Lippincott Nursing Pocket Card - January 2021

Recognizing and Managing Sepsis

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality (Singer et al., 2016). Early diagnosis and treatment has been shown to improve patient outcomes and decrease overall mortality from sepsis.

Recognition of Organ Dysfunction

Sequential (Sepsis-Related) Organ Failure Assessment (SOFA) Score (Vincent et al., 1996)

Provides clinical measures to identify organ dysfunction; these criteria can identify infected patients most likely to develop sepsis.
Baseline score is assumed to be zero in patients without preexisting organ dysfunction.
An increase in score of 2 points or more from baseline represents organ dysfunction.
Higher scores are associated with increased risk of mortality.

Score	0	1	2	3	4
Respiration
PaO₂/FiO₂ mm HG (kPa)	≥ 400 (53.3)	< 400 (53.3)	< 300 (40)	< 200 (26.7) with respiratory support	< 100 (13.3) with respiratory support
Coagulation
Platelets, x 10³/uL	≥ 150	< 150	< 100	< 50	< 20
Liver
Bilirubin, mg/dL (umol/L)	< 1.2 (20)	1.2- 1.9 (20- 32)	2.0-5.9 (33- 101)	6.0-11.9 (102 -204)	> 12.0 (204)
Cardiovascular
Mean arterial pressure (MAP) and vasopressor therapy (ug/kg/min for at least 1 hour)	MAP ≥ 70 mmHg	MAP < 70 mmHg	Dopamine < 5 or dobutamine (any dose)	Dopamine 5.1-15 or epinephrine ≤ 0.1 or norepinephrine ≤ 0.1	Dopamine > 15 or epinephrine > 0.1 or norepinephrine > 0.1
Central Nervous System
Glasgow Coma Scale score	15	13-14	10-12	6-9	< 6
Renal
Creatinine, mg/dL (umol/L)	< 1.2 (110)	1.2-1.9 (110-170)	2.0-3.4 (171-299)	3.5-4.9 (300-440)	> 5.0 (440)
Urine output, mL/day				< 500	< 200

Quick SOFA (qSOFA) (Singer et al., 2016)

The qSOFA provides simple bedside criteria to quickly identify adult patients with suspected infection who are likely to have poor outcomes.
This screening tool is positive in those with suspected infection and at least 2 of the following criteria:
- Respiratory rate ≥ 22/min
- Altered mental status
- Systolic blood pressure ≤ 100 mmHg
Positive screening should prompt further work-up for organ dysfunction and infection (if not already identified), and escalation of therapy or level of care.

Management

The Surviving Sepsis Campaign (SSC) Bundle (Levy, Evans, & Rhodes, 2018)

Initiate promptly upon recognition of sepsis/septic shock.
Prioritize resuscitation, diagnosis, and treatment by instituting the following interventions:
- Measure lactate level (repeat lactate if initial lactate elevated [>2mmol/L]).
- Obtain blood cultures before administering antibiotics.
- Administer broad-spectrum antibiotics.
- Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate greater than or equal to 4mmol/L.
- Give vasopressors if hypotensive during or after fluid resuscitation, to maintain mean arterial pressure greater than or equal to 65 mmHg.

Nursing Considerations

A detailed understanding of the specific measures recommended in the sepsis bundle is imperative in facilitating timely interventions and improved outcomes.

Lactate (lactic acid)
- A byproduct of glycolysis in anaerobic metabolism
- Considered a surrogate marker of tissue hypoperfusion in sepsis
Microbiologic cultures
- Directed at suspected source of infection
- Should include at least 2 sets of blood cultures (aerobic and anerobic)
- Obtain prior to initiation of antibiotics; sterilization of blood occurs within minutes to hours after first does of antibiotics; early cultures increase chance of pathogen identification.
- Inability to obtain cultures should not delay antibiotic treatment.
Broad spectrum antibiotics
- Early initiation is associated with decreased mortality.
- Controlling the source of infection either with antibiotics or intervention for those infections amenable (wound drainage, debridement, removal of potentially infected device, cholecystitis) is the foundation of treating patients with sepsis or septic shock.
- Failure to control source of infection could lead to persisting or worsening sepsis or septic shock and inability to stabilize your patient.
- If a patient is not getting better, think “Do we have adequate source control?”
Fluid resuscitation
- Supports tissue perfusion
- Crystalloids refer to IV fluids with a balanced electrolyte composition, such as normal saline or lactated ringers solution (as opposed to colloids, such as albumin or hetastarch).
- This initial fluid bolus is often referred to as a fluid challenge.
- In those patients diagnosed with sepsis, the nurse plays a critical role in monitoring appropriate administration of fluids as patient transitions between levels of care (i.e., ED to floor, floor to ICU).
Vasoactive medications
- Norepinephrine (Levophed) is typically the first vasopressor that is used. This is typically started at 2-5mcg/min and titrated to a MAP > 65 mmHg.
- The second vasoactive medication added is typically vasopressin at 0.03 U/min. This medication does NOT get titrated but can be added in attempt to decrease the dose of norepinephrine.
- An arterial line should be placed for continuous blood pressure monitoring.
Ongoing assessment
- In taking care of a patient with sepsis, it is imperative to re-assess hemodynamics, volume status and tissue perfusion regularly.
  - Frequently re-assess blood pressure, heart rate, respiratory rate, temperature, urine output, and oxygen saturation.
- Dynamic measurements such as passive leg raising (PLR) are recommended to assess for fluid responsiveness. PLR mimics endogenous volume expansion (equivalent to an approximate 300 mL fluid bolus) and can be thought of as a preload challenge. It is used to predict if a patient will respond to additional fluid bolus. Follow these steps to perform PLR (Mikkelsen et al., 2020):
  - Position the patient in the semi-recumbent position with the head and torso elevated at 45 degrees.
  - Obtain a baseline blood pressure measurement.
  - Lower the patient's upper body and head to the horizontal position and raise and hold the legs at 45 degrees for one minute.
  - Obtain subsequent blood pressure measurement.
  - The expected response to this maneuver in those that are fluid responsive is a 10% or greater increase in cardiac output (CO). Although not considered a validated measure, we often use blood pressure as a surrogate marker of CO in evaluating response to the PLR.

References:
Levy, M., et al. (2018). The Surviving Sepsis Campaign bundle: 2018 update. Critical Care Medicine, 46(6), 997–1000. https://www.doi.org/10.1097/CCM.0000000000003119

Mikkelsen, M.E., Gajeski, D.F., & Johnson, N.J. (2020, September 28). Novel tools for hemodynamic monitoring in critically ill patients with shock. UpToDate. https://www.uptodate.com/contents/novel-tools-for-hemodynamic-monitoring-in-critically-ill-patients-with-shock

Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., Kumar, A., Sevransky, J. E., Sprung, C. L., Nunnally, M. E., Rochwerg, B., Rubenfeld, G. D., Angus, D. C., Annane, D., Beale, R. J., Bellinghan, G. J., Bernard, G. R., Chiche, J. D., Coopersmith, C., De Backer, D. P., … Dellinger, R. P. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Critical Care Medicine, 43(3), 304–377. https://www.doi.org/10.1097/CCM.0000000000002255

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J. D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C., Martin, G. S., Opal, S. M., Rubenfeld, G. D., van der Poll, T., Vincent, J. L., & Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801–810. https://doi.org/10.1001/jama.2016.0287

Society of Critical Care Medicine. (2019, October 10). Sepsis Campaign Bundles. https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult-Patients

Vincent, J. L., Moreno, R., Takala, J., Willatts, S., De Mendonça, A., Bruining, H., Reinhart, C. K., Suter, P. M., & Thijs, L. G. (1996). The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive care medicine, 22(7), 707–710. https://doi.org/10.1007/BF01709751

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Recognizing and Managing Sepsis