0 0 <0.001* Fluid infuser 126 (49) 61 (23.7) 67 (26.1) 3 (1.2) 44 (100) 0 0 0 <0.001* Peritoneal dialysis 91 (36) 50 (19.8) 98 (38.7) 14 (5.5) 38 (86.4) 3 (6.8) 1 (2.3) 2 (4.5) <0.001* Hemodialysis/Hemofiltration 111 (43.2) 26 (10.1) 110 (42.8) 10 (3.9) 43 (97.7) 1 (2.3) 0 0 <0.001* *, significant group difference (’don’t know’ choices were not included in statistical comparisons); INR, international normalized ratio; All data are given as absolute values and percentages of completed responses. Table 4 Availability of disposable material to implement the surviving sepsis campaign guidelines African countries High-income countries P-value N = 263 N =44 Always Some-times Never Don’t know Always Some-times Never Don’t know Disposable material IV cannula 253 (97.3) 6 (2.3) 1 (0.4) 0 44 (100) 0 0 0 0.55 IV fluid giving set 253 (97.7) 3 (1.2) 3 (1.2) 0 44 (100) 0 0 0 0.6 Urinary catheter 249 (95.4) 12 (4.6) 0 0 44 (100) 0 0 0 0.15 Nasogastric tube 246 (94.3) 15 (5.7) 0 0 44 (100) 0 0 0 0.1 Endotracheal tube 251 (96.5) 6 (2.3) 3 (1.2) 0 44 (100) 0 0 0 0.46 Oxygen face mask 252 (96.6) 7 (2.7) 2 (0.8) 0 44 (100) 0 0 0 0.46 Oxygen nasal cannula 212 (81.5) 37 (14.2) 9 (3.5) 2 (0.8) 44 (100) 0 0 0 0.01* Central venous catheter 126 (48.8) 64 (24.8) 63 (24.4) 5 (1.9) 44 (100) 0 0 0 <0.001* Antithrombotic stockings 65 (25.4) 64 (25) 94 (36.7) 33 (12.9) 43 (97.7) 1 (2.3) 0 0 <0.001* *, significant group difference (’don’t know’ choices were not included in statistical comparisons); IV, intravenous. Baelani et al. Critical Care 2011, 15:R10 Page 8 of 12 http://ccforum.com/content/15/1/R10 Table 5 Possibility to implement the surviving sepsis campaign guidelines African countries High-income countries P-value Respondents n 263 44 Possibility to implement the SSC guidelines in entirety n (%) 4 (1.5) 36 (81.8) <0.001* Percentage of implementable recommendations/suggestions (%) 72.6 (57.5 to 87.7) 100 (100 to 100) <0.001* Possibility to implement all Grade 1 recommendations n (%) 15 (5.7) 40 (90.9) <0.001* Percentage of implementable Grade 1 recommendations (%) 80.8 (63.5 to 88.5) 100 (100 to 100) <0.001* Possibility to implement all Grade 1A and 1B recommendations n (%) 30 (11.4) 41 (93.2) <0.001* Percentage of implementable Grade 1A and 1B recommendations (%) 87.5 (70.8 to 95.8) 100 (100 to 100) <0.001* Possibility to implement all Grade 1C and 1D recommendations n (%) 26 (9.9) 40 (90.9) <0.001* Percentage of implementable Grade 1C and 1D recommendations (%) 71.4 (57.1 to 89.3) 100 (100 to 100) <0.001* Possibility to implement all Grade 2 recommendations n (%) 4 (1.5) 36 (81.8) <0.001* Percentage of implementable Grade 2 recommendations (%) 57.1 (38.1 to 81) 100 (100 to 100) <0.001* Possibility to implement all sepsis resuscitation bundles n (%) 43 (16.3) 41 (93.2) <0.001* Bundle element “Lactate” n (%) 64 (24.3) 43 (97.7) <0.001* Bundle element “Cultures” n (%) 188 (71.5) 44 (100) <0.001* Bundle element “Antibiotics” n (%) 204 (77.6) 44 (100) <0.001* Bundle element “Hypotension” n (%) 238 (90.5) 44 (100) 0.03* Bundle element “CVP/ScvO2” n (%) 70 (26.6) 41 (93.2) <0.001* Possibility to implement all sepsis management bundles n (%) 12 (4.6) 39 (88.6) <0.001* Bundle element “Steroids” n (%) 252 (95.8) 44 (100) 0.17 Bundle element “rhAPC” n (%) 15 (5.7) 39 (88.6) <0.001* Bundle element “Glucose” n (%) 221 (84) 44 (100) 0.004* Bundle element “Plateau Pressure” n (%) 182 (69.2) 44 (100) <0.001* SSC, Surviving Sepsis Campaign; *, significant group difference. Data are given as median values with interquartile ranges, if not otherwise indicated. The Surviving Sepsis Campaign categorized their recommendations using the GRADE system which classifies recommendations as strong (grade 1) or weak (grade 2). Furthermore, the system Classifies the quality of evidence as high (grade A), moderate (grade B), low (grade C), or very low (grade D).The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. Sepsis Resuscitation Bundles: Element “Lactate”, measurement of serum lactate; Element “Cultures”, obtainment of blood cultures prior to antibiotic administration; Element “Antibiotics”, administration of broad- spectrum antibiotics within three hours of emergency department admission and within one hour of non-emergency department admission; Element “Hypotension”, treatment of hypo-tension and/or elevated lactate with fluids; Element “CVP/ScvO2”, maintenance of adequate central venous pressure and central venous oxygen saturation. Sepsis Management Bundles: Element “Steroids”, administration of low-dose steroids for septic shock in accordance with a standardized ICU policy; Element “rhAPC”, administration of recombinant human activated protein C in accordance with a standardized ICU policy; Element “Glucose”, maintenance of blood glucose control lower limit of normal, but <180 mg/dL (10 mmol/L); Element “Plateau Pressure”, maintenance of a median inspiratory plateau pressure <30 cmH2O for mechanically ventilated patients. resources to treat sepsis were available at their hospital. Although no causative relationship can be drawn, high sepsis mortality as reported from low- or middle-income Given the drastic shortage of intensive care capacities in some African countries such as in Zambia [16], it must countries may be due to a lack of hospital facilities, be assumed that many clinicians from other medical spe- equipment, drugs and disposable materials. Accordingly, cialties routinely care for critically ill sepsis patients, for a Tunisian study including 100 septic shock patients example, on normal hospital wards. Considering this, our reported a lethality of 82% [23]. Similarly, mortality survey only reflects the possibility of African anaesthesia from severe sepsis was 80 and 92% in a tertiary centre providers to implement the SSC guidelines and cannot in Pakistan [24] and Turkey [25], respectively. Cheng yield data on resource availability of other African health et al. observed a mortality of 90% in patients with care workers to care for sepsis patients. Furthermore, the severe sepsis due to melioidosis in a Thai provincial study specifically assessed the availability of resources hospital [26]. required to implement the SSC guidelines and did not Our survey has important limitations. First, although appraise the process of clinical sepsis care itself. It the questionnaire used in this survey underwent pilot remains unknown whether the scarce resources are used testing, no assessment of test-retest reliability was per- appropriately. Similarly, our survey only evaluated the formed. Together with the lack of clinical sensibility qualitative availability of resources. Although some testing of the questionnaire, this limits the validity of resources may be available their quantity could still not the results [27]. Second, by including only anaesthesia be adequate to treat all patients with sepsis. providers attending a continent-wide congress our sur- The wide-ranging lack of resources as reflected by our vey most likely experienced a relevant selection bias due study entails that several potentially life-saving interven- to respondent clustering. Accordingly, the proportion of tions cannot be applied to sepsis patients in Africa. African respondents working either at university or Baelani et al. Critical Care 2011, 15:R10 Page 9 of 12 http://ccforum.com/content/15/1/R10 Table 6 Possibility to implement the surviving sepsis campaign guidelines per hospital African countries High-income countries P-value Hospital n 143 42 Possibility to implement the ssc guidelines in entirety n (%) 2 (1.4) 34 (81) <0.001* Percentage of implementable recommendations/suggestions (%) 67.1 (52.1 to 80.8) 100 (100 to 100) <0.001* Possibility to implement all Grade 1 recommendations n (%) 5 (3.5) 38 (90.5) <0.001* Percentage of implementable Grade 1 recommendations (%) 75 (59.6 to 84.6) 100 (100 to 100) <0.001* Possibility to implement all Grade 1A and 1B recommendations n (%) 16 (11.2) 39 (92.9) <0.001* Percentage of implementable Grade 1A and 1B recommendations (%) 83.3 (66.7 to 91.7) 100 (100 to 100) <0.001* Possibility to implement all Grade 1C and 1D recommendations n (%) 9 (6.3) 38 (90.5) <0.001* Percentage of implementable Grade 1C and 1D recommendations (%) 71.4 (57.1 to 82.1) 100 (100 to 100) <0.001* Possibility to implement all Grade 2 recommendations n (%) 2 (1.4) 34 (81) <0.001* Percentage of implementable Grade 2 recommendations (%) 47.6 (33.3 to 71.4) 100 (100 to 100) <0.001* Possibility to implement all sepsis resuscitation bundles n (%) 14 (9.8) 39 (92.9) <0.001* Bundle element “Lactate” n (%) 31 (21.7) 41 (97.6) <0.001* Bundle element “Cultures” n (%) 97 (67.8) 42 (100) <0.001* Bundle element “Antibiotics” n (%) 36 (25.2) 42 (100) <0.001* Bundle element “Hypotension” n (%) 129 (90.2) 42 (100) 0.04* Bundle element “CVP/ScvO2” n (%) 28 (19.6) 39 (92.9) <0.001* Possibility to implement all sepsis management bundles n (%) 3 (2.1) 37 (88.9) <0.001* Bundle element “Steroids” n (%) 137 (95.8) 42 (100) 0.18 Bundle element “rhAPC” n (%) 5 (3.5) 37 (88.9) <0.001* Bundle element “Glucose” n (%) 115 (80.4) 42 (100) 0.002* Bundle element “Plateau Pressure” n (%) 85 (59.4) 42 (100) <0.001* SSC, Surviving Sepsis Campaign; *, significant group difference. Data are given as median values with interquartile ranges, if not otherwise indicated. The Surviving Sepsis Campaign categorized their recommendations using the GRADE system which classifies recommendations as strong (grade 1) or weak (grade 2). Furthermore, the system Classifies the quality of evidence as high (grade A), moderate (grade B), low (grade C), or very low (grade D).The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. Sepsis Resuscitation Bundles: Element “Lactate”, measurement of serum lactate; Element “Cultures”, obtainment of blood cultures prior to antibiotic administration; Element “Antibiotics”, administration of broad- spectrum antibiotics within three hours of emergency department admission and within one hour of non-emergency department admission; Element “Hypotension”, treatment of hypo-tension and/or elevated lactate with fluids; Element “CVP/ScvO2”, maintenance of adequate central venous pressure and central venous oxygen saturation. Sepsis Management Bundles: Element “Steroids”, administration of low-dose steroids for septic shock in accordance with a standardized ICU policy; Element “rhAPC”, administration of recombinant human activated protein C in accordance with a standardized ICU policy; Element “Glucose”, maintenance of blood glucose control lower limit of normal, but <180 mg/dL (10 mmol/L); Element “Plateau Pressure”, maintenance of a median inspiratory plateau pressure <30 cmH2O for mechanically ventilated patients. private hospitals was high, while barely 25% came from necessary to manage children with sepsis. Since special- provincial or district hospitals which make up the cru- sized disposable materials and equipment are required, cial part of healthcare services in Africa. Some rural it is likely that resources necessary to care for critically African hospitals do not even have anaesthesia providers ill children with sepsis are even less frequently available. available [28]. Therefore, our results almost certainly Finally, we cannot exclude that some respondents may overestimate the true situation of resource availability to have misunderstood certain questions despite the avail- treat sepsis in Africa, particularly in rural hospitals. ability of ‘don’tknow’ choices. Although the congress Recent studies from Uganda [17] and Zambia [16] was held in English, it is possible that language pro- reported a much lower availability of basic monitoring blems contributed to misunderstandings. Some respon- devices or equipment than observed in our survey. dents chose to answer only questions they could Third, the present survey only evaluated the availability respond with ‘yes’ or ‘always’ leaving the remaining of material resources and not healthcare workers. Short- questions blank. age of sufficiently trained healthcare providers is another Several possibilities exist to improve sepsis care in threat to adequate patient care in Africa [28-30]. Even in Africa. While a consistent supply of resources to imple- high-income countries, barriers to implementation of ment the SSC guidelines in its entirety would not only the SSC guidelines may be related to inadequate staffing be logistically and economically unrealistic but also [31]. Fourth, although our survey included respondents require training of health care providers to use so far from half of African countries, its results must not be unavailable resources, modification of existing sepsis extrapolated to all of Africa. Additionally, the question- guidelines could help see that currently available naire did not assess the availability of resources resources are used according to the latest clinical Baelani et al. Critical Care 2011, 15:R10 Page 10 of 12 http://ccforum.com/content/15/1/R10 Table 7 Possibility to implement the surviving sepsis campaign guidelines in African countries Sub-Saharan African South Africa/ P-value countries Mauritius/Northern African countries Respondents n 248 15 Possibility to implement the SSC guidelines in entirety n (%) 3 (1.2) 1 (6.7) 0.09 Percentage of implementable recommendations/suggestions (%) 72.6 (56.2 to 86.3) 90.4 (71.2 to 94.5 0.02* Possibility to implement all Grade 1 recommendations n (%) 12 (4.8) 3 (20) 0.01* Percentage of implementable Grade 1 recommendations (%) 78.9 (63.5 to 88.5) 94.2 (76.9 to 98.1) 0.03* Possibility to implement all Grade 1A and 1B recommendations n (%) 27 (10.9) 3 (20) 0.28 Percentage of implementable Grade 1A and 1B recommendations (%) 87.5 (70.8 to 95.8) 95.8 (79.2 to 95.8) 0.09 Possibility to implement all Grade 1C and 1D recommendations n (%) 20 (8.1) 6 (40) <0.001* Percentage of implementable Grade 1C and 1D recommendations (%) 71.4 (57.1 to 85.7) 92.9 (67.9 to 100) 0.02* Possibility to implement all Grade 2 recommendations n (%) 3 (1.2) 1 (6.7) 0.09 Percentage of implementable Grade 2 recommendations (%) 52.4 (38.1 to 76.2) 81 (66.7 to 90.5) 0.009* Possibility to implement all sepsis resuscitation bundles n (%) 36 (14.5) 7 (46.7) 0.001* Bundle element “Lactate” n (%) 57 (23) 7 (46.7) 0.04* Bundle element “Cultures” n (%) 176 (71) 12 (80) 0.45 Bundle element “Antibiotics” n (%) 189 (76.2) 15 (100) 0.03* Bundle element “Hypotension” n (%) 225 (90.7) 13 (86.7) 0.6 Bundle element “CVP/ScvO2” n (%) 60 (24.2) 10 (66.7) <0.001* Possibility to implement all sepsis management bundles n (%) 11 (4.4) 1 (6.7) 0.69 Bundle element “Steroids” n (%) 237 (95.6) 15 (100) 0.41 Bundle element “rhAPC” n (%) 13 (5.2) 2 (13.3) 0.19 Bundle element “Glucose” n (%) 208 (83.9) 13 (86.7) 0.77 Bundle element “Plateau Pressure” n (%) 172 (69.4) 10 (66.7) 0.83 SSC, Surviving Sepsis Campaign; *, significant group difference. Data are given as median values with interquartile ranges, if not otherwise indicated. The Surviving Sepsis Campaign categorized their recommendations using the GRADE system which classifies recommendations as strong (grade 1) or weak (grade 2). Furthermore, the system Classifies the quality of evidence as high (grade A), moderate (grade B), low (grade C), or very low (grade D).The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. Sepsis Resuscitation Bundles: Element “Lactate”, measurement of serum lactate; Element “Cultures”, obtainment of blood cultures prior to antibiotic administration; Element “Antibiotics”, administration of broad- spectrum antibiotics within three hours of emergency department admission and within one hour of non-emergency department admission; Element “Hypotension”, treatment of hypotension and/or elevated lactate with fluids; Element “CVP/ScvO2”, maintenance of adequate central venous pressure and central venous oxygen saturation. Sepsis Management Bundles: Element “Steroids”, administration of low-dose steroids for septic shock in accordance with a standardized ICU policy; Element “rhAPC”, administration of recombinant human activated protein C in accordance with a standardized ICU policy; Element “Glucose”, maintenance of blood glucose control lower limit of normal, but <180 mg/dL (10 mmol/L); Element “Plateau Pressure”, maintenance of a median inspiratory plateau pressure <30 cmH2O for mechanically ventilated patients. evidence. This may be particularly relevant for therapeu- Conclusions tic interventions with a high chance of improving The results of this self-reported survey strongly suggest patient survival. Optimistically, respondents reported to that the most recent SSC guidelines cannot be implemen- have resources constantly available to implement up to ted in Africa, particularly not in Sub-Sahara Africa, due to 80% of grade 1A and 1B recommendations as well as a shortage of required hospital facilities, equipment, drugs sepsis bundles suggesting that guideline modification and disposable materials. However, availability of resources based on available resources may allow implementation to implement the majority of strong SSC recommendations of a substantial number of life-saving interventions. (grade 1a and 1b) and the sepsis bundles may allow modifi- However, considering the wide variability of resource cation of current sepsis guidelines based on available availability observed and the regional shortage of essen- resources and implementation of a substantial number of tial resources, basic resources need to be supplied to life-saving interventions into sepsis care in Africa. health care facilities to improve sepsis management. Furthermore, establishment of emergency and intensive Key messages care departments, adequate staffing and training of � Only a small percentage of African respondents sta- health care providers could be further options to ted that they have the required facilities, equipment, improve the care of African patients suffering from drugs and disposable materials available to implement severe infection. the Surviving Sepsis Campaign guidelines. Baelani et al. Critical Care 2011, 15:R10 Page 11 of 12 http://ccforum.com/content/15/1/R10 data, interpreted data, drafted the manuscript and has given final approval � The Surviving Sepsis Campaign guidelines may not of the version to be published. be implementable by African, particularly not by Sub-Saharan African, respondents due to a lack of Competing interests The authors declare that they have no competing interests. necessary resources. � Availability of resources to implement the majority Received: 26 April 2010 Revised: 1 December 2010 of strong SSC recommendations (grade 1A and 1B) Accepted: 10 January 2011 Published: 10 January 2011 may allow modification of current sepsis guidelines References based on available resources and implementation of 1. Annane D, Bellissant E, Cavaillon JM: Septic shock. Lancet 2005, 365:63-78. a substantial number of life-saving interventions into 2. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR: sepsis care in Africa. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001, 29:1303-1310. Additional material 3. Engel C, Brunkhorst FM, Bone HG, Brunkhorst R, Gerlach H, Grond S, Gruendling M, Huhle G, Jaschinski U, John S, Mayer K, Oppert M, Olthoff D, Quintel M, Ragaller M, Rossaint R, Stuber F, Weiler N, Welte T, Bogatsch H, Additional file 1: Electronic supplementary material. This file contains Hartog C, Loeffler M, Reinhart K: Epidemiology of sepsis in Germany: the study questionnaire; a list of African nations eligible for participation results from a national prospective multicenter study. Intensive Care Med in this survey; hospital facilities, equipment, drugs and disposable 2007, 33:606-618. materials required to implement single recommendations/suggestions of 4. World Bank: World Bank list of economies. 2009 [http://siteresources. the Surviving Sepsis Campaign guidelines; and tables on differences worldbank.org/DATASTATISTICS/Resources/CLASS.XLS]. between Sub-Saharan African countries and South Africa/Mauritius/ 5. Cheng AC, West TE, Limmathurotsakul D, Peacock SJ: Strategies to reduce Northern African countries. mortality from bacterial sepsis in adults in developing countries. PLOS Medicine 2008, 5:1173-1179. 6. World Health Organization: Global Burden of Disease Report - Update 2004. [http://www.who.int/healthinfo/global_burden_disease/ Abbreviations GBD_report_2004update_part2.pdf]. SSC: Surviving Sepsis Campaign. 7. Martin GS, Mannino DM, Eaton S, Moss M: The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003, Acknowledgements 348:1546-1554. The authors are indebted to all anaesthesia providers who participated in 8. Dellinger PR, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea- this survey to improve the care of patients with sepsis in Africa. Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Furthermore, the authors would like to thank all members of the congress Vincent JL, Levy MM: Suriving Sepsis Campaign guidelines for th committee of the 4 All African Anaesthesia Congress for their invaluable management of severe sepsis and septic shock. Crit Care Med 2004, support, as well as the World Federation of the Societies of 32:858-873. Anaesthesiologists which endorsed this survey. 9. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Author details Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Department of Anaesthesia and Critical Care Medicine, DOCS Hospital, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL: Goma, Democratic Republic of Congo, Africa. Klinik für Anästhesiologie der Surviving Sepsis Campaign: International guidelines for management of Technischen Universität München, Klinikum rechts der Isar, Ismaninger severe sepsis and septic shock: 2008. Crit Care Med 2008, 36:296-327. Strasse 22, 86175 München, Germany. Medical University Vienna, Spitalgasse 10. Ferrer R, Artigas A, Levy MM, Blanco J, Gonzalez-Diaz G, Garnacho- 23, 1090 Vienna, Austria. Department of Anesthesiology and Critical Care Montero J, Ibanez J, Palencia E, Quintana M, de la Torre-Prados MV: Medicine, Kenyatta National Hospital, Hospital Road, 00202 Nairobi, Kenya, Improvement in process of care and outcome after a multicenter severe Africa. Department of Anesthesiology, The Nairobi Hospital, Argwings sepsis educational program in Spain. JAMA 2008, 299:2294-2303. Kodhek Road, 00100 Nairobi, Kenya, Africa. Royal Devon and Exeter NHS 11. Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR, Edwards J, Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK. Department of Cho TW, Wittlake WA: Implementation of a bundle of quality indicators Physiology and Pharmacology, Karolinska Institute, Section for Anaesthesia for the early management of severe sepsis and septic shock is and Intensive Care, Karolinska University Hospital, Huddinge, 14186 associated with decreased mortality. Crit Care Med 2007, 35:1105-1112. Stockholm, Sweden. Department of Anaesthesiology, Perioperative and 12. Becker JU, Theodosis C, Jacob ST, Wira CR, Groce NA: Surviving sepsis in Intensive Care Medicine, Salzburg General Hospital and Paracelsus Private low-income and middle-income countries: new directions for care and Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria. research. Lancet Infect Dis 2009, 9:577-582. 13. Cheng AC, West TE, Peacock SJ: Surviving sepsis in developing countries. Authors’ contributions Crit Care Med 2008, 36:2487. IB designed the study, acquired data, interpreted data, drafted the 14. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, manuscript and has given final approval of the version to be published. SJ Tomlanovich M: Early goal-directed therapy in the treatment of severe designed the study, acquired data, interpreted data, revised the manuscript sepsis and septic shock. N Engl J Med 2001, 345:1368-1377. for important intellectual content, substantially contributed to revision of the 15. Khan NU, Razzak JA, Alam SM, Ahmad H: Emergency department deaths manuscript during the review process and gave final approval of the version despite active management: experience from a tertiary care center in a to be published. TL made substantial contributions to conception and low-income country. Emerg Med Austral 2007, 19:213-217. design of the study, acquired data, interpreted data, revised the manuscript 16. Jochberger S, Ismailova F, Lederer W, Mayr VD, Luckner G, Wenzel V, for important intellectual content and gave final approval of the version to Ulmer H, Hasibeder WR, Dünser MW: Anesthesia and its allied disciplines be published. DO made substantial contributions to the conception and in the developing world: a nationwide survey of the Republic of design of the study, acquired data, interpreted data, revised the manuscript Zambia. Anesth Analg 2008, 106:942-894. for important intellectual content and gave final approval of the version to 17. Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH: be published. JK, IW and TB made substantial contributions to conception Anaesthesia services in developing countries: defining the problems. and design of the study, acquired data, interpreted data, revised the Anaesthesia 2007, 62:4-11. manuscript for important intellectual content and gave final approval of the 18. Baker T: Critical care in low-income countries. Trop Med Int Health 2009, version to be published. MWD designed the study, acquired data, analysed 14:143-148. Baelani et al. Critical Care 2011, 15:R10 Page 12 of 12 http://ccforum.com/content/15/1/R10 19. Towey RM, Ojara S: Practice of intensive care in rural Africa: an assessment of data from Northern Uganda. Afr Health Sci 2008, 8:61-64. 20. Towey RM, Ojara S: Intensive care in the developing world. Anaesthesia 2007, 62(Suppl 1):32-37. 21. Dünser MW, Baelani I, Ganbold L: A review and analysis of intensive care medicine in the least developed countries. Crit Care Med 2006, 34:1234-1242. 22. Dünser M, Baelani I, Ganbold L: The speciality of anesthesia outside western medicine. With special consideration of personal experience in the Democratic Republic of the Congo and Mongolia. Anaesthesist 2006, 55:118-132. 23. Frikha N, Mebazaa M, Mnif L, El Euch N, Abassi M, Ben Ammar MS: Septic shock in a Tunisian intensive care unit: mortality and predictive factors. 100 cases. Tunis Med 2005, 83:320-325. 24. Siddqui S: Not “surviving sepsis” in the developing countries. J Indian Med Assoc 2007, 105:221. 25. Tanriover MD, Guven GS, Sen D, Unal S, Uzun O: Epidemiology and outcome of sepsis in a tertiary-care hospital in a developing country. Epidemiol Infect 2006, 134:315-322. 26. Cheng AC, Limmathuotsakul D, Chierakul W, Getchalarat N, Wuthiekanun V, Stephens DP, Day NP, White NJ, Chaowagul W, Currie BJ, Peacock SJ: A randomized controlled trial of granulocyte colony-stimulating factor for the treatment of severe sepsis due to melioidosis in Thailand. Clin Infect Dis 2007, 45:308-314. 27. Burns KEA, Duffett M, Kho ME, Meade MO, Adhikari NKJ, Sinuff T, Cook DJ: A guide to the design and conduct of self-administered surveys of clinicians. CMAJ 2008, 179:245-252. 28. Walker IA, Wilson IH: Anaesthesia in developing countries - a risk for patients. Lancet 2008, 371:968-969. 29. Mullan F, Frehywot S: Non-physician clinicians in 47 sub-Saharan African countries. Lancet 2007, 370:2158-2163. 30. Kumar P: Providing the providers - remedying Africa’s shortage of health care workers. N Engl J Med 2007, 356:2564-2567. 31. Carlbom DJ, Rubenfeld GD: Barriers to implementing protocol-based sepsis resuscitation in the emergency department–results of a national survey. Crit Care Med 2007, 35:2525-2532. 32. United Nations Statistics Division. Composition of macro geographical (continental) regions, geographical sub-regions, and selected economic and other groupings. [http://unstats.un.org/unsd/methods/m49/m49regin. htm#africa]. doi:10.1186/cc9410 Cite this article as: Baelani et al.: Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self- reported, continent-wide survey of anaesthesia providers. Critical Care 2011 15:R10. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Critical Care Springer Journals

Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self-reported, continent-wide survey of anaesthesia providers

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Springer Journals
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Copyright © 2011 by Baelani et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; Intensive / Critical Care Medicine; Emergency Medicine
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Abstract

Introduction: It is unknown whether resources necessary to implement the Surviving Sepsis Campaign guidelines and sepsis bundles are available in Africa. This self-reported, continent-wide survey compared the availability of these resources between African and high-income countries, and between two African regions (Sub-Sahara Africa vs. South Africa, Mauritius and the Northern African countries). Methods: The study was conducted as an anonymous questionnaire-based, cross-sectional survey among anaesthesia providers attending a transcontinental congress. Based on the respondents’ country of practice, returned questionnaires were grouped into African and high-income countries. The questionnaire contained 74 items and evaluated all material resources required to implement the most recent Surviving Sepsis Campaign guidelines. Group comparisons were performed with the Chi , Fisher’s Exact or Mann Whitney U test, as appropriate. Results: The overall response rate was 74.3% (318/428). Three-hundred-seven questionnaires were analysed (African countries, n = 263; high-income countries, n = 44). Respondents from African hospitals were less likely to have an emergency room (85.5 vs. 97.7%, P = 0.03) or intensive care unit (73.8 vs. 100%, P < 0.001) than respondents from high-income countries. Drugs, equipment, and disposable materials required to implement the Surviving Sepsis Campaign guidelines or sepsis bundles were less frequently available in African than high-income countries. Of all African and Sub-Saharan African countries, 1.5% (4/263) and 1.2% (3/248) of respondents had the resources available to implement the Surviving Sepsis Campaign guidelines in entirety. The percentage of implementable recommendations was lower in African than in high-income countries (72.6 (57.7 to 87.7)% vs. 100 (100 to 100)%, P < 0.001) and lower in Sub-Saharan African countries than South Africa, Mauritius, and the Northern African countries (72.6 (56.2 to 86.3)% vs. 90.4 (71.2 to 94.5)%, P = 0.02). Conclusions: The results of this self-reported survey strongly suggest that the most recent Surviving Sepsis guidelines cannot be implemented in Africa, particularly not in Sub-Saharan Africa, due to a shortage of required hospital facilities, equipment, drugs and disposable materials. However, availability of resources to implement the majority of strong Surviving Sepsis Campaign recommendations and the sepsis bundles may allow modification of current sepsis guidelines based on available resources and implementation of a substantial number of life-saving interventions into sepsis care in Africa. * Correspondence: [email protected] † Contributed equally Department of Anaesthesiology, Perioperative and Intensive Care Medicine, Salzburg General Hospital and Paracelsus Private Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria Full list of author information is available at the end of the article © 2011 Baelani et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Baelani et al. Critical Care 2011, 15:R10 Page 2 of 12 http://ccforum.com/content/15/1/R10 th providers attending the 4 All Africa Anaesthesia Con- Introduction gress held in Nairobi/Kenya from 12 to 16 September The annual incidence of sepsis is 750,000 cases in the 2009. During the opening plenary session of the con- United States and is increasing by 9% each year [1]. Sep- gress, all attendants were informed about the purpose sis is a major burden on the US healthcare system and anonymous design of the study together with the resulting in annual costs of $16.7 billion [2]. In fact that its results would be published in a scientific Germany, an annual sepsis case load of 76 to 110 per journal. Considering that participation in the survey and 100,000 inhabitants has been estimated and held respon- information disclosure were voluntary, the study proto- sible for approximately 60,000 deaths per year [3]. Despite these startling figures from high-income coun- col did not undergo review by an Ethics Committee. tries, the largest part of the global burden of sepsis still Participants occurs unrecognized by the Western medical commu- On thefirst twodaysofthe congress,questionnaires nity. Given that approximately 80% of the world’s popu- were haphazardly distributed to anaesthesia providers lation live in low- or middle-income countries [4], it can (both physicians and non-physicians) attending the con- be assumed that most sepsis cases occur outside the gress. No incentives to complete the survey were more economically developed world. While few reports offered. Throughout the congress, seven investigators on the outcome of sepsis in these countries exist, low were on site to collect the completed questionnaire hygienic standards, widespread malnutrition and a high responses and to be available for assistance in complet- incidence of bacterial, parasitic and HIV infection sug- ing the form. Questionnaires retrieved from respondents gest a disproportionally high morbidity and mortality practicing in an African (Table S1 in Additional file 1) from sepsis in low- and middle-income countries [5]. or high-income country were eligible for study inclusion. Indeed, the latest global burden of disease report of the High-income countries were defined according to the World Health Organization found that three infectious latest World Bank report [4]. Questionnaires completed diseases (lower respiratory tract infection, diarrhoeal dis- by non-healthcare providers or those from non-African eases, HIV/AIDS) range among the four most frequent low- or middle-income countries were excluded. causes of death in low-income countries [6]. During recent years, sepsis care in high-income coun- Survey instrument and data collection tries has substantially improved due to extensive The questionnaire was designed by all investigators research efforts allowing novel insights into the patho- based on the latest SSC guidelines. It was anonymous, physiology and treatment of sepsis [7]. Current scientific evidence to improve the care of severe sepsis or septic contained 74 items grouped into seven main categories shockpatientsissummarizedinthe SurvivingSepsis (general information, hospital facilities, drugs, patient monitoring, laboratory, equipment, disposables) and can Campaign (SSC) guidelines [8,9], which are considered be downloaded from the Additional file 1. Responses the gold standard of care in many countries. As repeat- were classified as ‘yes’, ‘no’, ‘don’t know’ for the category edly shown [10,11], implementation of the SSC guide- ‘hospital facilities’,and ‘always’, ‘sometimes’, ‘never’, lines into routine care can improve outcome from ‘don’tknow’ for the remaining categories. The ‘general severe sepsis and septic shock. However, the possibility information’ category optionally required two open- to implement the SSC guidelines in low- and middle- ended text responses (’other hospital type’ and ‘other income countries has been questioned [5,12,13]. medical grade’) which were retrospectively coded by two The aim of this survey was to compare availability of study investigators. The study questionnaire was written resources required to implement the SSC guidelines and in English, underwent pre-testing by the investigators sepsis bundles between anaesthesia providers from and subsequently pilot testing by 10 anaesthesia provi- African and high-income countries as well as bet- ders in two African countries (Hospital of Kisumu/ ween anaesthesia providers from two African regions Kenya, n = 5; Muhimbili Hospital, Dar-Es-Salaam/ (Sub-Sahara Africa vs. South Africa, Mauritius and the Tanzania, n = 5). For the pilot test, anaesthesia provi- Northern African countries). Based on personal experience ders were asked to complete and examine the question- and recent data, we hypothesized that the SSC guidelines naire with regard to its flow, salience, acceptability and could not effectively be implemented by African anaesthe- administrative ease. Inter-rater reliability was assessed sia providers due to a lack of necessary hospital facilities, for all five respondents from each hospital and yielded a equipment, drugs and disposable materials. Cohen’s Kappa of 0.71. Based on the results of the pilot testing and individual feedback, the questionnaire was Materials and methods modified. Finally, it was again reviewed and approved by This study was conducted as a self-reported, question- naire-based, cross-sectional survey among anaesthesia all investigators. Baelani et al. Critical Care 2011, 15:R10 Page 3 of 12 http://ccforum.com/content/15/1/R10 Study variables ranges. Categorical and non-continuous variables were The main study variable was availability of resources compared between groups using the Chi -or Fisher’s necessary to implement the latest SSC guidelines and Exact test, as appropriate. For comparisons of resource their sepsis resuscitation/management bundles [9]. Prior availability, only ‘always’, ‘sometimes’ and ‘never’ choices to the survey, hospital facilities, equipment, drugs and were statistically evaluated. Group comparisons of con- disposable materials required to implement individual tinuous data were performed with the Mann Whitney U SSC recommendations and sepsis bundles were defined test. P-values < 0.05 were considered to indicate statisti- by consensus of the investigators (Table S2 in Addi- cal significance. tional file 1). In order to consistently implement the SSC guidelines, resources had to be ‘always’ available. Results Resources ‘sometimes’ or ‘never’ available, as well as Questionnaires were randomly distributed to 428 of 832 those respondents who did not know whether they were congress attendants. A total of 318 questionnaires were available at their hospital were considered insufficient returned (overall response rate, 74.3%). Eleven question- to implement the SSC guidelines. Furthermore, the naires had to be excluded because respondents practi- percentage of implementable recommendations of cing in non-African middle-income countries (India, n = the SSC guidelines was calculated for each returned 5; Romania, n = 2), were returned blank (n =3), or questionnaire. were completed by non-healthcare providers (n =1). Finally, 307 questionnaires were statistically analysed Study cohorts and survey goals (African countries, n = 263; high-income countries, n = Based on the respondents’ countries of practice, ques- 44). Respondents from 185 hospitals located in 14 high- tionnaires were grouped into African and high-income income and 24 African countries (45.3% of all 53 Afri- countries. Furthermore, African countries were sub- can countries) were included (Sub-Saharan African grouped into two regions: 1) Sub-Saharan African coun- countries, n = 248; South Africa, Mauritius, and the tries generally representing low-income countries, and Northern African countries, n = 15) (Figure 1). The 2) South Africa, Mauritius, and the Northern African median (interquartile range) number of respondents per countries rated as middle-income countries according to hospital, respondents per country, and respondents’ hos- the World Bank [4]. With few exceptions, this econ- pitals per country was 1 (1 to 1), 2 (1 to 5), and 2 (1 to omy-based country classification by the World Bank 4), respectively. One hundred-nine questionnaires correlates well with the quality and development of the (35.5%) were partially incomplete. The median number national health care systems [4]. of missing responses per incomplete questionnaire was The primary goal of our survey was to compare the 1 (interquartile range, 1 to 3). availability of each resource to implement the SSC Characteristics of respondents and their hospitals are guidelines, the percentage of implementable guidelines, summarized in Table 1. Significant differences between and the possibility to implement the SSC guidelines respondents from African and high-income countries (Grade 1 and 2 recommendations) and their associated were observed in regards to the respondent’s specialty, sepsis bundles (resuscitation and management bundles) hospital type and size, as well as the availability of an between respondents and hospitals from African and emergency room and an intensive care unit. Differences high-income countries. Comparison of the same vari- in the availability of an intensive care unit were ables between respondents from Sub-Saharan African observed between Sub-Saharan African countries and countries and South Africa, Mauritius, and the Nor- South Africa, Mauritius, and the Northern African thern African countries was considered the secondary countries (Table S3 in Additional file 1). survey goal. Respondents from African countries reported to have drugs (Table 2), equipment (Table 3), and disposable Data processing and statistical analysis materials (Table 4) required to implement the SSC Questionnaires were manually entered into a centralized guidelines less frequently available than respondents database. After random cross-checking, the database was from high-income countries. Certain drugs, equipment, re-checked by calculating minimum and maximum and disposable materials (Table S4-6 in Additional file values of each question in order to detect entry errors. 1) were less frequently available for respondents from The SPSS software package (SPSS 13.0.1; SPSS Inc., Sub-Saharan African countries compared to those from Chicago, IL, USA) was used for statistical analysis. Fre- South Africa, Mauritius, and the Northern African quencies based on the number of completed questions countries. The possibility to perform thick drop analysis (some questions were not completed by all respondents) to diagnose malaria was the single resource more fre- were calculated for all categorical data. Continuous vari- quently available for respondents from African countries ables are presented as median values with interquartile compared to high-income countries and for respondents Baelani et al. Critical Care 2011, 15:R10 Page 4 of 12 http://ccforum.com/content/15/1/R10 African countries (n=263) High-income countries (n=44) � Australia � Austria � Belgium � Canada � France � Germany � Ireland � Netherlands � New Zealand � Norway � Sweden � Switzerland � United Kingdom � United States of America Figure 1 Countries of practice of survey participants. Sub-Saharan African countries (n = 248) are marked in dark grey. South Africa, Mauritius and the Northern African countries (n = 15) are marked in light grey. from Sub-Saharan African countries compared to South or any of their sepsis resuscitation and management Africa, Mauritius, and the Northern African countries. bundles (Tables 5 and 6). Respondents and hospitals Of all African respondents and hospitals, four (1.5%) from African countries less frequently had all resources and two (1.4%), respectively, stated to have the resources available to implement the SSC guidelines (Grade 1 and available to consistently implement the SSC guidelines 2 recommendations) than respondents from high- Baelani et al. Critical Care 2011, 15:R10 Page 5 of 12 http://ccforum.com/content/15/1/R10 Table 1 Characteristics of respondents and their hospitals African countries High-income countries P-value n 263 44 Specialty of respondent n (%) 0.002* Physician anaesthetist 150 (57) 35 (81.8) Non-physician anaesthetist 92 (35) 5 (11.4) Other physician 6 (2.3) 3 (6.8) Other 15 (5.7) 0 Type of hospital n (%) 0.01* University teaching 117 (44.5) 19 (43.2) Regional/Provincial 30 (11.4) 11 (25) District 34 (12.9) 9 (20.5) Private 61 (23.2) 3 (6.8) Other 21 (8) 2 (4.6) Size of hospital (beds) 350 (200 to 1,000) 600 (388 to 800) 0.03* Availability of hospital facilities n (%) Emergency room 225 (85.6) 43 (97.7) 0.03* Operation theatre 260 (98.9) 44 (100) 1 Intensive care unit 194 (73.8) 44 (100) <0.001* *, significant group difference. Data are given as median values with interquartile ranges, if not otherwise indicated. Comparisons were made with a Fisher’s Exact or a Mann Whitney U test (size of hospital). income countries. The percentage of implementable individual SSC recommendations. These results are grade 1 and 2 recommendations was lower in respon- important for the future management of sepsis care in Africa. dents and hospitals from African compared to high- income countries (Tables 5 and 6). The percentage of The finding that only 1.5% of African respondents and implementable SSC guidelines was different between even less from Sub-Sahara Africa (1.2%) reported to African respondents working in hospital of different have the resources constantly available to treat sepsis types (<0.01 for all comparisons; data not shown). patients according to the latest SSC guidelines in Resources to implement the SSC guidelines (grade 1 entirety is striking on the first sight. However, almost and 2 recommendations) tended to be less frequently three-quarters of individual SSC recommendations and available for respondents from Sub-Saharan African sepsis resuscitation/management bundles could be countries than those from South Africa, Mauritius, and implemented by African respondents. The interquartile the Northern African countries (Table 7). range of implementable guidelines (57.5 to 87.7%) was wide, suggesting considerable heterogeneity among Discussion respondents. When interpreting these figures, it needs The results of this continent-wide, cross-sectional, self- to be taken into account that 16 of the 73 (21.9%) reported, questionnaire-based survey indicate that while recommendations of the SSC guidelines are either pas- almost all respondents from high-income countries sive (’do not use’)orrequire no resourcesatall.These reported to be able to implement the latest SSC guide- results underline earlier criticism that SSC guidelines lines, only a small percentage of African respondents may not be feasible in low- or middle-income countries stated to have the required facilities, equipment, drugs [5,12,13]. Our finding that not even all respondents of and disposable materials consistently available to imple- high-income countries reported to have resources avail- ment the SSC in entirety. These results remained able to implement the SSC guidelines was unexpected. unchanged when comparisons were made between hos- However, this was due to the lack of selected resources pitals instead of respondents. Supporting our hypothesis, (for example, vasopressin or activated protein C). The median percentage of implementable SSC recommenda- these data imply that the SSC guidelines cannot be implemented in entirety by African, particularly not by tions reported by respondents from high-income coun- Sub-Saharan African, respondents due to a lack of tries was 100%. necessary resources. However, with a wide variability Lack of resources required to implement the SSC among African respondents, resources appear to be guidelines and sepsis bundles by African anaesthesia available to implement approximately three-quarter of providers was not confined to specific materials but Baelani et al. Critical Care 2011, 15:R10 Page 6 of 12 http://ccforum.com/content/15/1/R10 Table 2 Availability of drugs to implement the surviving sepsis campaign guidelines African countries High-income countries P-value N = 263 N =44 Always Some-times Never Don’t know Always Some-times Never Don’t know Oxygen 243 (93.8) 15 (5.8) 1 (0.4) 0 44 (100) 0 0 0 0.24 Antibiotics Ampicilline 201 (78.5) 47 (18.4) 5 (2) 3 (1.2) 44 (100) 0 0 0 0.004* Gentamycine 243 (92.4) 19 (7.2) 0 1 (0.4) 44 (100) 0 0 0 0.07 rd th 3 /4 Gen Cephalosporine 203 (77.5) 57 (21.8) 1 (0.4) 1 (0.4) 44 (100) 0 0 0 0.002* Piperacilline 65 (26.4) 40 (16.3) 83 (33.7) 58 (23.6) 43 (97.7) 0 0 1 (2.3) <0.001* Carbapenem 79 (32.1) 46 (18.7) 68 (27.6) 53 (21.5) 43 (97.7) 0 0 1 (2.3) <0.001* IV fluids Crystalloids 254 (96.6) 9 (3.4) 0 0 44 (100) 0 0 0 0.21 Colloids 158 (60.8) 81 (31.2) 16 (6.2) 5 (1.9) 44 (100) 0 0 0 <0.001* Blood products Red blood cells 206 (79.5) 51 (19.7) 1 (0.4) 1 (0.4) 44 (100) 0 0 0 0.005* Fresh frozen plasma 109 (42.6) 81 (31.6) 59 (23) 7 (2.7) 44 (100) 0 0 0 <0.001* Platelets 69 (27.2) 93 (36.6) 79 (31.1) 13 (5.1) 44 (100) 0 0 0 <0.001* Cardiovascular drugs Noradrenaline 119 (46.7) 60 (23.5) 67 (26.3) 9 (3.5) 44 (100) 0 0 0 <0.001* Dopamine 133 (51.4) 68 (26.3) 52 (20.1) 6 (2.3) 44 (100) 0 0 0 <0.001* Dobutamine 94 (37.2) 67 (26.5) 77 (30.4) 15 (5.9) 44 (100) 0 0 0 <0.001* Adrenaline 255 (97.3) 7 (2.7) 0 0 44 (100) 0 0 0 0.27 Hydrocortisone 252 (96.2) 9 (3.4) 0 1 (0.4) 44 (100) 0 0 0 0.21 Vasopressin 76 (29.8) 66 (25.9) 93 (36.5) 20 (7.8) 43 (97.7) 0 0 1 (2.3) <0.001* Anesthetic/sedative drugs Thiopentone 243 (93.1) 11 (4.2) 7 (2.7) 0 43 (97.7) 1 (2.3) 0 0 0.44 Propofol 154 (59) 71 (27.2) 36 (13.8) 0 43 (97.7) 1 (2.3) 0 0 <0.001* Succinylcholine 242 (93.4) 9 (3.5) 7 (2.7) 1 (0.4) 44 (100) 0 0 0 0.24 ND Muscle Relaxant 185 (70.6) 59 (22.5) 18 (6.9) 0 44 (100) 0 0 0 <0.001* IV opiate/opioide 208 (79.7) 50 (19.2) 3 (1.1) 0 44 (100) 0 0 0 0.004* Diazepam 251 (95.8) 11 (4.2) 0 0 44 (100) 0 0 0 0.17 Midazolam 138 (52.9) 72 (27.6) 48 (18.4) 3 (1.1) 44 (100) 0 0 0 <0.001* Others Insulin 232 (89.2) 27 (10.4) 1 (0.4) 0 44 (100) 0 0 0 0.07 Heparin or LMWH 174 (67.7) 56 (21.8) 21 (8.2) 6 (2.3) 44 (100) 0 0 0 <0.001* H2-Blockers 182 (70.3) 64 (24.7) 9 (3.5) 4 (1.5) 44 (100) 0 0 0 <0.001* Proton pump inhibitor 145 (55.1) 82 (31.2) 18 (7.1) 10 (3.9) 42 (95.5) 0 0 2 (4.5) <0.001* Activated protein C 15 (6.1) 32 (13) 139 (56.3) 61 (24.7) 39 (88.6) 1 (2.3) 2 (4.5) 2 (4.5) <0.001* *, significant group difference (’don’t know’ choices were not included in statistical comparisons); H2, histamine receptor 2; IV, intravenous; LMWH, low molecular weight heparin; ND, non-depolarizing. All data are given as absolute values and percentages of completed responses. appears multi-faceted. For example, 25% of respondents disposables and monitoring equipment reported by stated that their hospital did not have an intensive care some respondents. As suggested before [16,17], the lack unit. Similarly, an emergency room, a key hospital facil- of resources was especially pronounced for respondents ity to timely recognize, triage and treat sepsis patients practicing in Sub-Sahara Africa. [14,15], was not available in the hospitals of 15% of Although our survey did not specifically ask whether respondents. Nearly all materials necessary to imple- respondents routinely care for sepsis patients, several ment the SSC guidelines were less frequently available earlier studies reported that anaesthetists are crucially for African respondents compared to those from high- involved in intensive care medicine and in the care of income countries. Particularly shocking is the inconsis- critically ill sepsis patients in Africa [16,18-22]. None- tent supply or lack of basic resources such as oxygen, theless, it is notable that a relevant number of respon- fluids and broad-spectrum antibiotics or essential dents stated that they did not know whether certain Baelani et al. Critical Care 2011, 15:R10 Page 7 of 12 http://ccforum.com/content/15/1/R10 Table 3 Availability of equipment to implement the surviving sepsis campaign guidelines African countries High-income countries P-value N = 263 N =44 Always Some-times Never Don’t know Always Some-times Never Don’t know Diagnostic equipment X-ray 236 (90.8) 14 (5.4) 10 (3.8) 0 44 (100) 0 0 0 0.11 Sonography 216 (83.4) 17 (6.6) 25 (9.7) 1 (0.4) 43 (97.7) 1 (2.3) 0 0 0.04* Echocardiography 152 (60.6) 30 (12) 61 (24.3) 8 (3.2) 40 (90.9) 4 (9.1) 0 0 <0.001* Laboratory investigations Thick drop 251 (96.5) 4 (1.5) 3 (1.2) 2 (0.8) 35 (79.5) 3 (6.8) 5 (11.4) 1 (2.3) <0.001* Gram stain 238 (92.2) 18 (7) 2 (0.8) 0 43 (97.7) 1 (2.3) 0 0 0.41 Microbiological cultures 193 (75.1) 44 (17.1) 19 (7.4) 1 (0.4) 44 (100) 0 0 0 0.001* Antibiogram 181 (70.4) 51 (19.8) 21 (8.2) 4 (1.6) 44 (100) 0 0 0 <0.001* Blood sugar 242 (93.1) 17 (6.5) 1 (0.4) 0 44 (100) 0 0 0 0.2 Blood gas analysis 110 (43.5) 48 (19) 89 (35.2) 6 (2.4) 44 (100) 0 0 0 <0.001* Lactate 64 (25.7) 60 (24.1) 92 (36.9) 33 (13.3) 43 (97.7) 1 (2.3) 0 0 <0.001* Blood count 227 (87.6) 27 (10.4) 4 (1.5) 1 (0.4) 44 (100) 0 0 0 0.05 Creatinine 201 (78.2) 40 (15.6) 15 (5.8) 1 (0.4) 44 (100) 0 0 0 0.003* Bilirubin 194 (74.6) 46 (17.7) 18 (6.9) 2 (0.8) 44 (100) 0 0 0 0.001* Prothrombin time/INR 176 (68.5) 39 (15.2) 36 (14) 6 (2.3) 44 (100) 0 0 0 <0.001* Other coagulation tests 149 (60.1) 59 (23.8) 29 (11.7) 11 (4.4) 44 (100) 0 0 0 <0.001* Monitoring equipment Body temperature 205 (79.2) 50 (19.3) 2 (0.8) 2 (0.8) 42 (95.5) 2 (4.5) 0 0 0.04* Non-invasive blood pressure 241 (93.8) 11 (4.3) 5 (1.9) 0 43 (97.7) 1 (2.3) 0 0 0.52 Invasive blood pressure 58 (23.1) 84 (33.5) 102 (40.6) 7 (2.8) 41 (93.2) 3 (6.8) 0 0 <0.001* Oxygen saturation 199 (76.8) 42 (16.2) 18 (6.9) 0 44 (100) 0 0 0 <0.001* Central venous pressure 87 (33.9) 78 (30.4) 90 (35) 2 (0.8) 41 (93.2) 3 (6.8) 0 0 <0.001* Cardiac output 30 (12) 62 (24.8) 146 (58.4) 12 (4.8) 37 (84.1) 5 (11.4) 2 (4.5) 0 <0.001* Pulmonary arterial pressure 22 (8.6) 45 (17.6) 174 (68) 15 (5.9) 34 (77.3) 8 (18.2) 2 (4.5) 0 <0.001* Endtidal carbon dioxyde 99 (38.2) 78 (30.1) 78 (30.1) 4 (1.5) 43 (97.7) 1 (2.3) 0 0 <0.001* Other equipment Mechanical ventilator 184 (71.9) 38 (14.8) 34 (13.3) 34 (13.3) 44 (100) 0 0 0 <0.001* Syringe pump 138 (53.9) 53 (20.7) 61 (23.8) 4 (1.6) 44 (100) 0 0 0 <0.001* Fluid infuser 126 (49) 61 (23.7) 67 (26.1) 3 (1.2) 44 (100) 0 0 0 <0.001* Peritoneal dialysis 91 (36) 50 (19.8) 98 (38.7) 14 (5.5) 38 (86.4) 3 (6.8) 1 (2.3) 2 (4.5) <0.001* Hemodialysis/Hemofiltration 111 (43.2) 26 (10.1) 110 (42.8) 10 (3.9) 43 (97.7) 1 (2.3) 0 0 <0.001* *, significant group difference (’don’t know’ choices were not included in statistical comparisons); INR, international normalized ratio; All data are given as absolute values and percentages of completed responses. Table 4 Availability of disposable material to implement the surviving sepsis campaign guidelines African countries High-income countries P-value N = 263 N =44 Always Some-times Never Don’t know Always Some-times Never Don’t know Disposable material IV cannula 253 (97.3) 6 (2.3) 1 (0.4) 0 44 (100) 0 0 0 0.55 IV fluid giving set 253 (97.7) 3 (1.2) 3 (1.2) 0 44 (100) 0 0 0 0.6 Urinary catheter 249 (95.4) 12 (4.6) 0 0 44 (100) 0 0 0 0.15 Nasogastric tube 246 (94.3) 15 (5.7) 0 0 44 (100) 0 0 0 0.1 Endotracheal tube 251 (96.5) 6 (2.3) 3 (1.2) 0 44 (100) 0 0 0 0.46 Oxygen face mask 252 (96.6) 7 (2.7) 2 (0.8) 0 44 (100) 0 0 0 0.46 Oxygen nasal cannula 212 (81.5) 37 (14.2) 9 (3.5) 2 (0.8) 44 (100) 0 0 0 0.01* Central venous catheter 126 (48.8) 64 (24.8) 63 (24.4) 5 (1.9) 44 (100) 0 0 0 <0.001* Antithrombotic stockings 65 (25.4) 64 (25) 94 (36.7) 33 (12.9) 43 (97.7) 1 (2.3) 0 0 <0.001* *, significant group difference (’don’t know’ choices were not included in statistical comparisons); IV, intravenous. Baelani et al. Critical Care 2011, 15:R10 Page 8 of 12 http://ccforum.com/content/15/1/R10 Table 5 Possibility to implement the surviving sepsis campaign guidelines African countries High-income countries P-value Respondents n 263 44 Possibility to implement the SSC guidelines in entirety n (%) 4 (1.5) 36 (81.8) <0.001* Percentage of implementable recommendations/suggestions (%) 72.6 (57.5 to 87.7) 100 (100 to 100) <0.001* Possibility to implement all Grade 1 recommendations n (%) 15 (5.7) 40 (90.9) <0.001* Percentage of implementable Grade 1 recommendations (%) 80.8 (63.5 to 88.5) 100 (100 to 100) <0.001* Possibility to implement all Grade 1A and 1B recommendations n (%) 30 (11.4) 41 (93.2) <0.001* Percentage of implementable Grade 1A and 1B recommendations (%) 87.5 (70.8 to 95.8) 100 (100 to 100) <0.001* Possibility to implement all Grade 1C and 1D recommendations n (%) 26 (9.9) 40 (90.9) <0.001* Percentage of implementable Grade 1C and 1D recommendations (%) 71.4 (57.1 to 89.3) 100 (100 to 100) <0.001* Possibility to implement all Grade 2 recommendations n (%) 4 (1.5) 36 (81.8) <0.001* Percentage of implementable Grade 2 recommendations (%) 57.1 (38.1 to 81) 100 (100 to 100) <0.001* Possibility to implement all sepsis resuscitation bundles n (%) 43 (16.3) 41 (93.2) <0.001* Bundle element “Lactate” n (%) 64 (24.3) 43 (97.7) <0.001* Bundle element “Cultures” n (%) 188 (71.5) 44 (100) <0.001* Bundle element “Antibiotics” n (%) 204 (77.6) 44 (100) <0.001* Bundle element “Hypotension” n (%) 238 (90.5) 44 (100) 0.03* Bundle element “CVP/ScvO2” n (%) 70 (26.6) 41 (93.2) <0.001* Possibility to implement all sepsis management bundles n (%) 12 (4.6) 39 (88.6) <0.001* Bundle element “Steroids” n (%) 252 (95.8) 44 (100) 0.17 Bundle element “rhAPC” n (%) 15 (5.7) 39 (88.6) <0.001* Bundle element “Glucose” n (%) 221 (84) 44 (100) 0.004* Bundle element “Plateau Pressure” n (%) 182 (69.2) 44 (100) <0.001* SSC, Surviving Sepsis Campaign; *, significant group difference. Data are given as median values with interquartile ranges, if not otherwise indicated. The Surviving Sepsis Campaign categorized their recommendations using the GRADE system which classifies recommendations as strong (grade 1) or weak (grade 2). Furthermore, the system Classifies the quality of evidence as high (grade A), moderate (grade B), low (grade C), or very low (grade D).The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. Sepsis Resuscitation Bundles: Element “Lactate”, measurement of serum lactate; Element “Cultures”, obtainment of blood cultures prior to antibiotic administration; Element “Antibiotics”, administration of broad- spectrum antibiotics within three hours of emergency department admission and within one hour of non-emergency department admission; Element “Hypotension”, treatment of hypo-tension and/or elevated lactate with fluids; Element “CVP/ScvO2”, maintenance of adequate central venous pressure and central venous oxygen saturation. Sepsis Management Bundles: Element “Steroids”, administration of low-dose steroids for septic shock in accordance with a standardized ICU policy; Element “rhAPC”, administration of recombinant human activated protein C in accordance with a standardized ICU policy; Element “Glucose”, maintenance of blood glucose control lower limit of normal, but <180 mg/dL (10 mmol/L); Element “Plateau Pressure”, maintenance of a median inspiratory plateau pressure <30 cmH2O for mechanically ventilated patients. resources to treat sepsis were available at their hospital. Although no causative relationship can be drawn, high sepsis mortality as reported from low- or middle-income Given the drastic shortage of intensive care capacities in some African countries such as in Zambia [16], it must countries may be due to a lack of hospital facilities, be assumed that many clinicians from other medical spe- equipment, drugs and disposable materials. Accordingly, cialties routinely care for critically ill sepsis patients, for a Tunisian study including 100 septic shock patients example, on normal hospital wards. Considering this, our reported a lethality of 82% [23]. Similarly, mortality survey only reflects the possibility of African anaesthesia from severe sepsis was 80 and 92% in a tertiary centre providers to implement the SSC guidelines and cannot in Pakistan [24] and Turkey [25], respectively. Cheng yield data on resource availability of other African health et al. observed a mortality of 90% in patients with care workers to care for sepsis patients. Furthermore, the severe sepsis due to melioidosis in a Thai provincial study specifically assessed the availability of resources hospital [26]. required to implement the SSC guidelines and did not Our survey has important limitations. First, although appraise the process of clinical sepsis care itself. It the questionnaire used in this survey underwent pilot remains unknown whether the scarce resources are used testing, no assessment of test-retest reliability was per- appropriately. Similarly, our survey only evaluated the formed. Together with the lack of clinical sensibility qualitative availability of resources. Although some testing of the questionnaire, this limits the validity of resources may be available their quantity could still not the results [27]. Second, by including only anaesthesia be adequate to treat all patients with sepsis. providers attending a continent-wide congress our sur- The wide-ranging lack of resources as reflected by our vey most likely experienced a relevant selection bias due study entails that several potentially life-saving interven- to respondent clustering. Accordingly, the proportion of tions cannot be applied to sepsis patients in Africa. African respondents working either at university or Baelani et al. Critical Care 2011, 15:R10 Page 9 of 12 http://ccforum.com/content/15/1/R10 Table 6 Possibility to implement the surviving sepsis campaign guidelines per hospital African countries High-income countries P-value Hospital n 143 42 Possibility to implement the ssc guidelines in entirety n (%) 2 (1.4) 34 (81) <0.001* Percentage of implementable recommendations/suggestions (%) 67.1 (52.1 to 80.8) 100 (100 to 100) <0.001* Possibility to implement all Grade 1 recommendations n (%) 5 (3.5) 38 (90.5) <0.001* Percentage of implementable Grade 1 recommendations (%) 75 (59.6 to 84.6) 100 (100 to 100) <0.001* Possibility to implement all Grade 1A and 1B recommendations n (%) 16 (11.2) 39 (92.9) <0.001* Percentage of implementable Grade 1A and 1B recommendations (%) 83.3 (66.7 to 91.7) 100 (100 to 100) <0.001* Possibility to implement all Grade 1C and 1D recommendations n (%) 9 (6.3) 38 (90.5) <0.001* Percentage of implementable Grade 1C and 1D recommendations (%) 71.4 (57.1 to 82.1) 100 (100 to 100) <0.001* Possibility to implement all Grade 2 recommendations n (%) 2 (1.4) 34 (81) <0.001* Percentage of implementable Grade 2 recommendations (%) 47.6 (33.3 to 71.4) 100 (100 to 100) <0.001* Possibility to implement all sepsis resuscitation bundles n (%) 14 (9.8) 39 (92.9) <0.001* Bundle element “Lactate” n (%) 31 (21.7) 41 (97.6) <0.001* Bundle element “Cultures” n (%) 97 (67.8) 42 (100) <0.001* Bundle element “Antibiotics” n (%) 36 (25.2) 42 (100) <0.001* Bundle element “Hypotension” n (%) 129 (90.2) 42 (100) 0.04* Bundle element “CVP/ScvO2” n (%) 28 (19.6) 39 (92.9) <0.001* Possibility to implement all sepsis management bundles n (%) 3 (2.1) 37 (88.9) <0.001* Bundle element “Steroids” n (%) 137 (95.8) 42 (100) 0.18 Bundle element “rhAPC” n (%) 5 (3.5) 37 (88.9) <0.001* Bundle element “Glucose” n (%) 115 (80.4) 42 (100) 0.002* Bundle element “Plateau Pressure” n (%) 85 (59.4) 42 (100) <0.001* SSC, Surviving Sepsis Campaign; *, significant group difference. Data are given as median values with interquartile ranges, if not otherwise indicated. The Surviving Sepsis Campaign categorized their recommendations using the GRADE system which classifies recommendations as strong (grade 1) or weak (grade 2). Furthermore, the system Classifies the quality of evidence as high (grade A), moderate (grade B), low (grade C), or very low (grade D).The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. Sepsis Resuscitation Bundles: Element “Lactate”, measurement of serum lactate; Element “Cultures”, obtainment of blood cultures prior to antibiotic administration; Element “Antibiotics”, administration of broad- spectrum antibiotics within three hours of emergency department admission and within one hour of non-emergency department admission; Element “Hypotension”, treatment of hypo-tension and/or elevated lactate with fluids; Element “CVP/ScvO2”, maintenance of adequate central venous pressure and central venous oxygen saturation. Sepsis Management Bundles: Element “Steroids”, administration of low-dose steroids for septic shock in accordance with a standardized ICU policy; Element “rhAPC”, administration of recombinant human activated protein C in accordance with a standardized ICU policy; Element “Glucose”, maintenance of blood glucose control lower limit of normal, but <180 mg/dL (10 mmol/L); Element “Plateau Pressure”, maintenance of a median inspiratory plateau pressure <30 cmH2O for mechanically ventilated patients. private hospitals was high, while barely 25% came from necessary to manage children with sepsis. Since special- provincial or district hospitals which make up the cru- sized disposable materials and equipment are required, cial part of healthcare services in Africa. Some rural it is likely that resources necessary to care for critically African hospitals do not even have anaesthesia providers ill children with sepsis are even less frequently available. available [28]. Therefore, our results almost certainly Finally, we cannot exclude that some respondents may overestimate the true situation of resource availability to have misunderstood certain questions despite the avail- treat sepsis in Africa, particularly in rural hospitals. ability of ‘don’tknow’ choices. Although the congress Recent studies from Uganda [17] and Zambia [16] was held in English, it is possible that language pro- reported a much lower availability of basic monitoring blems contributed to misunderstandings. Some respon- devices or equipment than observed in our survey. dents chose to answer only questions they could Third, the present survey only evaluated the availability respond with ‘yes’ or ‘always’ leaving the remaining of material resources and not healthcare workers. Short- questions blank. age of sufficiently trained healthcare providers is another Several possibilities exist to improve sepsis care in threat to adequate patient care in Africa [28-30]. Even in Africa. While a consistent supply of resources to imple- high-income countries, barriers to implementation of ment the SSC guidelines in its entirety would not only the SSC guidelines may be related to inadequate staffing be logistically and economically unrealistic but also [31]. Fourth, although our survey included respondents require training of health care providers to use so far from half of African countries, its results must not be unavailable resources, modification of existing sepsis extrapolated to all of Africa. Additionally, the question- guidelines could help see that currently available naire did not assess the availability of resources resources are used according to the latest clinical Baelani et al. Critical Care 2011, 15:R10 Page 10 of 12 http://ccforum.com/content/15/1/R10 Table 7 Possibility to implement the surviving sepsis campaign guidelines in African countries Sub-Saharan African South Africa/ P-value countries Mauritius/Northern African countries Respondents n 248 15 Possibility to implement the SSC guidelines in entirety n (%) 3 (1.2) 1 (6.7) 0.09 Percentage of implementable recommendations/suggestions (%) 72.6 (56.2 to 86.3) 90.4 (71.2 to 94.5 0.02* Possibility to implement all Grade 1 recommendations n (%) 12 (4.8) 3 (20) 0.01* Percentage of implementable Grade 1 recommendations (%) 78.9 (63.5 to 88.5) 94.2 (76.9 to 98.1) 0.03* Possibility to implement all Grade 1A and 1B recommendations n (%) 27 (10.9) 3 (20) 0.28 Percentage of implementable Grade 1A and 1B recommendations (%) 87.5 (70.8 to 95.8) 95.8 (79.2 to 95.8) 0.09 Possibility to implement all Grade 1C and 1D recommendations n (%) 20 (8.1) 6 (40) <0.001* Percentage of implementable Grade 1C and 1D recommendations (%) 71.4 (57.1 to 85.7) 92.9 (67.9 to 100) 0.02* Possibility to implement all Grade 2 recommendations n (%) 3 (1.2) 1 (6.7) 0.09 Percentage of implementable Grade 2 recommendations (%) 52.4 (38.1 to 76.2) 81 (66.7 to 90.5) 0.009* Possibility to implement all sepsis resuscitation bundles n (%) 36 (14.5) 7 (46.7) 0.001* Bundle element “Lactate” n (%) 57 (23) 7 (46.7) 0.04* Bundle element “Cultures” n (%) 176 (71) 12 (80) 0.45 Bundle element “Antibiotics” n (%) 189 (76.2) 15 (100) 0.03* Bundle element “Hypotension” n (%) 225 (90.7) 13 (86.7) 0.6 Bundle element “CVP/ScvO2” n (%) 60 (24.2) 10 (66.7) <0.001* Possibility to implement all sepsis management bundles n (%) 11 (4.4) 1 (6.7) 0.69 Bundle element “Steroids” n (%) 237 (95.6) 15 (100) 0.41 Bundle element “rhAPC” n (%) 13 (5.2) 2 (13.3) 0.19 Bundle element “Glucose” n (%) 208 (83.9) 13 (86.7) 0.77 Bundle element “Plateau Pressure” n (%) 172 (69.4) 10 (66.7) 0.83 SSC, Surviving Sepsis Campaign; *, significant group difference. Data are given as median values with interquartile ranges, if not otherwise indicated. The Surviving Sepsis Campaign categorized their recommendations using the GRADE system which classifies recommendations as strong (grade 1) or weak (grade 2). Furthermore, the system Classifies the quality of evidence as high (grade A), moderate (grade B), low (grade C), or very low (grade D).The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. Sepsis Resuscitation Bundles: Element “Lactate”, measurement of serum lactate; Element “Cultures”, obtainment of blood cultures prior to antibiotic administration; Element “Antibiotics”, administration of broad- spectrum antibiotics within three hours of emergency department admission and within one hour of non-emergency department admission; Element “Hypotension”, treatment of hypotension and/or elevated lactate with fluids; Element “CVP/ScvO2”, maintenance of adequate central venous pressure and central venous oxygen saturation. Sepsis Management Bundles: Element “Steroids”, administration of low-dose steroids for septic shock in accordance with a standardized ICU policy; Element “rhAPC”, administration of recombinant human activated protein C in accordance with a standardized ICU policy; Element “Glucose”, maintenance of blood glucose control lower limit of normal, but <180 mg/dL (10 mmol/L); Element “Plateau Pressure”, maintenance of a median inspiratory plateau pressure <30 cmH2O for mechanically ventilated patients. evidence. This may be particularly relevant for therapeu- Conclusions tic interventions with a high chance of improving The results of this self-reported survey strongly suggest patient survival. Optimistically, respondents reported to that the most recent SSC guidelines cannot be implemen- have resources constantly available to implement up to ted in Africa, particularly not in Sub-Sahara Africa, due to 80% of grade 1A and 1B recommendations as well as a shortage of required hospital facilities, equipment, drugs sepsis bundles suggesting that guideline modification and disposable materials. However, availability of resources based on available resources may allow implementation to implement the majority of strong SSC recommendations of a substantial number of life-saving interventions. (grade 1a and 1b) and the sepsis bundles may allow modifi- However, considering the wide variability of resource cation of current sepsis guidelines based on available availability observed and the regional shortage of essen- resources and implementation of a substantial number of tial resources, basic resources need to be supplied to life-saving interventions into sepsis care in Africa. health care facilities to improve sepsis management. Furthermore, establishment of emergency and intensive Key messages care departments, adequate staffing and training of � Only a small percentage of African respondents sta- health care providers could be further options to ted that they have the required facilities, equipment, improve the care of African patients suffering from drugs and disposable materials available to implement severe infection. the Surviving Sepsis Campaign guidelines. Baelani et al. Critical Care 2011, 15:R10 Page 11 of 12 http://ccforum.com/content/15/1/R10 data, interpreted data, drafted the manuscript and has given final approval � The Surviving Sepsis Campaign guidelines may not of the version to be published. be implementable by African, particularly not by Sub-Saharan African, respondents due to a lack of Competing interests The authors declare that they have no competing interests. necessary resources. � Availability of resources to implement the majority Received: 26 April 2010 Revised: 1 December 2010 of strong SSC recommendations (grade 1A and 1B) Accepted: 10 January 2011 Published: 10 January 2011 may allow modification of current sepsis guidelines References based on available resources and implementation of 1. Annane D, Bellissant E, Cavaillon JM: Septic shock. Lancet 2005, 365:63-78. a substantial number of life-saving interventions into 2. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR: sepsis care in Africa. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001, 29:1303-1310. Additional material 3. Engel C, Brunkhorst FM, Bone HG, Brunkhorst R, Gerlach H, Grond S, Gruendling M, Huhle G, Jaschinski U, John S, Mayer K, Oppert M, Olthoff D, Quintel M, Ragaller M, Rossaint R, Stuber F, Weiler N, Welte T, Bogatsch H, Additional file 1: Electronic supplementary material. This file contains Hartog C, Loeffler M, Reinhart K: Epidemiology of sepsis in Germany: the study questionnaire; a list of African nations eligible for participation results from a national prospective multicenter study. Intensive Care Med in this survey; hospital facilities, equipment, drugs and disposable 2007, 33:606-618. materials required to implement single recommendations/suggestions of 4. 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Dellinger PR, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea- this survey to improve the care of patients with sepsis in Africa. Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Furthermore, the authors would like to thank all members of the congress Vincent JL, Levy MM: Suriving Sepsis Campaign guidelines for th committee of the 4 All African Anaesthesia Congress for their invaluable management of severe sepsis and septic shock. Crit Care Med 2004, support, as well as the World Federation of the Societies of 32:858-873. Anaesthesiologists which endorsed this survey. 9. 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Crit Care Med 2007, 35:2525-2532. 32. United Nations Statistics Division. Composition of macro geographical (continental) regions, geographical sub-regions, and selected economic and other groupings. [http://unstats.un.org/unsd/methods/m49/m49regin. htm#africa]. doi:10.1186/cc9410 Cite this article as: Baelani et al.: Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self- reported, continent-wide survey of anaesthesia providers. Critical Care 2011 15:R10. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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Critical Care – Springer Journals

Published: Jan 10, 2011

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