Sepsis is a life-threatening, medical emergency affecting approximately one million persons annually in the United States (NIH, 2017). Patients hospitalized with sepsis are eight times more likely to die during hospitalization (Hall et al., 2011). As nurses, we are in a position to directly impact sepsis-related morbidity and mortality. Early identification and treatment are the cornerstone of sepsis management. We are on the frontline in the care of the hospitalized patient. Being cognizant of the subtle clinical changes indicative of impending clinical decline is critical for timely interventions and avoidance of poor clinical outcomes.
In 2016, “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” was published (Singer et al., 2016). As nurses, there are several key points from this publication that we should be familiar with. First, the terminology related to sepsis has changed, but the basis of the definition of sepsis has not. Sepsis
is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection;” the term severe sepsis
has been eliminated; and septic shock
is defined as a “subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities are profound enough to substantially increase mortality” (Singer et al., 2016). Clinically, those in septic shock have been given the standard fluid resuscitation (30 mL/kg) with refractory hypotension/hypo-perfusion requiring vasoactive medications to maintain a mean arterial pressure (MAP) > 65 mmHg. Furthermore, Systemic Inflammatory Response Syndrome (SIRS) is no longer part of “sepsis” terminology. Previously, sepsis was considered SIRS with an infectious etiology.
As with many medical conditions that we see on a regular basis, there are continual advances in the understanding of disease, both from a medical and scientific perspective. With these advances come changes to best practice recommendations. It is essential that nurses stay well-informed on these changes. Below is a summary of recommendations based on the most recent literature on sepsis with a focus on what is most pertinent to our practice as nurses.
Tips for nurses taking care of patients with sepsis
Administer 30 mL/kg crystalloids within three hours of confirmed or suspected sepsis or sepsis related hypo-perfusion.
- Tip: 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).
- Tip: This initial fluid bolus is often referred to as a fluid challenge.
- Tip: In those patients diagnosed with sepsis, the nurse plays a critical role in monitoring appropriate administration of fluids as the patient transitions between levels of care (i.e. ED to floor, floor to ICU).
Measure lactate level; if elevated (>2 mmol/L), ensure that a repeat level is obtained within 6 hours.
- Tip: Lactate (or lactic acid) is a byproduct of glycolysis in anaerobic metabolism.
- Tip: In the septic patient, think of elevated lactate as a sign of tissue hypo-perfusion.
Obtain two or more sets of blood cultures prior to the administration of antibiotics; at least one set should be peripheral, the other from a vascular access device, if present.
- Tip: Bacteremia is common in patients with sepsis; collecting cultures prior to administration of antibiotics gives us the best chance of identifying the correct organism before antibiotics have a chance to affect the growth of pathogens.
- Tip: A “set” of blood cultures is collected in 2 separate bottles, one anaerobic culture bottle and one aerobic culture bottle.
Administer broad spectrum antibiotics (covering gram-positive and gram-negative organisms) within one hour of diagnosis or in those with high clinical suspicion for sepsis or septic shock.
- Tip: Controlling the source of infection, either with antibiotics or intervention for those infections amenable (wound drainage, debridement, removal of potentially infected device, cholecystectomy), is the foundation of treating patients with sepsis or septic shock.
- Tip: Failure to control source of infection could lead to persisting or worsening sepsis or septic shock and inability to stabilize your patient.
- Tip: If a patient is not getting better, think “Do we have adequate source control?”
Administer vasoactive medications if a patient remains hypotensive or if lactate remains elevated following the initial fluid challenge. Vasoactive medications should be titrated to a mean arterial pressure (MAP) of > 65 mmHg.
- Tip: Norepinephrine (Levophed) is typically the first vasopressor that is initiated. This is typically started at 2-5 mcg/min and titrated to a MAP > 65 mmHg.
- Tip: The second vasoactive medication added is typically vasopressin at 0.03 U/min. This medication does NOT get titrated and can be added in attempt to decrease the dose of norepinephrine.
Recommendation: In taking care of a patient with sepsis, it is imperative to re-assess hemodynamics, volume status and tissue perfusion regularly.
- Tip: Frequently re-assess blood pressure, heart rate, respiratory rate, temperature, urine output, and oxygen saturation.
- Tip: 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., 2016):
- Position the patient in the semi-recumbent position with the head and torso elevated at 45 degrees.
- Obtain a baseline 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 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.
Recommendation: In patients in the ED or admitted to the general hospital floor with infection, use the quick sequential organ failure assessment (qSOFA) to identify patients at risk for clinical decline and sepsis-related organ dysfunction (Singer et al., 2016). The presence of any two of the qSOFA criteria should prompt further evaluation.
- Tip: qSOFA
- Respiratory rate > 22 breaths/min
- Altered mental status
- Systolic blood pressure of 100 mmHg or less
- If your patient has 2 of these criteria, be concerned for sepsis.
- Tip: It is important to know your patient’s baseline when possible. Be aware of other variables that could potentially affect qSOFA score (dementia, baseline low systolic blood pressure [SBP]). Alternately, if your patient’s SBP is typically in the 200s and now it’s 140 with no other explanation, this should prompt further evaluation.
- Tip: The qSOFA was derived from the sequential organ failure assessment (SOFA), a tool that numerically quantifies the number and severity of organs failed (Hall et al., 2009). The SOFA score allows us to predict prognosis and severity of illness in those patients with sepsis.
Remember, sepsis is a medical emergency and should be treated as one. Early identification and management of sepsis improves patient outcomes.
Nurses have the capacity to make a difference both clinically and system-wide. Actively participate in hospital-wide performance improvement programs and share your experiences and expertise. You can have a global impact on how we manage sepsis and septic shock in the future.
Hall, M.J., Williams, S.N, DeFrances, C.J, & Golosinkiy, A. (2011). Inpatient Care for Septicemia or Sepsis: A Challenge for Patients and Hospital. NCHS Data Brief No. 62, June 2011. Centers for Disease Control and Prevention (CDC). https://www.cdc.gov/nchs/data/databriefs/db62.htm. Accessed August 22, 2017.
Jones, A. E., Trzeciak, S., & Kline, J. A. (2009). The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Critical Care Medicine, 37(5), 1649–1654. http://doi.org/10.1097/CCM.0b013e31819def97. Accessed September 6, 2017.
National Institutes of Health (NIH): National Institute of General Medical Sciences. Sepsis Fact Sheet. Updated January 2017. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Accessed August 22, 2017.
Mikkelsen, M.E., Gajeski, D.F., & Johnson, N.J. (2016). Novel tools for hemodynamic monitoring in critically ill patients with shock. UpToDate. Last updated December 20, 2016. https://www.uptodate.com/contents/novel-tools-for-hemodynamic-monitoring-in-critically-ill-patients-with-shock?source=search_result&search=passive%20leg%20raise&selectedTitle=1~13#H2842418748 Accessed September 6, 2017.
Singer M, Deutschman CS, Seymour CW, et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).