Introduction
Materials and methods
Participants
Survey instrument and data collection
Study variables
Study cohorts and survey goals
Data processing and statistical analysis
Results
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* |
African countries N= 263 | High-income countries N= 44 | P-value | |||||||
---|---|---|---|---|---|---|---|---|---|
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 |
3
rd
/4
th
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* |
African countries N= 263 | High-income countries N= 44 | P-value | |||||||
---|---|---|---|---|---|---|---|---|---|
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* |
African countries N= 263 | High-income countries N= 44 | P-value | |||||||
---|---|---|---|---|---|---|---|---|---|
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* |
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* |
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* |
Sub-Saharan African countries | South Africa/Mauritius/Northern African countries | P-value | ||
---|---|---|---|---|
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 |
Discussion
Conclusions
Key messages
-
Only a small percentage of African respondents stated that they have the required facilities, equipment, drugs and disposable materials available to implement the Surviving Sepsis Campaign guidelines.
-
The Surviving Sepsis Campaign guidelines may not be implementable by African, particularly not by Sub-Saharan African, respondents due to a lack of necessary resources.
-
Availability of resources to implement the majority of strong SSC recommendations (grade 1A and 1B) 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.