Symposium

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World Sepsis Day

Early identification of sepsis in our hospitals
will save many lives - Prof. Sadiqa Afatab
Guidelines are best practices not standard of care - Prof. Saeeda Haider

KARACHI: Pakistan Society of Anaesthesiologists and Pakistan Society of Critical Care Medicine organized a meeting to celebrate the World Sepsis Day here on September 13th 2013. Prof. Sadiqa Aftab in charge of Surgical ICU at CHK discussed the guidelines on management of Sepsis which was followed by a panel discussion. The panelists included Prof. Saeeda Haider, Prof. Fazal Hameed, Prof. Sadiqa Aftab, Dr. Akhtar Hameed and Dr. Afia Zafar.

Group photograph taken during World Sepsis Day meeting held at a local hotel in Karachi shows
Mr. Javed Iqbal, Dr. Hasan Jamal, Dr. Zia Akhtar, Dr. Zahid Akhtar Rao, Prof. Tipu Sultan,
Mr. Sohail Feroze, Mr. Mahtabuddin Feroz, Dr. Bari and others.

Prof. Sadiqa Aftab in her presentation stated that it is because of infection which leads to sepsis. In diagnostic criteria infection has been documented in addition to general inflammatory variables. Immunosuppression increases the incidence of sepsis. It could be due to surgical stress, trauma, and infection. Quoting their own figures of Surgical ICU at Civil Hospital Karachi she pointed out that abdominal surgical patients accounted for 23.2% of sepsis cases followed by ventilator associated 19.2% and obstetrics and gynaecology related 12.5%. In severe sepsis, the patient is in septic shock and presents with low blood pressure. Sometimes the patient has multiple organ dysfunction which then leads to death. With appropriate timely treatment, some patients do survive.
If the patient has developed sepsis in ICU, one should send the blood for culture immediately, start broad spectrum antibiotics and add vasopressors if needed. After initial resuscitation, screen the patient for sepsis. Do not delay in starting the antibiotics and it must be started within forty five minutes. Start empirical therapy which can last for three to five days and then reassess the patient. Over all duration of therapy should be seven to ten days. Start antiviral therapy early in severe sepsis cases. If the cause of infection is some IV device, remove it immediately. For fluid therapy in sepsis, crystalloids should be used. Dopamine is the alternative to vasopressin. She also mentioned the inotropic therapy with dobutamine infusion. In selected cases, one may have to use corticosteroids, PRBC infusions. For control of bleeding, FFP is recommended. Keep head of the patient at 30-45 degree, use conservative fluid therapy and for glucose control, practice protocolized approach. Monitor blood glucose every one or two hours. She then talked about renal replacement therapy and prophylaxis for DVT. Use of PPIs is advocated to manage stress, avoid full dose of calories in the first week and practice low dose feeding. Make sure that the relatives of the patient, family members are involved in decision making and they should also be told about the likely prognosis within seventy two hours. Tight glucose control may reduce mortality. TPN carries inherent risk and one must use the steroids carefully.
Through Video link, Dr. Joshi from Japan described the early use of Polymyxin B in the management of septic shock. I have been involved with research in this area since 1982 and it was in 1994 that this molecule was introduced in Japan where now it being safely used to manage sepsis. It results in improvement of blood pressure, oxygenation. Now it is being used in many countries of the world and so far over hundred thousand patients have been treated with this drug. He also gave details of two clinical trials with this drug.
Dr. Gueltiero Guadagni from Canada gave further details of this new ethnology for the treatment of sepsis. Speaking about the anti endotoxin therapies, he pointed out that this polymyxin B has antibacterial capabilities of destroying bacterial outdoor membrane. He also discussed how to measure endotoxin in blood. He then discussed inhibition of endotoxin activity by addition of polymyxin B and said that so far over hundred thousand patients have been safely treated without any side effects.
Participating in the discussion Prof. Saeeda Haider said that guidelines on management of sepsis are best practices and not standard of care. These recommendations are very simple and clear and easy to follow. Prof. Sadiqa Aftab said that sometimes the abdominal surgery patients are managed by junior doctors and these patients have to be opened quite a few times and most of the time such patients do not survive. We try to follow the sepsis management guidelines. If the patient comes to the Surgical ICU within three hours but the problem is that people in Casualty, ER are not able to identify these sepsis patients and treat them. When the patient comes to ICU they are already on antibiotics for many days but through hard work, we can reduce the mortality in such cases. Most often the patients coming to ICU are in a very advanced stage and those few who are saved are because of good treatment. Dr. Hameedullah who was moderating the session opined that we should start treating the patient following the guidelines when we come in contact with these patients irrespective of the delay. Patients who come with gun shot injuries can be helped as they come in time and one can prevent them going into septic shock. It was also pointed out that almost 50% of these patients get sepsis while under treatment in tertiary care hospitals. We do not diagnose these patients in time which is our major problem. It was suggested that one must suspect infection and if a few other variables are present, consider it sepsis and start treatment immediately. If we can identify sepsis in our hospitals in time, we can reduce the mortality considerably. Every hospital should have an infection control and antibiotics use policy. The use of antibiotics may vary from hospital to hospital. It was also emphasized that we must educate our paramedics if we wish to reduce mortality due to sepsis. Not only that, junior doctors, interns and even senior consultants all should be trained. For fluid therapy crystalloids should be preferred and do not stop fluids till the patient is resuscitated.
Earlier Prof. Tipu Sultan in his welcome address said that we have managed many sepsis patients in Surgical ICU at CHK. We saved some patients and also lost some. The menace of sepsis needs to be taken care of and now even a new technology has been introduced for the management of sepsis. We do not know what the infection is and we are supposed to threat these patients. The newly discovered antimicrobial agents and the new management techniques may prove to be helpful in managing these patients. Critical care, he said is a well developed specialty overseas but it has not yet fully developed in Pakistan, he added.
Dr. Zahid Akhtar Rao Secretary of Pakistan Society of Anesthetists in his introductory remarks said that World Sepsis Day is a call for action. We need to educate the patient, families and healthcare professionals to treat sepsis as a medical emergency. Every year about twenty to thirty million patients are affected by sepsis and it has lot of mortality. Mr. Sohail Feroze Director Hospital Supply presented the vote of thanks. The meeting was sponsored by Hospital Supply Corporation and it was very well attended by anesthetists and surgeons.

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