Sepsis Management Guidelines ( incorporating BUFALO ) - ( Adults )

Publication: 01/11/2007  --
Last review: 08/02/2017  
Next review: 08/02/2020  
Clinical Guideline
CURRENT 
ID: 886 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Leeds Teaching Hospitals NHS Trust Adult Sepsis Management Guidelines 2016 (incorporating BUFALO)

Summary Pathways


Figure 1


Figure 2

Table 1 - INITIAL ANTIBIOTIC GUIDELINES FOR ADULTS WITH SEVERE SEPSIS

INITIAL ANTIBIOTIC GUIDELINES FOR ADULTS WITH SEVERE SEPSIS
(all antibiotics given IV)

Suspected source

Regimen

Severe allergic reaction to penicillin

*Community acquired pneumonia

Co-Amoxiclav (Amoxicillin-Clavulanate) electronic Medicines Compendium information on Co-Amoxiclav (Amoxicillin-Clavulanate) 1.2g 8-hourly + Clarithromycin electronic Medicines Compendium information on Clarithromycin 500 mg 12-hourly

Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg 12-hourly

Hospital acquired pneumonia
(>72 hours after admission)

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid* 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly
or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400 mg IV 12-hourly 

Urinary tract infection
(check previous colonisation e.g. ESBL)

Patients < 65 years old - Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5g 8-hourly +/- Gentamicin. Refer to LTHT Gentamicin prescribing guidance

Patients > 65 years oldAztreonam electronic Medicines Compendium information on Aztreonam IV 1g 8-hourly +/- Gentamicin
Refer to LTHT Gentamicin prescribing guidance

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO 500mg 12-hourly#
+/- Gentamicin
Refer to LTHT Gentamicin prescribing guidance

Intra-abdominal infection (uncomplicated)
For complicated patients (recent antibiotic/surgery/ colonised with resistant pathogens/requiring ICU admission) Discuss with Microbiologist."

Patients < 65 years old - Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5g 8-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500 mg 8-hourly

Patients > 65 years old - Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly +Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly
or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin $ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

Meningitis

Cefotaxime electronic Medicines Compendium information on Cefotaxime 2g 6-hourly

Consult with microbiology or infectious diseases

Cellulitis

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 2g 6-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid* 600mg 12-hourly PO/IV or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin IV (see dosing guideline)

Other severe soft tissue infection

Consult with microbiology or infectious diseases

Consult with microbiology or infectious diseases

Unknown source

Patients < 65 years old - Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5g 8-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500 mg 8-hourly

Patients > 65 years old - Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly
or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin $ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

Other severe soft tissue infections e.g. necrotising fasciitis
Unusual infections e.g. endocarditis, grafts/prostheses or known antibiotic resistance

Consult with microbiology or infectious diseases

Consult with microbiology or infectious diseases

*Linezolid electronic Medicines Compendium information on Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient.

$Use of linezolid and teicoplanin in intra-abdominal infection and sepsis of unknown source is off-label and the patient should be informed of this.

# If unable to tolerate oral ciprofloxacin replace with IV ciprofloxacin 400mg 12-hourly. If known to be (or previously) positive with MRSA, replace ciprofloxacin with co-trimoxazole 960mg 12-hourly if no contra-indication; or seek Microbiology advice



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Introduction

Sepsis is a complex disease process associated with multiple pathologies, and high mortality rates. Sepsis causes about 37,000 deaths per year in the United Kingdom alone, as such accounting for more deaths than lung cancer alone, or breast and bowel cancer combined (Survive Sepsis, 2010).

Sepsis has been defined by the Global Sepsis Alliance as

..Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Sepsis can lead to shock, multiple organ failure and death especially if not recognized early and treated promptly.’
(GSA, 2010)

In recent years international consensus has been reached about the management of sepsis, both in terms of identification, through standardised screening criteria, and management (Surviving Sepsis Campaign.
In the UK, Survive Sepsis has adapted these guidelines for practical implementation within NHS trusts.

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Purpose

This guidance describes the standardised approach to identification and management of the adult patient under the care of Leeds Teaching Hospitals (LTHT) with sepsis, severe sepsis and septic shock. This applies to all adult in patient areas, acute admission areas and the emergency department.
This guidance applies to all clinical staff - nursing, medical and AHP (including temporary, agency staff and students).

The management of Neutropenic sepsis is outside the scope of this document – please see separate guidance on Leeds health pathways.

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Definitions

The following definitions are used within LTHT to ensure consistency in discussions and to reduce error.

  • Care bundle: A set of evidence based steps that when performed collectively and reliably have been proven to achieve a specific outcome.
  • Infection: microbiological phenomenon characterised by an inflammatory response in the presence of micro-organisms.
  • Systemic Inflammatory Response Syndrome (SIRS); group of clinic signs which the presence of two or more abnormalities may be an indicator of sepsis.
  • Sepsis: A disease continuum ranging from simple uncomplicated infection to the development of severe sepsis and septic shock. Diagnosed where there are 2 or more abnormal SIRS plus a suspected, or proven, infection.
  • Sepsis Screen: The initial response to a patient who shows altered physiology (NEWS score) or an infection to identify the possibility of sepsis in adult patients.
  • Red Flag Sepsis: The presence of any of the “Red Flag” features which can be assessed for at the bedside to predict if the patient is at a higher risk of severe sepsis or septic shock. The Red Flag features correlate with markers of severity from the NEWS scoring tool.
  • Severe Sepsis: The presence of one or more organ system dysfunctions in the context of sepsis defines severe sepsis for example Acute Kidney Injury in a patient with pneumonia.
  • Septic shock: There is inadequate tissue perfusion to key organs. Severe sepsis plus hypotension (Mean Arterial Pressure ≤65mmHg or systolic BP ≤ 90mmHg) following an initial fluid bolus.
  • BUFALO: The six clinical management steps that should be applied within the first hour of identifying Red Flag Sepsis. Also known as the Sepsis Six
  • Time Zero: The time point where the patient first displays a NEWS score ≥5 or ≥3 in one category, or presents with signs and symptoms of an infection.

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Sepsis Screening & Red Flag Sepsis

Achieving successful outcomes for patients with sepsis is dependent upon clinicians being able to identify the early signs and initiating interventions that have been proven to save lives.

LTHT guidance regarding screening for sepsis is in line with the Surviving Sepsis Campaign and UK Sepsis Trust clinical toolkits. The initial screen should be used to help identify the cause of the infection and severity of the sepsis.

Screen for Sepsis, Check the Severity, Identify the Source, Initiate Treatment! - See Figure 1

Screening should be completed on the following patients

  • Total NEWS score ≥5 or ≥3 in a single category.
  • Clinical signs of an infection
  • 2 or more of Temp >38 or <36OC, Respiratory rate >20/min, Heart rate >90/min, new acute confusion or a Blood glucose >7.7 (not diabetic)
  • A patient whose observations may be normal but as a healthcare professional you feel is “just not right”

The initial assessment aims to use bedside observations and point of care testing to highlight those with Red Flag sepsis. Along with a focused history and examination to determine a likely cause and working diagnosis. This highlights those who require immediate intervention but also those where sepsis may be present but the severity is less, such that there is more time to focus down to the exact cause and ensure appropriate targeted antimicrobial therapy. The BUFALO sticker should be placed in the notes. If there are no Red Flags this can be written on the sticker. If Red Flags are present the time the BUFALO interventions are completed should be written on the sticker.

Those patients with Red Flag sepsis should be considered as a medical emergency and the aim should be to complete the BUFALO package within 1 hour and obtain senior medical review as soon as possible. This is the equivalent of seeing ST elevation on an ECG in a patient with chest pain.

The Red Flag Features are as follows:

  • Systolic blood pressure <90mmHg or MAP < 65mmHg
  • Lactate > 2 mmol/L
  • Heart Rate >130 per minute
  • Respiratory Rate >25/min
  • Oxygen Saturation <91%
  • Responds only to Voice or Pain or unresponsive
  • Purpuric rash
  • NEWS >7

If Red Flags are present immediate action is required.

Grab a BUFALO bag and ensure the BUFALO is completed within 1 hour. In the ED move the patient to Resus and obtain an immediate Chest x ray

If Sepsis is present but there are no Red Flags inform the responsible clinical team, begin hourly observations (or in line with NEWS policy for current score), ensure bloods for markers of sepsis are sent (FBC/U+E/LFT/Amylase/Clotting), monitor urine output, consider alternative causes such as GI bleed/asthma/pancreatitis and re-assess for Red Flag sepsis at an hour. BUFALO stickers can be placed in the notes to indicate that blood cultures have been taken, the lactate result and to document no Red Flag features are present. If a focus of infection is found ensure correct specimen samples are taken (Blood cultures, swabs etc.) and commence treatment with antibiotics in line with LTHT Antimicrobial guidance.

 The sepsis screening tool will not identify every patient with sepsis. If the initial assessment is negative patients should continue to be monitored as per deteriorating patient policy.

The screening tool can be used at any time during a patient’s admission.

All patients with Red Flag sepsis, severe sepsis or septic shock should be referred to senior help immediately (refer to CT3/ST3 or above) and the Critical Care Outreach team unless a decision not to escalate care is taken in the interests of the patient. Clinical responsibility for the patient will remain with the on-going consultant team unless a joint decision is made to transfer care.

All patients with Red Flag Sepsis should have a senior review within 4 hours of initial diagnosis, and ideally sooner than this. There should be a written plan for care completed. Senior review is defined as Consultant or Registrar review. If not done sooner a Consultant review of the patient should occur within 8 hours of Red Flag Sepsis being identified.

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BUFALO

When Red Flag Sepsis is diagnosed patient outcome is improved by the delivery of a set of standardised set of actions known at LTHT as BUFALO. The speed and appropriateness of intervention is highly likely to influence outcome. Some of these components will already have been completed as part of the Sepsis severity screening process you will have already completed.

6.1 Blood cultures
Aim: To identify organism, guide on going antibiotic therapy and assess
organ function.

Action:

  • Take a minimum of 1 set of blood cultures, paired cultures (ideally peripheral and central, taken simultaneously) should be sent when a central line is present preferably before starting antibiotics unless this causes significant delay (>45 minutes delay to administration of antibiotics).
  • Take samples for FBC, U&E, LFT, CSF, clotting, glucose Group and Save and Venous gas.
  • Clearly identify sepsis on request form.
  • Send other cultures as appropriate (sputum, urine, wound swabs) for microbiology culture/sensitivity depending on suspected source of sepsis.
  • Take 2 sets of blood cultures in a patients with prosthetic heart valves, pacemakers, known or new heart valve disease and vascular grafts

Link to Blood culture sampling SOP

6.2 Urine output monitoring

Aim: To monitor response to therapy and renal function

Action:

  • Initiate strict hourly fluid balance and consider urinary catheterisation if shocked or unable to provide regular urine samples.  

6.3 Fluid Resuscitation:

Aim: To restore intravascular volume and maintain adequate tissue perfusion.

Action:

  • If BP systolic <90 or lactate >4 mmol/L give up to 30 mL/kg of Hartmann’s or 0.9% Sodium Chloride in <30 minutes and reassess (in 500 ml boluses, assessing response)
  • Additional boluses of 250-500mLup to 60mL/kg can be given but get help if no response to initial bolus.
  • In patients with cardiac failure use 250-500 mL boluses with more frequent reassessment and get help earlier.
  • Consider IVC ultrasound to monitor response to fluid responsiveness

6.4 Antibiotics (IV)

Aim: Treatment of the underlying infection.

Action:

  • Refer to the Table 1 - discuss with Microbiology in complex cases.
  • Blood cultures should always been taken before starting a new course of IV antibiotics.
  • Administer antibiotics. Do not delay early empirical antibiotic therapy as this may prove lifesaving particularly in patients with shock or signs of organ failure.
  • Review history of colonisation/previous infection with resistant organisms e.g. MRSA, ESBLs (Contact Microbiology if needed).
  • Ensure good prescribing practice with indication e.g. “Red Flag Sepsis – pneumonia”, duration and review date, correct name “Piperacillin/tazobactam” not “Tazocin” and time of prescription and administration
  • Ensure Day 3 review of Antibiotics

6.5 Lactate Monitoring

Aim: Identify tissue hypoperfusion and those patients with increased risk of dying from Sepsis. >2mmol/L = Red Flag sepsis, >4mmol/L = severe sepsis and independent risk factor for mortality.

Action:

  • Take blood for serum lactate; venous or arterial blood gas samples will give lactate result.
  • If venous sample; use blood gas bottle and blood gas machine for faster result
  • Venous lactate can be requested as part of blood profile sent to laboratory however will take longer for result to be returned (Glucose/ Grey Top tube)
  • Repeat at least once in the first 4 hours to ensure clearing to normal levels and not rising.

6.6 Oxygen

Aim: to maintain adequate oxygenation. In all cases the aim should be to achieve targeted saturations. In patients with no coexisting lung disease the aim is for saturations ≥94%.If the patient has a background of Chronic Obstructive Pulmonary Disease target saturations should be adjusted accordingly and usually aim for between 88 and 92%.

Action:

  • Prescribe and apply oxygen to achieve targeted saturations.
  • Initially 15L via Non re breathe mask
  • Check for history of hypercarbia/previous NIV
  • Titrate to target saturations as necessary.

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Source Control

Remove all infected invasive devices immediately and send line/catheter tips to microbiology (in line with Guideline 1599 Management of infected temporary central venous catheters and arterial catheters in adults). Consider urgent surgical intervention if patient has a source amenable to draining or removal.
Patients with an indwelling catheter and symptomatic urinary tract infection should ideally have their catheter changed in addition to appropriate antibiotic treatment for infection (see guideline 3504)

Whenever feasible significant sources of infection should be drained or removed within 12 hours of onset of severe sepsis/ shock in order to improve outcomes- antibiotics alone are often inadequate to control systemic infection in the presence of collections of undrained pus or infected prosthetic devices such as intravascular lines or urinary catheters.

Bundle documentation must to attached/ inserted into the medical record in time order. Any results from investigations must be reviewed as soon as they are available to ensure any actions necessary are initiated.

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Critical Care input

Patients with severe sepsis or septic shock, who are for full escalation of care should be managed in a facility which can provide invasive monitoring of blood pressure, cardiac filling and output pressures.

In LTHT these patients will be managed in ICU or HDU, or occasionally in specialty ward areas with critical care support.

The Critical Care outreach Team/ICU Registrar (Out of hours) should be contacted once Red Flag sepsis is confirmed to help facilitate the initial resuscitation with timely and safe transfer to the HDU/ICU.
The pathways for these patients are highlighted above.

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Sepsis Management - Non-Critical Care Environment

Some patients with sepsis will be managed outside critical care facilities. Most will have uncomplicated sepsis with no organ dysfunction, and will respond well to initial treatment. They may have had Red Flag Sepsis but have responded well to initial therapy. Others may have some level of underlying organ dysfunction but are best managed in a specialty area, e.g. oncology, respiratory patients. Finally, there will be some who are not suitable for critical care, where their disease has a very poor prognosis and a decision not to intervene has been taken. All patients cared for outside Critical Care need to be monitored closely for at least 24 hours for signs of deterioration or improvement.

  • Senior Medical Review – should happen within 4 hours of initial diagnosis and a written plan for care completed. Senior review is defined as Consultant or Registrar. If not done sooner a Consultant review of the patient should occur within 12 hours of Sepsis being identified
  • Escalation/Treatment Ceiling – all patients should have a documented escalation plan and/or treatment ceiling within 6hrs of diagnosis, preferably at the point of senior review during initial treatment with BUFALO.
    Mortality in sepsis is high, even with rapid intervention and treatment. Some patients may not be suitable for invasive monitoring/therapy, due to underlying co-morbidities or advanced care plans.
  • Review – patient with sepsis to be formally reviewed 12 hourly for first 24 hours from sepsis diagnosis by consultant in charge of care.
  • Critical Care Outreach– Critical Care teams to be aware of all patients with severe sepsis on non-critical care areas, including clear escalation plan.
  • Fluid management plan – a 24hr plan for IV/oral fluid management to be documented. 0.9% Sodium chloride and Hartmann’s solution should provide the mainstay of resuscitation fluids here.
  • Intake/Output – hourly monitoring to continue for 12hrs at least to ensure adequate fluid balance.
  • Glucose monitoring – monitor glucose every 4 hours, or more often if abnormal for the patient.
  • Observations – To be performed in line with the ‘Deteriorating Adult Patients Monitoring and Escalation Policy’ as per NEWS score.
  • Lactate – Lactate via a blood gas sample after an hour to identify response to treatment. Repeat standard bloods at 12 hours and review microbiology every 12 hours - consider escalation/de-escalation as appropriate.

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Documentation/Coding of Sepsis

Sepsis may arise from a range of infective sources e.g. urinary, respiratory, abdominal etc. As such, a huge range of terms are used for diagnosis, which makes it difficult to identify cases of sepsis – e.g. they may be coded as pneumonia, or urinary infection, rather than sepsis.

The terms ‘sepsis’, ‘severe sepsis’ “sepsis with organ failure”, or ‘septic shock’ should be routinely documented in the medical notes alongside associated source of infection, e.g. pneumonia, UTI and/or identified bacteria as grown on culture. This will ensure appropriate coding and payment.

Death certificates must align to cause of death and in cases of sepsis must align to this e.g. ‘UTI’ is not acceptable but ‘urinary sepsis’ is.

CQUIN 2016

Sepsis screening and treatment is a CQUIN in 2016 across all ward areas including Paediatrics, and Maternity and all adult ward and admission areas across LTHT. As highlighted in Figure 1 the CQUIN focuses on 2 areas.

Firstly, on the initial screening of admissions and ward based patients for the presence of infection or abnormal physiology and NEWS score and secondly, on the time to antibiotics in cases of Red Flag Sepsis and 72 hour review of these antibiotics.

The approximate value of the CQUIN to LTHT is £2.5million. Performance in these 2 areas will be audited through 2016/17 with feedback and support available through the Trusts Sepsis team (contacts below).

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Training and Implementation

Increased knowledge around sepsis and management will improve compliance with evidence based care bundles.
Training associated with this guidance will include defining sepsis, severe sepsis, and septic shock, use of the screening tool as part of the observation measurement, and implementation of the BUFALO bundle. Clinical areas will be encouraged to review their systems and processes to facilitate achieving compliance with delivery of the care bundles i.e. are there enough staff who can cannulate/ take blood, access blood gas machines, take blood cultures etc.

Ward implementation packs including promotional material and ward readiness checklists are available to aid with quality improvement work in this area

For help and advice regarding Sepsis Training please contact Dawn Stevenson Critical Care Outreach Sister, Dr Stuart Nuttall Consultant in Emergency Medicine or Sarah Fiori Patient Safety and Quality Manager.

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Associated Documents

This policy should be read in accordance with the following Trust policies, procedures and guidance:

  • Adult Observation Policy
  • ANTT
  • Antibiotic Guidance
  • Blood Cultures

BUFALO Sepsis Intervention Tool Sticker

Provenance

Record: 886
Objective:
  • To improve the diagnosis and management of sepsis
  • To provide evidence-based recommendations for appropriate diagnosis and investigation of sepsis
  • To provide evidence-based recommendations for appropriate non-antimicrobial management of sepsis
  • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of sepsis
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition: Sepsis
Target patient group: Adult patients with sepsis presentation
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Acknowledgement

Thanks to Calderdale NHS Trust for allowing us to use their ‘Guidelines for the early recognition and management of sepsis within adult acute hospital settings’ in the development of this policy.


Evidence base

The Surviving Sepsis Campaign. www.survivingsepsis.org

The UK Sepsis Trust 

Daniels R, Nutbeam T, Mcnamara G et al 2011. The sepsis six and the severe sepsis resuscitation bundle; a prospective observational cohort study. Emerg Med J 28(6):507-12.

Jones A, Shaprio N, Trezeciak S et al. 2010. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomised clinical trial. JAMA 303(8):739-746.

Mouncey P, Osborn T, Power S, et al. 2015. Trial of early goal directed resuscitation for septic shock. N Engl J Med. DOI: 10.1056/NEJMoa1500896

Peak S, Delaney A, Bailey M, et al for the ARISE investigators. 2014. Goal directed resuscitation for patients with early septic shock. N Engl J Med 371: 1496-506

Angus D, Shapiro N, et al. 2014. A randomised trial of protocol based care for early septic shock. N Engl J Med. DOI:10.1056/NEJMoa1401602

Dipti A, Soucy Z, Surana A, et al. 2012. Role of inferior vena cava diameter in assessment of volume status: a meta analysis. Am J Emerg Med 30(8);1414-1419.

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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