2021 Sepsis Guidelines for Resource-limited environments

The new guidelines are published with some changes that will be useful for the Remote Medic. First, they dropped phenylephrine from the sepsis guidelines. That is helpful for those of us working in austere environments because we seldom had that option anyway. Second, the MAP target for septic shock is now 65 mmHg or higher. Third, for casualties on norepinephrine with less than the target MAP should be given vasopressin instead of increasing the norepi dose. They also mention that it is acceptable to give vasopressin via peripheral IV. That is great to hear especially since we have been giving that drug via peripheral IV/IO for years during cardiac ROSC. The study did say that vasopressin should be started once we reach a nor-epi dose of 0.5 mcg/kg/min and are still not reaching the minimum MAP.

But what if I only have epinephrine for my sepsis patient? This is a valid concern for those of us working in remote, austere and resource-limited environments. Often, we are given our medical rucksacks full of the cheapest equipment and medicines. Companies want to shave off costs to maximise profits and are happy to give us the cheapest vasoactive drug. Hey, it works, doesn’t it? Epinephrine is an excellent drug with many uses and it is cheap as chips. I buy five epi vials from my local chemist in Malta for 3 euro. So, what can we do with five vials of 1:1000 epinephrine? Well, a lot actually.....

1. Dirty Epi. The dirty epi drip is not the best option and can be dangerous. It can be used to buy some time until you can set up the pumps or transfer your patient into a local hospital ICU.
2. Push Dose Epi. This option is your best option if you do not have a syringe pump and very few austere environments have these close to hand.

Resources

• You can download the ‘Sepsis Management in Resource-limited Settings’ for free.
• Day NP, Phu NH, Bethell DP, Mai NT, Chau TT, Hien TT, White NJ. The effects of dopamine and adrenaline infusions on acid-base balance and systemic haemodynamics in severe infection. Lancet. 1996;348:219–23.