Norepinephrine may improve survival of septic shock patients in a low-resource setting: a proof-of-concept study on feasibility and efficacy outside the Intensive Care Unit

ABSTRACT

Septic shock treatment in sub-Saharan African hospitals is challenging due to limited availability of ICUs, central venous catheters, vasopressors, and trained staff. We designed this proof-of-concept study to determine efficacy, safety, and feasibility of norepinephrine (NE) use in a non-intensive setting in a low-resource country, consisting in a peripheral infusion via a mechanical drop counter. Septic shock patients accessing a rural hospital in Uganda were included: the 2020 group (N = 12) was prospectively enrolled (Jan–Mar 2020) when NE was available; the 2019 group (N = 11) was retrospectively enrolled (Oct–Dec 2019). Enrollment was continuous to reduce selection bias. Basic clinical endpoints (noninvasive blood pressure, tissue perfusion, diuresis) defined shock control and the prognostic endpoint was survival at hospital discharge. Shock control at 6 and 12 hours was higher in the 2020 group (p = 0.012 for both). Survival at hospital discharge was 75% and 27.3%, respectively (p = 0.039). NE infusion was associated with a Hazard Ratio of 0.23 (p = 0.041) in a multivariate Cox model. No NE-induced adverse effects were detected. These preliminary results suggest that implementing NE infusion in a low-resource setting without ICU could be a safe and effective strategy in managing septic shock and that this approach could lead to a lower mortality rate.

KEYWORDS:

• Septic shock
• norepinephrine
• amines
• sympathomimetic
• Sub-Saharan Africa
• developing countries
• sepsis

Acknowledgments

Authors would like to thank IDEA (Italian Doctors for Emerging Africa, President Prof. Alberto Biglino) and the Fondazione Dr. Ambrosoli (President Dott. Giovanna Ambrosoli) for their role in supporting the local staff and for fostering educational and professional exchange activities between the University of Torino and the Dr. Ambrosoli Memorial Hospital.

A warm thanks to all the members, at every level, of the Hospital, particularly in this moment of great difficulty.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Authors’ contributions

PB and CO conceived the study and designed the study protocol; PB, CO, OGS were locally involved in data collection; PB, MT, GM drafted the manuscript and carried out statistical analysis; OGS, FM, LB reviewed and edited the manuscript; All authors read and approved the final manuscript.

Ethics approval

The study was performed in line with the principles of the Declaration of Helsinki and the study was approved by the CEO (further details in the ‘Method’ section), that even allowed the use of the collected hospital clinical data.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.