What are the guidelines for managing sepsis in the Philippine context?

Philippine Sepsis Guidelines 2020

I cannot provide specific Philippine sepsis guidelines from 2020, as the evidence provided does not contain official Philippine-specific sepsis management guidelines from that year or any year. However, I can provide guidance on implementing international sepsis guidelines in resource-limited settings like the Philippines, based on the available evidence.

Adapting International Guidelines to Philippine Context

For sepsis management in the Philippines, implement the core components of the Surviving Sepsis Campaign 1-hour bundle while adapting to local resource constraints, focusing on early recognition, immediate antibiotics, fluid resuscitation, and source control. 1, 2

The 1-Hour Sepsis Bundle (Core Interventions)

Within one hour of sepsis recognition, complete these five interventions:

• Measure serum lactate levels as a marker of tissue hypoperfusion, and remeasure within 2-4 hours if initially elevated 1, 2
• Obtain at least two sets of blood cultures before starting antimicrobials, as long as this doesn't delay treatment >45 minutes 1, 2
• Administer intravenous broad-spectrum antimicrobials within one hour of recognizing sepsis or septic shock 1, 3, 2
• Begin rapid fluid resuscitation with 30 mL/kg of crystalloid for hypotension or lactate ≥4 mmol/L 1, 2
• Start vasopressors if patient remains hypotensive despite adequate fluid resuscitation, targeting mean arterial pressure (MAP) ≥65 mmHg 1, 2

Hemodynamic Management

• Use norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg 1, 3
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 1, 3
• Consider vasopressin (0.03 U/min or 0.01-0.04 units/min) as rescue therapy in refractory shock 1, 3
• Monitor urine output (target ≥0.5 mL/kg/hr), lactate levels, and clinical signs of perfusion 1

Respiratory Support

• Apply oxygen to achieve oxygen saturation >90% 1, 3
• Position patients semi-recumbent (head of bed elevated 30-45°) 1, 3
• Use low tidal volume ventilation (6 mL/kg predicted body weight) for sepsis-induced ARDS 1, 3

Source Control

• Identify and control the source of infection as rapidly as possible 1, 3
• Drain or debride infected sites whenever feasible 1, 3
• Remove foreign bodies or devices that may be the source of infection 1, 3

Resource-Limited Setting Adaptations

Practical Implementation Strategies

Create standard operating procedures and sepsis carts with prepacked kits containing intravenous cannulas, fluid administration sets, and readily accessible essential drugs to improve compliance in resource-limited environments. 4

• Incorporate sepsis screening into triage processes rather than performing it separately 4
• Use less invasive monitoring and peripheral vasopressors when central access is limited 4
• Implement standard flow sheets to avoid duplication of work 4

Education and Training

• Train non-physician clinicians (nurses, anesthetic assistants, village health workers) to recognize and treat sepsis 4
• Utilize WHO-sanctioned courses such as Emergency Triage Assessment and Treatment and Integrated Management of Adolescent and Adult Illness 4
• Ensure familiarity with guidelines and avoid multiple versions circulating simultaneously 4

Overcoming Implementation Barriers

• Establish a team-based model, which increases guideline compliance from 40% to 80% compared to non-team models 4
• Designate sepsis ambassadors and implement feedback systems for sustainability 4
• Build a community of practice emphasizing shared values, goals, and learning experiences 4
• Secure leadership support to change organizational culture and embrace guidelines as standard work 4

Special Considerations for the Philippines

Malaria-Endemic Areas

• Give parenteral antibiotics in addition to antimalarial treatment for patients with slide-proven malaria presenting with severe clinical syndromes 4
• Manage fluids judiciously and more restrictively than in bacterial sepsis, in the absence of shock 4
• Consider blood transfusion for severe anemia (hemoglobin <6 g/dL) 4

Dengue Shock Syndrome

• Consider colloid solutions for fluid resuscitation in children with severe Dengue shock syndrome 1

Tuberculosis and HIV/AIDS

• Initiate combination therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months, followed by isoniazid and rifampicin for 4 months in tuberculosis 4
• Isolate or cohort patients with open mycobacterial infections 4
• Use trimethoprim/sulfamethoxazole for 3 weeks for Pneumocystis jiroveci pneumonia, with prednisolone added for hypoxemia 4

Critical Pitfalls to Avoid

• Each hour of delay in antibiotic administration is associated with a 7.6% decrease in survival—never delay beyond one hour 3
• Failure to identify and control the infection source leads to persistent sepsis 3
• Overlooking daily antimicrobial reassessment contributes to antimicrobial resistance 3
• Excessive fluid administration without frequent reassessment can cause fluid overload 1, 2
• Leaving septic patients unattended—ensure continuous observation and clinical examinations several times per day 1