Mastering hemodynamics can be tricky, but the first step is understanding the terminology. Let’s take a look at cardiac output and cardiac index – how to calculate them and why they’re important.
Cardiac Output (CO)
is the volume of blood the heart pumps per minute. Cardiac output is calculated by multiplying the stroke volume by the heart rate. Stroke volume
is determined by preload
, contractility, and afterload
. The normal range for cardiac output is about 4 to 8 L/min, but it can vary depending on the body’s metabolic needs. Cardiac output is important because it predicts oxygen delivery to cells.
Here’s an example:
If a patient's stroke volume is 75 mL with each contraction and his heart rate is 60 beats/minute, his cardiac output is 4,500 mL/minute (or 4.5 L/minute).
Cardiac Index (CI)
The cardiac index
is an assessment of the cardiac output value based on the patient’s size. To find the cardiac index, divide the cardiac output by the person’s body surface area (BSA). The normal range for CI is 2.5 to 4 L/min/m2
Here’s an example of how to calculate the cardiac index:
If a patient’s cardiac output is 4.5 L/minute and his BSA is 1.25 m2
, his CI would be 3.6 L/min/m2
. If another patient has a cardiac output of 4.5 L/minute, but he has a BSA of 2.5 m2
, his CI would be 1.8 L/min/m2
Both cardiac output and cardiac index are important to let us know if a patient’s heart is pumping enough blood and delivering enough oxygen to cells. We also use CO and CI values to manage certain drug therapy, such as inotropics and vasopressors.
Below are the results of a recent nursing quiz about lung auscultation posted on our Twitter page
. This revealed a need for clarification of common adventitious lung sounds and the commonly associated clinical conditions.
Answer: B. Crackles are heard when collapsed or stiff alveoli snap open, as in pulmonary fibrosis. Wheezes are commonly associated with asthma and diminished breath sounds with neuromuscular disease. Breath sounds will be decreased or absent over the area of a pneumothorax.
First, let’s review the most common adventitious lung sounds.
is high-pitched continuous musical sound, which may occur during inspiration and/or expiration, due to an obstructive process. The classic wheeze may be referred to as “sibilant wheeze.” This refers to the high-pitched whistle-like sound heard during expiration, typically in the setting of asthma, as air moves through a narrow or obstructed airway.
Alternately, what we often refer to as rhonchi
is the “sonorous wheeze,” which refers to a deep, low-pitched rumbling or coarse sound as air moves through tracheal-bronchial passages in the presence of mucous or respiratory secretions.
you’ll hear high-pitched, monophonic inspiratory wheezing. It’s typically loudest over the anterior neck, as air moves turbulently over a partially-obstructed upper airway.
are short, high pitched, discontinuous, intermittent, popping sounds created by air being forced through an airway or alveoli narrowed by fluid, pus, or mucous. These sounds may also be heard when there is delayed opening of collapsed alveoli.
Crackles are typically heard during inspiration and can be further defined as coarse or fine. Coarse crackles
are heard during early inspiration and sound harsh or moist. They are caused by mucous in larger bronchioles, as heard in COPD. Fine crackles
are heard during late inspiration and may sound like hair rubbing together. These sounds originate in the small airways/alveoli and may be heard in interstitial pneumonia or pulmonary fibrosis.
Now, let’s think about test-taking strategies. In this instance, it would be helpful to go through each clinical condition separately and predict what you may hear on auscultation.
The first choice was asthma
. Asthma is a condition mediated by inflammation. The resulting physiologic response in the airways is bronchoconstriction and airway edema. This response is triggered by an irritant, allergen, or infection. As air moves through these narrowed airways, the primary lung sound is high-pitched wheeze. Initially the wheezes are expiratory but depending on confounding factors or worsening clinical symptoms, there may be inspiratory wheezes, rhonchi or crackles. For testing purposes, however, expiratory wheezes are associated with asthma.
The second choice was pulmonary fibrosis.
This is a form of interstitial lung disease in which scarring (or fibrosis) is the hallmark clinical feature. This scarring leads to thickness and stiffness in the lungs. The most common adventitious sound associated with pulmonary fibrosis is fine bibasilar crackles. This may be hard to distinguish from congestive heart failure. The crackles are the result of the snapping open of collapsed, stiff alveoli.
was the third choice. Neuromuscular disorders can cause respiratory problems through several pathways as the muscles responsible for breathing are affected. Diaphragmatic weakness can lead to hypoventilation; chest wall muscle weakness can lead to ineffective cough; and upper airway muscle weakness can lead to difficult swallowing and ineffective clearing of upper airway secretions. In general, there are not specific adventitious sounds associated with neuromuscular disorders.
Lastly, a pneumothorax
is a collapsed lung. There would be loss of breath sounds over the area of a pneumothorax as there is no air movement in the area of auscultation.
So, this leads us to the correct answer. During lung auscultation, crackles are heard in pulmonary fibrosis, which is choice B.
Reviewing what you know and thinking about each response choice can help you focus in on the correct answer. Do you have an easy acronym or pearl for remembering breath sounds, or some test-taking strategies to share?
Megan Doble, MSN, RN, CRNP
Hinkle, J. & Cheever, K. (2013). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins.
With Zika virus in the news and on our minds this season, we know some of the best advice for preventing this illness is to prevent infection via mosquito bites. See the infographic below for recommendations to prevent transmission of Zika virus and other mosquito-borne illnesses.
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In January of 2016, we shared 5 Things Nurses Need to Know about Zika Virus
. Since that time, ongoing research and monitoring has increased what we know, and recommendations have been updated based on the latest evidence. Here are five more things that are important for nurses to understand:
1. Is there a test for Zika virus?
Early in the course of Zika virus, a serum real-time reverse transcription-polymerase chain reaction (rRT-PCR) may detect Zika virus RNA in the blood. The virus RNA may remain present in the urine longer than in the blood; the CDC recommends that urine samples be collected less than 14 days after onset of symptoms for rRT-PCR testing. Virus-specific IgM and neutralizing antibodies typically develop toward the end of the first week of illness, so Zika virus serologic testing can be done later in the course of illness. All submissions go through the state or local health department and there are specific instructions from the CDC on how to collect, prepare, and ship specimens for testing.
2. What are the current recommendations related to sexual transmission?
3. What is microcephaly?
- Men who have been diagnosed with Zika virus should use condoms or abstain from sex for at least six months.
- Pregnant women with male partners who live in or travel to areas with Zika should use condoms every time they have vaginal, anal, or oral sex, or abstain from sex for during the pregnancy.
- Both men and women should be counselled about contraceptive planning. Women with Zika virus should wait at least eight weeks after symptom onset before conceiving; men with Zika virus should wait at least six months, as it is unknown how long the virus may remain in semen. Women with possible exposure to Zika virus should wait at least eight weeks after being exposed to attempt conception; men should wait at least six months.
Microcephaly is a neonatal malformation in which infants are born with a head smaller than normal due to abnormal brain development. In some cases, newborns may develop normally, however, possible associated neurologic complications include developmental delay and seizures, as well as speech, hearing, and vision deficits, and feeding difficulties. Diagnosis can be made by ultrasound late in the second trimester or early in the third trimester, or after a baby is born. Microcephaly is a lifelong condition and treatment depends on the severity of the malformation and associated health problems.
4. Is Zika virus associated with Guillain-Barré syndrome (GBS)?
The CDC is investigating the link between Zika virus and GBS, as the Brazil Ministry of Health has reported an increased number of people who have been infected with Zika virus who also have GBS. GBS is an autoimmune disease which attacks the peripheral nervous system. Weakness of the arms and legs results, and flaccid paralysis often develops. In severe cases, the muscles of the face weaken and affect the eyes, swallowing, and breathing. Many patients with GBS have a history of a recent viral or bacterial infection, so it is possible that a percentage of those infected with Zika virus could develop GBS as well.
5. How should symptoms of Zika virus be managed?
At this time, there is no antiviral or other medication available to prevent or treat Zika virus. Rest, fluids, antipyretics, and analgesics are recommended for symptom management. It’s important to remember that aspirin and NSAIDs should be avoided until dengue virus is ruled out.
Centers for Disease Control and Prevention. (2016, July 14). Zika virus. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/zika/
Coyle, A. (2016). Zika virus: What nurses need to know. Nursing2016, 22-24.
O'Malley, P. A. (2016). Zika Virus: What We Know and Do Not Know. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 194-197.
Todd, B. (2016). Zika Virus: An Unfolding Epidemic. AJN, American Journal of Nursing, 59-60.
Don’t you wish it was that easy? You could just pick up the phone, hire Bugbusters, and they’d come out and use their Sci-fi equipment to rid your facility of all those nasty “bugs” or organisms that cause health care-associated infections (HAIs). Unfortunately, it isn’t that easy; there’s no Sci-fi equipment to magically rid your facility of organisms. We’ve made strides, however, towards reducing the incidence of these infections by using a variety of evidence-based best practices.
The Centers for Disease Control and Prevention recently published the National and state healthcare associated infections: Progress report using 2014 infection data from national acute care hospitals. This report revealed significant progress towards reducing HAIs:
- Central line-associated bloodstream infections declined by 50% between 2008 and 2014.
- Catheter-associated urinary tract infections showed no change overall, but there was progress made in non-critical care settings between 2009 and 2014, and in all settings between 2013 and 2014.
- Surgical site infection declined by 17% between 2008 and 2014.
- Clostridium difficile infections declined by 8% between 2011 and 2014.
- Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia declined by 13% between 2011 and 2014.
As you can see, we’ve made significant progress, but there’s still much more work to be done. Every day, nearly one in 25 patients in the United States has at least one infection that they acquired during their stay in a health care facility. This shows the need to improve infection control and prevention practices in health care facilities, and other various settings.
Bugbusting best practices
So, what can we do to bust those “bugs” and prevent HAIs in our health care facilities? To start, research shows that when members of the multidisciplinary team are aware of infections and join together to take steps to prevent those infections, infection rates can be reduced by more than 70%. Developing a culture of safety that includes teamwork, evidence-based infection prevention processes, and accountability for preventing infections is key.
Making it real
Make infections real to all members of the health care team, including environmental services personnel, transportation staff, sterile processing department staff, patients, visitors, and volunteers; not just those directly involved in patient care. After all, everyone plays a role in preventing the spread of infection.
Share stories… nothing hits home like a story of a patient who suffered harm as a result of an infection that could’ve been prevented. Take for instance, the story of an elderly patient admitted to a health care facility for knee replacement surgery. The surgical procedure itself went smoothly, but the patient soon developed a surgical site infection, the responsible organism was MRSA. The patient spent months in the hospital for IV antibiotics, prosthetic joint removal, spacer insertion, and eventually an above the knee amputation of the affected leg. The patient, the mother of a staff physician, eventually succumbed to complications of the MRSA infection.
How could a seemingly uncomplicated surgery result in an infection that ultimately resulted in this patient’s death? Was it by the hands of a health care worker who didn’t take time to perform hand hygiene? An operating room team member who failed to follow sterile technique during the procedure? An environmental services staff member who didn’t properly clean surfaces in the patient care area? A sterile processing staff member who didn’t properly sterilize surgical instruments? A visitor who failed to perform hand hygiene before visiting the patient? The patient herself who failed to properly perform personal hygiene after surgery? Any of these scenarios could’ve caused the patient’s infection and subsequent death. When this story was told, it was difficult not to feel accountable.
There are many opportunities for infection to spread in a health care facility. It’s important to make sure that everyone is educated about measures to prevent infection, using methods that they understand. Start with the basics...we’ve all heard it before, hand hygiene
is the single most effective thing you can do to keep infection from spreading. Make sure everyone performs hand hygiene properly, every time that it’s indicated.
Develop a culture that has zero tolerance for infection and zero tolerance for failure to follow proper infection prevention practices. Empower patients, family, and other staff to speak up when infection prevention practices aren’t followed. Getting to zero is the only sure way to keep our patients safe from infection.
What infection prevention practices have been successful at your facility? Have you done anything creative to engage staff, patients, and visitors; something outside the box that you’d like to share with us?
Centers for Disease Control and Prevention. (2016). “National and state healthcare associated infections: Progress report” [Online]. Accessed April 2016 via the Web at http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf
Collette Bishop Hendler, RN, MS, CIC
Institute for Healthcare Improvement. (n.d.). “What zero looks like: Eliminating hospital-acquired infections” [Online]. Accessed April 2016 via the Web at http://www.ihi.org/resources/Pages/ImprovementStories/WhatZeroLooksLikeEliminatingHospitalAcquiredInfections.aspx
Yokoe, D.S., et al. (2014). SHEA/IDSA practice recommendation: Introduction to a compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. Infection Control & Hospital Epidemiology, 36(5), 455-459.
Senior Clinical Editor
Clinical Project Manager, Lippincott Procedures
Wolters Kluwer, Health Learning Research & Practice
I have learned quite a bit on my journey to gaining a better understanding of Negative Pressure Wound Therapy (NPWT). In Part 1
of this series, I provided an overview of NPWT, including what it is, how it works and the risks and benefits. In Part 2 of the series I will review the practical application of NPWT including prescribing orders, procedural steps, general patient care, and tips to troubleshoot the device.
Let’s jump in!
What are the steps in applying NPWT?
Each device has a specific design and manufacturer’s instructions for use that should be reviewed. The following procedural steps provide a general guide.
- Pre-medicate the patient for pain as needed and as prescribed.
- Prepare the wound by:
- removing the prior dressing very carefully to avoid tissue damage and bleeding
- debriding the wound, performed by a qualified practitioner
- cleansing the wound as needed/prescribed
- assessing wound size and depth
- Cut foam dressing to size and place into the wound. Document the number of foam pieces used; foam acts as a filter to catch blood clots and large tissue particles that might clog the vacuum system.
- Trim clear occlusive dressing to size, peel back one side of Layer 1 and place adhesive side down over wound. (see photo 1)
- Remove the remaining side of Layer 1 ensuring it creates a tight seal.
- Cut a hole into the clear dressing about the size of a quarter (2.5 cm). (see photo 2)
- Remove Layer 1 from adhesive pad connected to the pump tubing.
- Place pad and tubing directly over hole affixing it to the clear dressing. (see photo 3)
- Remove Layer 2 from the adhesive pad.
- Connect pad tubing to canister tubing and be sure the clamps are open.
- Turn on power to the vacuum device, set the prescribed pressure settings, and confirm that the dressing and foam shrink down. (see photo 4)
Wound Care Tips:
General Patient Care:
- Use protective barriers, such as non-adherent or petroleum gauze, to protect sutured blood vessels or organs near areas being treated with NPWT. 2
- Avoid overpacking the wound too tightly with foam; this prevents negative pressure from reaching the wound bed, causing exudate to accumulate. 2
- Avoid placing the tubing over bony prominences, skinfolds, creases, and weight-bearing surfaces to prevent tubing-related pressure ulcers. 2
- Count and document all pieces of foam or gauze on the outer dressing and in the medical record, to help prevent retention of materials in the wound; 2 when possible, only use one piece of foam dressing.
- With a heavy colonized or infected wound, consider changing the dressing every 12 to 24 hours as directed by the prescribing clinician.2
Troubleshooting the Device
- Assess the patient for wound healing issues, such as poor nutrition (low protein levels), diminished oxygenation, decreased circulation, diabetes, smoking, obesity, foreign bodies, infection and low blood levels.2
- Assess and manage the patient’s pain; be sure to premedicate as needed before each dressing change.
- Provide patient education on:
- Alarms and device ‘noise’
- Dressing changes
- Signs of complications (bleeding, infection)
- Patients should seek medical care if they notice:
- Significant change in the color of the drainage (cloudy or bright red)
- Excessive bleeding under the clear dressing, in the tubing or in the canister
- Increased redness or odor from the wound
- Increased pain
- The device has been left off for more than 2 hours
- Signs of infection, such as fever, redness or swelling of the wound, itching/rash, warmth, pus or foul smelling drainage
- Allergic reaction to the drape/dressing: redness, swelling, rash, hives, severe itching. Patient should seek immediate medical assistance if they experience difficulty in breathing
- Confirm that the unit is on and set to the appropriate negative pressure, that the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure. 2
- Be sure the negative pressure seal has not been broken and leaks are minimal.4
- Ensure there are no kinks in the tubing and that all clamps are open.4
- Address and resolve alarm issues; reasons for the unit to alarm include: canister is full, there is a leak in the system, battery is low/dead, therapy is not activated.
- Do not leave the device off for more than two hours; while device is off, apply a moist dressing 2 and notify the prescribing clinician immediately.
- Avoid getting the electrical device wet; educate the patient to disconnect the unit from the tubing and clamp the tubing before bathing.
- Check the drainage chamber to make sure it is filling correctly and does not need changing.4
While I am not an expert in the field of wound care, I am now more confident and better prepared to manage patients receiving Negative Pressure Wound Therapy. I would love to hear your experiences. Let me know if you have any tips or other suggestions that can help nurses and patients safely operate and maintain these devices.
1. Centers for Medicare and Medicaid Services. (2014). Negative Pressure Wound Therapy Technologies for Chronic Wound Care in the Home Setting. Retrieved from the Centers for Medicare and Medicaid Services: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id96ta.pdf
2. Rock, R. (2014). Guidelines for Safe Negative-Pressure Wound Therapy: Rule of Thumb: Assess Twice, Dress Once. Wound Care Advisor, 3(2), 29 – 33
3. Federal Drug Administration. (2009). FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. Retrieved from the Federal Drug Administration: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm190658.htm#table1
4. Wound Care Centers. (2016). Negative Pressure Wound Therapy. Retrieved from Wound Care Centers: http://www.woundcarecenters.org/article/wound-therapies/negative-pressure-wound-therapy
Myrna B. Schnur, RN, MSN
Since I began working in a reconstructive surgery clinic several years ago, I have been exposed to a myriad of complex acute and chronic wounds that require advanced treatment modalities, such as Negative Pressure Wound Therapy (NPWT), in order to heal. These devices were new to me, and I quickly realized that they can be a source of great anxiety for both patient and clinician. I decided I needed more information and education on the topic. In Part 1 of this blog series, I will discuss the basics of NPWT, what it is, how it works, as well as risks and benefits.
What is Negative Pressure Wound Therapy (NPWT)?
Also known as vacuum-assisted wound closure (VAC), NPWT is the distribution of negative pressure across a wound1. The therapy, which emerged in the early 1980’s, includes the placement of a dressing (foam or gauze) onto the wound and is connected to a vacuum pump via tubing1
. A clear occlusive dressing is placed on top, forming an air tight closed system. Gentle, controlled suction is applied pulling wound debris into a collection chamber. The Food and Drug Administration (FDA) approved the first device for NPWT in 1997. Currently, there are over a dozen FDA approved devices available on the market1, many of which are small and lightweight, allowing patients full mobility3
. Due to varying designs, it is important that you become familiar with the manufacturer instructions for the specific device in use.
Which types of wounds benefit most from NPWT?
How effective is NPWT?
- Surgical wounds, especially those which need to heal by secondary intention1
- Open abdominal incisions1
- Dehisced surgical wounds1
- Skin flaps and preparation for skin graft sites1
- Traumatic wounds1
- Chronic wounds, such as venous insufficiency ulcers, diabetic foot ulcers, and pressure ulcers1,4
- Wounds at high risk for infection4
- Wounds with copious drainage4
- Meshed grafts, to either secure the graft in place or improve epithelialization4
- Adjunct to skin graft/flap procedure4
Compared to traditional forms of wound therapy, advantages of NPWT include:
What are the factors that increase a patient’s risk for adverse events with NPWT:
- Improved healing of transplanted skin and decreased length of hospital stay for patients receiving split thickness skin grafts.4
- Decreased wound infections in patients following orthopedic trauma and open fractures.4
- Improved wound healing, shorter length of stay, lower hospital mortality in patients with mediastinitis and unsuccessful wound healing following sternotomy.4
- Improved wound healing in patients with diabetes mellitus and gangrene that might require amputation.4
Are there any contraindications for NPWT?
- Increased risk for bleeding and hemorrhage2,3
- Anticoagulant or platelet aggregation inhibitor therapy2,3
- Friable or infected blood vessels2,3
- Vascular anastomosis3
- Infected wounds3
- Spinal cord injury2
- Enteric fistulas2
- Exposed organs, vessels, nerves, tendons, and ligaments3
- Inadequately debrided wounds2
- Necrotic tissue with eschar
- Untreated osteomyelitis2,3
- Cancer in the wound2,3
- Untreated coagulopathy2
- Unexplored fistulas
- Exposed vasculature, nerves3, anastomotic site3, vital organs2
While great strides have been made to improve the safety of NPWT devices, serious adverse events may still occur. Clinicians should take time to review specific device instructions for use, indications, and contraindications and adequate staff training should be provided. Healthcare providers that understand the principles of NPWT can then collaborate to ensure that each patient is selected appropriately for therapy based on wound type, risk profile and care setting. In Part 2
of this series, I will review the procedure for applying a NPWT dressing, general patient care, and tips to trouble-shoot the device.
Myrna B. Schnur, RN, MSN
1. Centers for Medicare and Medicaid Services. (2014) Negative Pressure Wound Therapy Technologies for Chronic Wound Care in the Home Setting. Retrieved from the Centers for Medicare and Medicaid Services: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id96ta.pdf
2. Rock, R. (2014). Guidelines for Safe Negative-Pressure Wound Therapy: Rule of Thumb: Assess Twice, Dress Once. Wound Care Advisor, 3(2), 29 – 33.
3. Federal Drug Administration. (2009). FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. Retrieved from the Federal Drug Administration: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm190658.htm#table1
4. Wound Care Centers. (2016) Negative Pressure Wound Therapy. Retrieved from Wound Care Centers: http://www.woundcarecenters.org/article/wound-therapies/negative-pressure-wound-therapy
As National Nutrition Month comes to an end, I am reminded how nutrition isn’t just about cutting calories and eating healthy. There is so much more that we don’t think about on a regular basis, unless it affects the patients in our care or our personal lives.
I regularly visit an adolescent sports medicine facility with one of my children. The clinicians there deal with a variety of conditions and issues, ranging from orthopedic injuries and concussions to eating disorders and, in our case, impaired growth related to caloric expenditure through sport.
Some people may see a kid who is fit and active and think “Wow, he is so lucky!” I see a kid who is competitive to the point that his growth charts have taken some sharp declines during a critical adolescent growth period. While I’m proud of his commitment and determination, I also am concerned for his growth and development.
We are fortunate to have a great resource in our area that has helped us turn things around for my son. He is a swimmer and a runner who trains for hours each day, and to meet his nutritional needs for sport and catch-up growth, he must take in over 5,000 calories each day! Sounds easy, right? Actually, it is a challenge and requires quite a bit of hard work. I ask that you let this post serve as a reminder to be open to the struggles of others; sometimes the problems they face aren’t as simple as you may think.
For some related reading on this topic and more on nutrition, explore Nutrition Today
, a journal with articles written by “leading nutritionists and scientists who endorse scientifically sound food, diet, and nutritional practices,” including the following related to sports nutrition:
Last month, new definitions for sepsis and septic shock (Sepsis-3) were released and published in the Journal of the American Medical Association (JAMA). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
is the work of a consensus panel of experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. There have been multiple revisions and evolutions to the definitions of sepsis and treatment strategies over the years as we continue to increase our understanding of the complex biology of sepsis and the physiologic effects of sepsis on the body. We are constantly adapting this knowledge to clinical practice. Despite advances in our understanding of sepsis biology, it remains a condition associated with high morbidity and mortality worldwide. Despite constant advances in pharmacologic treatments and organ support devices (i.e. mechanical ventilation, renal replacement therapies, etc.) early identification and treatment of patients with sepsis remains the cornerstone of improving survival. The new definitions simplify the classification of sepsis and provide tools to identify those with suspected infection that are at risk of developing complications of sepsis by utilizing the Sequential (sepsis-related) Organ Failure Assessment (SOFA)
and qSOFA scores.
The new definitions and risk assessment scores take the focus off inflammation and place it on the organ dysfunction related to the dysregulated host response that is sepsis. In fact, Sepsis-3 defines sepsis as “Life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al. 2016).” A lay term definition is also provided in the article describing sepsis as “a life-threatening condition that arises when the body’s response to infection injures its own tissues and organs” (Singer et al. 2016). This provides helpful terminology in speaking with families about the complex and complicated condition.
Why the change?
Prior to the release of Sepsis-3, healthcare providers generally referred to four different levels of sepsis: systemic inflammatory response syndrome (SIRS), sepsis
(SIRS in response to a confirmed infectious process), severe sepsis
(sepsis plus organ dysfunction as evidenced by hypotension or hypoperfusion to one or more organs), and septic shock
(sepsis with persisting arterial hypotension or hypoperfusion despite adequate fluid resuscitation).
Over the years, there has been much controversy over the SIRS criteria, as they are considered to have poor specificity and sensitivity for predicting the development of sepsis. The SIRS criteria – fever, tachycardia, tachypnea, leukopenia/leukocytosis – are present in many conditions, both in chronic medical illness and in acute reactions to infection. A patient with acute bacterial pharyngitis with dehydration from poor intake and tachycardia from dehydration and fever can be treated outpatient and is at very low risk of progressing to septic shock despite meeting SIRS criteria. Furthermore, the “levels” of sepsis infers there is a continuum or spectrum that a patient with sepsis follows in the course of illness and this is not the case.
In a nutshell, the focus of the new definitions as described above is defining sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sequential (sepsis-related) Organ Failure Assessment (SOFA)
is presented as a tool to identify organ dysfunction and the risk of a patient with infection in developing sepsis. SIRS has been eliminated from sepsis vocabulary, as has severe sepsis, which was considered redundant. So now we have:
- Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction is measured by changes in the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score of two points or more. In a patient with unknown baseline, the beginning score is zero.
- Septic shock: a subset of sepsis with vasopressor requirement to maintain MAP >65 and serum lactate > 2 mmol/L in the absence of hypovolemia (i.e. after a patient has received adequate fluid resuscitation).
The SOFA Score (Vincent et. al 1996) provides clinical measures to identify organ dysfunction; these criteria identify infected patients most likely to develop sepsis. Organ dysfunction is identified as an acute change in SOFA score of greater than or equal to two. These clinical variables include PaO2/FiO2 ratio, platelet count, bilirubin, MAP with and without the presence of vasoactive agents, Glascow Coma Scale, creatinine and urine output.
(Quick SOFA) Criteria is an additional tool highlighted in Sepsis-3. The clinical variables of the qSOFA are:
- Respiratory rate > 22
- Altered mentation (GCS < 15)
- Systolic blood pressure ≤ 100
The presence of any two of these criteria (qSOFA) in a patient with a known infection should prompt further evaluation for organ dysfunction. This tool can be utilized by the bedside nurse.
Nursing implications of Sepsis-3
While these definitions will not change how we treat patients with sepsis or presumed sepsis, they do provide more straightforward terminology, as well as a bedside tool to evaluate a patient with infection, potentially allowing us to both identify at-risk patients sooner and treat earlier. The presence of the qSOFA criteria in a patient with infection should prompt further evaluation of the patient and possible measurement of the more detailed SOFA criteria to evaluate for organ dysfunction. As a nurse, awareness and understanding of the most up-to-date terminology surrounding sepsis improves care of our patients and allows for better communication of patient information to colleagues in a consistent manner. Nurses are in a key position at the bedside to monitor and identify patient in the early stages of clinical decline and have the potential to positively impact patient outcomes by facilitating early interventions and treatment of the septic patient.
With this information, we can improve our communication. In the past, we might have said, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. I just have a feeling this patient is declining; he looks like he might be septic.” Now, with our new definitions, we can say, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. Since admission, he has deteriorated clinically; his qSOFA score is two, he has a respiratory rate of 30 and his systolic blood pressure is 80. When he arrived in the ED, his SOFA score was one due to a creatinine of 1.5. Now his urine output is down to 15 mL/hr, and his MAP is 60. I think we need to order more labs and have someone come re-evaluate the patient for possible transfer to the ICU.” As nurses, we often know when something is changing and our patient’s clinical condition is headed in the wrong direction. Familiarization with these tools provides us with more objective data to present and support our concerns.
It has now been several weeks since the release of Sepsis-3. In reviewing medical commentary, there are varying supports and criticisms of both the new definitions and on the utility of the SOFA and qSOFA scores. True, qSOFA and SOFA are not diagnostic of sepsis or septic shock, the SOFA is a predictor of mortality; but they provide objective data points that can be easily measured in the hospital setting. What remains unchanged is our goal of early identification and early treatment to reduce overall morbidity and mortality related to sepsis. Sepsis is a complex condition; in addition to overt symptomatology, there is complex biochemical, genetic and endogenous factors involved in the pathobiology of sepsis. Some pathways are well understood while others are only on the brink of being understood.
I am personally happy with the new definitions and the simplicity of the diagnostic terms of sepsis vs. septic shock. I am looking forward to the improved dialogue and communication using the SOFA criteria. As with any changes in medicine, there is typically a lag time from publication to implementation. At my hospital, in particular in the ICU, there has certainly been a lot of buzz and support for the new terminology. I would love to hear how other hospitals and facilities have reacted to Sepsis-3!
Megan Doble, MSN, RN, CRNP
Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
Vincent JL, Moreno R, Takala J, et al; Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22(7):707-710.
By Kim Fryling-Resare
I was going to put together a collection of information and statistics to share about multiple sclerosis, but as I started to write, it became more about what I personally do to raise MS awareness. My hope is that my story will give insight and shed some light onto a patient’s perspective. I feel like understanding is one of the keys to better support and care for patients living with a chronic illness.
March is MS Awareness Month – a topic near and dear to my heart. I’ve been living with relapse-remitting multiple sclerosis since 2003 and I try to live my life every day as if it is “MS Awareness Day.”
Unfortunately, I’m not a scientist who will discover a cure. I’m not a neurologist or a nurse who will treat patients. And lastly, I’m not fortunate enough to be rolling in money that I could fund clinical trials or research studies. So what can I do to raise awareness about MS?
I can SUPPORT.
Whenever I hear about someone who is newly-diagnosed, or someone who may be struggling with the disease, I’m always ready to hand out my phone number or email address. I know all too well that it can be a continuous struggle, but I want them to know they are not alone. There is hope, and they will get through this battle learning strategies to improve life and ultimately discovering how truly strong they are.
I can stay POSITIVE.
I went through all of the typical emotions after my MS diagnosis, and I had to go through the grieving process and let go of my life, or at least my perceived life, before MS. Now, I’m actually thankful for MS. I have let go of a lot of toxic people and negativity, and I try not to sweat the small stuff. I have chosen to take the path where I value life and take little to nothing for granted.
I can EDUCATE.
I have always been very open about living with multiple sclerosis. I love shocking people with the fact that I have MS. I encourage questions and enjoy sharing my experiences and knowledge. There is a lot of misinformation out there and people tend to have such misconceptions about what MS looks like, and what it means to live with MS. It is such a varying disease that presents so differently and affects people in so many different ways.
I can LIVE fully.
I live the best life that I can with MS, and along the way, I try to educate others on what MS is and what it means to people battling it every day, every month, every year. Raising awareness for MS and living fully is my way of advocating and giving back to the MS community.
I will never give up HOPE.
I have this silly personal belief that if I say something, or believe something long enough, it will manifest and become reality. So…There will be a cure for MS. There will be a cure for MS. There will be a cure for MS…
To continue raising awareness, I’m marking my 13th year living with MS by participating in my first half marathon this summer. 13 years, 13.1 miles! Never give up!
Please use these free resources on NursingCenter to learn more about MS and to help spread awareness by sharing with your colleagues, patients, and the public.
The Journal of Neuroscience Nursing
and the Journal of Infusion Nursing
are both honoring MS Awareness Month by offering subscription discounts in March. Enter promotion code, WFS115GN, and take 40% off the subscription price for either journal.