What is herd immunity?

Influenza season is in full swing and the headlines are troubling. For example, CDC Confirms Widespread and Intense Flu Season All Across the US, CDC official on why the flu is near-epidemic, peaking early this year, and Severe flu brings medicine shortages, packed ERs and a rising death toll in California, are a just a few headlines causing distress for many. According to the Centers for Disease Control and Prevention, the most important method to prevent the flu is getting the flu vaccine every year. Keep in mind, that recommendation is not just made for your own protection.

herd-immunity.pngHerd immunity, or community immunity, makes it less easy for communicable diseases to spread, especially to those for whom vaccination is contraindicated. It’s an indirect way to protect individuals through vaccination of the public. Herd immunity protects everyone, but it is especially important for those who can’t get vaccinated – for example, those with life-threatening allergies to any part of the influenza vaccine.

An example of a disruption in herd immunity occurred in the not-so-distant past. If you recall, back in 2015, a measles outbreak began in California when an unvaccinated child was hospitalized with rash. The child’s travel history included a recent visit to a Disney theme park, and within two months, about 125 additional cases were connected with visits to Disneyland (Gould, 2017).

So, what’s the problem? Of late, vaccine safety is being questioned by many and the controversy is getting more attention than the diseases they are intended to prevent. Also, many of us weren’t alive when certain communicable diseases – those for which vaccinations are currently available and recommended – even existed. Most of us haven’t been affected by the crippling effects of polio or the devastation from diphtheria.

While influenza may not seem like a scary illness to some, it can be devastating for others. According to the Centers for Disease Control and Prevention, 6,486 laboratory-confirmed influenza-associated hospitalizations have been reported since October 1, 2017, and 7% (the epidemic threshold) of deaths for the year (up to and including the week ending December 23, 2017) were attributable to pneumonia and influenza. Twenty influenza-related pediatric deaths have been reported during the 2017-2018 influenza season thus far (Centers for Disease Control and Prevention, 2018).

When it comes to vaccination, remember that by protecting yourself, you are protecting so many others. As nurses, we are in a key position to educate our patients and the public. Use these tools for Staying Healthy This Flu Season and be sure to SHARE the Flu Vaccine Recommendation.
Centers for Disease Control and Prevention. (2018, January 12). Influenza (Flu). Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/flu/index.htm

Gould, K. (2017). Vaccine Safety: Evidence-Based Research Must Prevail. Dimensions of Critical Care Nursing, 145-147.

U.S. Department of Health & Human Services. (2017, December). Community Immunity. Retrieved from Vaccines.gov: https://www.vaccines.gov/basics/work/protection/index.html


Posted: 1/18/2018 9:13:56 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Diseases & Conditions

SHARE the Flu Vaccine Recommendation

The Centers for Disease Control and Prevention offers the SHARE method to approach the conversation on flu vaccination. This is a great way to help patients make informed decisions.

Centers for Disease Control and Prevention. (2017, December 11). Make a Strong Flu Vaccine Recommendation. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/flu//professionals/vaccination/flu-vaccine-recommendation.htm


Posted: 12/13/2017 12:46:46 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions

Lippincott NursingCenter.com Announces a Donation Campaign to the American Red Cross

In a time following numerous natural disasters and the deadliest mass shooting in modern U.S. history, healthcare professionals are reminded how vitally important emergency preparedness protocols are in times of crisis. However, the rippling side effects continue after the initial impact of traumatic incidents. Crises of this size and scale can trigger post-traumatic stress disorder (PTSD) among anyone who experiences or witnesses the traumatic event. In the wake of these recent events, Lippincott NursingCenter.com is offering a PTSD continuing education (CE) collection for $1.00 until 12/31/2017. All proceeds from this collection will be donated to the American Red Cross.

Recognizing PTSD Symptoms
Nurses are in the position to make an impact in times of crisis beyond providing acute patient care. In the aftermath, recognizing the signs of post-traumatic stress disorder (PTSD) is critically important. Managing PTSD in patients and, at times, amongst peers requires nurses to stay in-the-know on what classifies as PTSD and how they can deliver care. The National Institutes for Mental Health identifies four diagnostic criteria for PTSD (National Institute of Mental Health, 2016):

  1. At least one re-experiencing symptom (flashbacks, bad dreams, frightening thoughts)
  2. At least one avoidance symptom (staying away from places that are reminders of the trauma, avoiding related thoughts and feelings)
  3. At least two arousal and reactivity symptoms (startling easily, feeling tense, sleeping difficulty, angry outbursts)
  4. At least two cognition and mood symptoms (trouble remembering key features of the trauma, negative thoughts about self or the world, guilt or blame, loss of interest in enjoyable activities)

Continuing Education
It is imperative for nurses to perpetually learn and prepare for crises of this nature in an effort to provide optimal patient care and patient outcomes. Lippincott NursingCenter.com offers an array of free journal articles and resources that can be found here to help nurses be prepared to exercise their training in an unpremeditated situation and successfully recognize and manage PTSD in patients and peers.

                                                                More Reading & Resources
                                                              Focus On: Post-Traumatic Stress Disorder


Posted: 10/20/2017 10:31:07 AM by Lindsey Lynch | with 8 comments

Categories: Diseases & Conditions

What is sepsis? What the public needs to know

sepsis-is-a-medical-emergency-(2).PNGSepsis is a medical emergency. It is a complication of the body’s response to an infection that can lead to life threatening tissue damage, organ failure and death (CDC, 2017). By increasing awareness of the early signs and symptoms of sepsis and risk factors for developing sepsis, we could improve survival and decrease complications. Like many life-threatening conditions, time is of the essence. Early detection and treatment of sepsis is the cornerstone of managing this medical emergency. According to the most recent data from 2013, sepsis was the most expensive condition treated in US hospitals accounting for $23.7 billion, or 6.2% of aggregate cost for all hospitalizations (Torio & Moore, 2016). To increase awareness and improve outcomes related to sepsis, we summarized key teaching points to communicate with patients and the public about this medical emergency. 

Here are the top 10 things to teach patients and the public about sepsis:

  1. Any type of infection can lead to sepsis. The four most common are lung, urinary tract, GI tract, and skin infections (CDC, 2017). 
  2. Sepsis begins outside the hospital in 80% of those affected (CDC, 2017).
  3. Sepsis affects approximately one million people in the US annually (NIH, 2017); patients hospitalized with sepsis are eight times more likely to die during hospitalization (Hall et al. 2011). 
  4. Sepsis is the result of an abnormal inflammatory response that the body has to an infection. The overwhelming inflammatory reaction is what leads to the symptoms of sepsis and the associated organ failures.
  5. Risk factors for developing sepsis are age (those older than 65 and those under one-year old [CDC, 2017] are highest at risk); weakened immune systems due to medication or disease; and chronic illness, such as diabetes or COPD.
  6. Early signs and symptoms of sepsis include fever, chills, fast heartbeat, confusion, shortness of breath, rapid breathing or severe pain (with no obvious cause).
  7. There are no specific diagnostic tests for sepsis. Diagnosis is based on clinical examination which is why it is critical to seek prompt medical attention if there is any concern for sepsis.  
  8. Taking measures to prevent infection, such as hand washing, vaccinations, and smoking cessation (since chronic lung disease is a risk factor), can help prevent infections that could lead to sepsis.
  9. There are likely genetic components and other biological factors that make some people more susceptible to developing sepsis in response to an infection. Ongoing research continues to help us understand sepsis and the optimal treatment supporting the goal to improve early diagnosis and improve outcomes. 
  10. Seek medical attention if you have an infection and any signs or symptoms of sepsis. Early identification and treatment are critical in improving survival and reducing complications.
Improving public awareness of sepsis can save lives. By educating patients and the public, you can make a difference by encouraging someone to seek treatment for this medical emergency that can potentially be overlooked and mistaken for other less threatening illness. Are there any other important items you routinely educate your patients and families about to improve awareness of sepsis? If so, please share your expertise with us.

Centers for Disease Control and Prevention (CDC). Sepsis Questions and Answers. Updated April 13, 2017. https://www.cdc.gov/sepsis/basic/qa.html. Accessed August 21, 2017.  
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.
Torio, C.M. & Moore, B.J. (2016). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013. Statistical Brief #204. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. May 2016. https://www.ncbi.nlm.nih.gov/books/NBK368492/#sb204.s2. Accessed August 20, 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.

Posted: 9/19/2017 10:39:22 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Diseases & Conditions

Sepsis: What nurses need to know

sepsis-(2).pngSepsis 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

Recommendation: 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).
Recommendation: 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.
Recommendation: 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.
Recommendation: 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?”
Recommendation: 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 Medicine37(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).

Posted: 9/13/2017 10:07:02 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions

Top 10 Things Advanced Practice Nurses Need to Know about the Updated Guidelines for Management of Sepsis and Septic Shock

TOP-TEN-THINGS-APNS-NEED-TO-KNOW-ABOUT-NEW-SEPSIS-GUIDELINES_300.pngThe Surviving Sepsis Campaign (SSC) is the leading organization responsible for educating healthcare professionals on the most current scientific evidence on the timely and appropriate treatment of sepsis. This ultimately allows us to positively impact sepsis-related morbidity and mortality.

Over the past year and a half there have been several major updates to best practices in the field of sepsis. In 2016, Singer, et al., published “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” which provided updated definitions and clinical criteria for Sepsis and Septic Shock with the elimination of the terms severe sepsis and SIRS. The new terminology defines sepsis as life threatening organ dysfunction caused by a dysregulated host response to infection and septic shock as a subset of sepsis in which underlying circular and cellular/metabolic abnormalities are profound enough to substantially increased mortality (Singer et al. 2016). Clinically, the septic shock subset are those patients with refractory hypotension despite adequate fluid resuscitation requiring vasoactive medications to maintain a mean arterial pressure (MAP) > 65 mmHg.

In March 2017, the Surviving Sepsis Campaign (SSC) published updated guidelines on the management of Sepsis and Septic Shock. This document, titled “Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” provides updated recommendations to the version published in 2012 and includes 93 statements on early management of sepsis and septic shock. A major difference evident in the new guidelines is a movement from protocolized management to a more individualized, “patient-centered” approach guided by dynamic variables and ongoing evaluation of clinical response to treatment (DeBaker & Dorman, 2017).

As the scientific and medical community’s understanding of sepsis and the pathobiology driving this life-threatening condition grows, it is essential that the APN stays abreast of changes to management based on the most up-to-date information.

Below is a summary of the recent SSC guidelines (Rhodes, et al., 2017) with a focus on material most pertinent to our practice as APNs.
  1. Initial Resuscitation
    1. Fluids
      1. Begin fluid resuscitation with crystalloid fluids immediately for sepsis-induced hypo-perfusion. Ideally, aim for at least 30 mL/kg completed within the first 3 hours from time of diagnosis.
        • Crystalloids are the fluid of choice for initial fluid resuscitation.
        • Recommendations against hydroxyethyl starches or bicarbonate therapy as an agent to improve hemodynamics or reduce vasopressor requirement.
      2. Following initial resuscitation, hemodynamic assessment should be used to guide further fluid administration using invasive and non-invasive measures.
        • Include clinical exam and evaluation of available physiologic variables including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output.
      3. Evaluate fluid responsiveness by the following means:
        • Dynamic variables:
          • Passive leg raise
          • Pulse or stroke volume variations induced by mechanical ventilation
        • Lactate clearance
      4. Discontinue fluid administration if response is no longer beneficial.
      5. Target a mean arterial pressure (MAP) of 65 mmHg in those with septic shock.
    2. Vasoactive Medications
      1. Initial vasoactive medication of choice should be norepinephrine.
      2. Consider the addition of vasopressin (at 0.03 units/min) or epinephrine to reach target MAP or to decrease the dose of norepinephrine.
      3. Consider arterial catheter placement for the monitoring of blood pressure in those requiring the use of vasoactive medications.
    3. In the absence of response or if clinical assessment does not lead to clear diagnosis, consider evaluation for other types of shock (DeBaker & Dorman, 2017).
  2. Diagnosis/Source Control – obtain both as soon as possible with early antibiotic therapy.
    1. Goal to identify or exclude anatomic source requiring emergent intervention as soon as possible; this includes removal of intravascular access if possible source of infection.
    2. Obtain at least two sets of blood cultures prior to initiation of antibiotics in all patients with suspected sepsis or septic shock if it will not delay initiation of treatment.  
  3. Antibiotic therapy
    1. Initiate one or more empiric broad-spectrum antibiotics as early as possible and within 1 hour (maximum) of recognition of sepsis or septic shock to cover all suspected pathogens.
    2. Evaluate daily for potential de-escalation/narrowing of antibiotics based on pathogen identification and clinical improvement.  
    3. Limit combination therapy (double coverage) to patients with septic shock.
    4. Do not continue antibiotics for severe inflammatory states (i.e. systemic inflammatory response syndrome [SIRS]) with no infectious etiology.
    5. Duration of antibiotic treatment should be 7-10 days.
      • Extend for slow clinical response, undrainable foci, staph aureus, or neutropenia.
      • Shorten course for quick clinical response, adequate source-controlled, GU/UTI or simple pyelonephritis.
    6. Consider procalcitonin measurement to support de-escalation of antibiotics in patients with sepsis and to support discontinuation of antibiotics in those who ultimately have limited clinical evidence of bacterial infection.
      • Although there is low quality of evidence and a weak recommendation by the SSC, many institutions have adopted use of this biomarker in the management of sepsis.
  4. Blood products
    1. Limit red blood cell transfusions to those patients with hemoglobin concentration < 7 g/dL. Consider higher threshold in select clinical populations (i.e. acute hemorrhage/ongoing active bleeding, acute coronary syndrome with ischemia, symptomatic anemia).  
  5. Mechanical ventilation
    1. In all mechanically ventilated patients with sepsis:
      1. Utilize lower tidal volume strategy using predicted body weight.
      2. HOB 30-45 degrees.
      3. Spontaneous breathing trials in those ready for weaning.
      4. Minimize sedation and set targets for titration end points.
    2. In patients with sepsis-induced acute respiratory distress syndrome (ARDS):
      1. Target tidal volume = 6 mL/kg
      2. Upper limit goal for plateau pressures of 30 cm H20
      3. Higher PEEP strategy
      4. Recruitment maneuvers for those with sepsis-induced severe-ARDS and refractory hypoxemia  
      5. Consider prone positioning if paO2/FiO2 ratio < 150.
      6. Conservative fluid strategy
  6. Glucose Control
    1. Begin an insulin administration protocol for patients with sepsis and two consecutive blood glucose readings > 180 mg/dL.
    2. Target glucose ≤ 180 mg/dL, rather than upper limit ≤ 110 mg/dL
  7. Nutrition
    1. Begin early enteral nutrition rather than parenteral nutrition or combination in critically ill patients with sepsis or septic shock (Rhodes et al. 2017).
    2. If early enteral feeds are not possible, begin IV dextrose and advance enteral feeds as tolerated rather than initiating parenteral nutrition during the first seven days of critical illness. This may include trophic or hypocaloric feedings and advance as tolerated.
    3. Gastric residual volumes should only be considered when there is enteral feeding intolerance or high risk of aspiration, rather than routinely.
  8. Stress Ulcer prophylaxis
    1. Begin in those patients with sepsis and septic shock AND risk factors for gastrointestinal bleeding; may use either proton pump inhibitor or histamine-2 blocker.
  9. VTE prophylaxis
    1. Initiate pharmacologic prophylaxis unless contraindicated. Rhodes et al. (2017) recommends LMWH rather than UFH in absence of contraindications to LMWH, in combination with mechanical prophylaxis in absence of contraindications.
  10. Communication
    1. Discuss goals of care and prognosis with patients and family as early as feasible, incorporating end-of-life planning and palliative care principles, when appropriate.
De Backer, D. and Dorman, T. (2017). Surviving Sepsis Guidelines. A Continuous Move Towards Better Care of Patients With Sepsis. The Journal of the American Medical Association, 317(8).
Rhodes, M.B., Evans, L.E., Alhazzani, W, et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
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).


Posted: 9/8/2017 12:04:17 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions

Sepsis: Learning from the past to improve patient outcomes

As many of you know, I am a practicing acute care/critical care nurse practitioner in a hospital in the Philadelphia area. Recently I was called to a rapid response on a medical floor. The patient was an elderly gentleman who was admitted for a urinary tract infection the day prior and now had a temperature of 103° F, a systolic blood pressure of 80/50 mm Hg (normally 130/72), a respiratory rate of 26/min and has gone from being awake, alert and oriented to being lethargic. This scene plays out every day in our healthcare system; so how did the nurse know to call for the rapid response team to come evaluate the patient? She used the qSOFA (Quick Sequential Organ Failure Assessment) tool which identifies patients who are at risk for a poor outcome. Based on the nurse’s quick, critical thinking, the patient was evaluated and the diagnosis was changed to septic shock secondary to a urinary tract infection and he was transferred to the critical care unit for management and he survived. The nurse was the hero in this situation because she recognized this patient was in septic shock.  

Sepsis, learning from the past
Sepsis is thought to occur in 750,000 people in the U.S. each year and it’s one of the leading causes of mortality and critical illness worldwide (Angus, 2013; Dieter-Lessnau, 2015). Sepsis is not a new diagnosis but, the guidelines on how to best recognize and manage it have been refined over the years as we learn more about this devastating diagnosis. In 2016, the definition of sepsis was changed to better reflect new knowledge on the pathophysiology of sepsis. For years, we have used the Systematic Inflammatory Response Syndrome (SIRS) criteria to identify patients with sepsis; however, new research has determined that the SIRS criteria was unhelpful because a SIRS response occurs with many other conditions and does not indicate dysregulation as once thought (Singer, et al., 2016; Rhodes, et al., 2017).

A new sepsis definition
As a result, a new definition of sepsis was established and was described in The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) in 2016 (Singer, et al., 2016). In 2017, The Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock were published (Rhodes, et al., 2017).  Sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer, et al., 2016; Rhodes, et al., 2017).  Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality (Singer, et al., 2016; Rhodes, et al., 2017). The term ‘severe sepsis’ has been eliminated from the definitions.

Early recognition is key
We know that early recognition of a patient with sepsis and septic shock is the first step in sepsis management. What tools are available to nurses to identify a patient who is likely to have a poor outcome due to organ dysfunction potentially related to sepsis? New definitions and guidelines have identified two tools that can be used by healthcare professionals to help identify a patient at risk for poor outcomes.

The qSOFA tool is a resource to be used outside of a critical care unit, such as in the emergency department or a medical/surgical unit, or primary care/urgent care, to identify these types of patients.

The qSOFA tool looks at 3 variables:
  • Respiratory rate greater than or equal to 22/min
  • Altered mentation
  • Systolic blood pressure less than or equal to 100 mm Hg (Singer, et al., 2016; Rhodes, et al., 2017).
The SOFA tool is used with critical care patients to identify a higher risk of patient mortality. Any change in 2 points or greater is equal to a higher risk of mortality. The variables evaluated in the SOFA tool are:
  • Respirations
  • Coagulation
  • Liver function
  • Cardiovascular system
  • Central nervous system
  • Renal system
Post-Sepsis Syndrome Reality
Patients who live through an experience of sepsis often have post-sepsis syndrome and exhibit long-term physical, psychological, and cognitive disabilities which result in health and social implications (Iwashyna, 2010). It is imperative that nurses recognize this syndrome and educate their patients and their families and other members of the support network, about this condition.

Sepsis-Alliance-SAM-Support-Badges-(2).pngNurses, you are an integral part of the interdisciplinary team
Without a doubt, nurses are key in sepsis early recognition, management and education because you are with the patient 24 hours a day. Having access to the latest evidence-based clinical practice guidelines and using them for clinical decision support is crucial to improving patient outcomes. Sepsis Alliance has an assortment of valuable resources for healthcare professionals and patients on sepsis. Wolters Kluwer is proud to partner with Sepsis Alliance to improve knowledge on this devastating, but preventable, condition.  
Angus, D. C. (2013). Severe sepsis and septic shock. New England Journal of Medicine, 840-851.
Dieter-Lessnau, K. (2015, Oct. 8). Distributive shock. Retrieved July 20, 2016 from Medscape: http://emedicine.Medscape.com/article/168689-overview#a3
Iwashyna, T., et al. (2010). Long-term cognitive impairment and functional disability among survivors of sepsis. JAMA,304(16):1787-1794.
Rhodes, M.B., Evans, L.E., Alhazzani, W., et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
Singer M., Deutschman, C.S., Seymour C.W., et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).




Posted: 8/31/2017 5:39:49 AM by Lisa Bonsall, MSN, RN, CRNP | with 5 comments

Categories: Diseases & Conditions

Zika in 2017

The majority of healthcare providers in the United States (US) first became familiar with Zika virus in early 2016 when it gained national attention following a large Zika virus outbreak in Brazil in 2015. With this outbreak, a concurrent increase in rates of microcephaly and ocular abnormalities in newborns was observed, suggesting an association between the two (Martines, 2016). Subsequent, retrospective analysis of a Zika outbreak in French Polynesia in 2013-2014 further supported the association between Zika virus infection and neurologic birth defects in newborns (Martines, 2016). The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) first issued public health alerts in January 2016 and February 2016 to increase public awareness, mobilize resources, and expand knowledge of Zika virus. A priority of these efforts was preventing infection in pregnant women and women of reproductive age to avoid birth defects resulting from transmission of Zika virus to the fetus.

Since the initial public health alert, the CDC has provided extensive guidance and resources for healthcare providers based on current knowledge of Zika virus. Although the virus can be asymptomatic in adults, we know that it can cause significant morbidity and mortality to a fetus when contracted in utero, most significantly microcephaly and fetal demise.

Since the initial advisories of 2016, scientists and healthcare professionals have gained a better understanding of both transmission and the pathophysiologic effects of the virus. The CDC has an extensive system of surveillance, and a registry to monitor cases in the US as well as a registry of all pregnant women with Zika virus infection (the US Pregnancy Zika Virus Registry [USPZR]). All serologic testing for Zika virus is monitored through the CDC allowing for accurate and detailed surveillance.

zika-counseling.pngFrom the perspective of the healthcare provider, some of the more significant benefits of the CDC efforts have been the provision of straightforward guidelines for prevention and screening, and anticipatory guidance specific to pregnant women and women of reproductive age. Nurses play a critical role in educating patients and families and can be instrumental in reducing fears by providing patients with the accurate and up-to-date information necessary to remain healthy and reduce the risk of Zika virus infection and spread.

What We Know about Zika virus in 2017 (CDC, 2017):

  • Zika virus is spread primarily through the bite of the Aedes species of mosquito which are known to bite during both day and night.
  • Zika virus can be passed from a pregnant woman to her fetus and is linked to neurologic birth defects, specifically microcephaly.
    • Pregnant women should not travel to geographic regions with risk of Zika.
  • Zika virus can be passed sexually from a person who has Zika virus to his or her sex partners.
    • Pregnant women living with partners who have Zika virus or have traveled to regions with Zika virus should not have sex with their partner, or should use barrier protection/condoms during pregnancy.
    • Women of reproductive age (those reproductive planning and those at risk for unplanned pregnancy) should receive counseling similar to that of pregnant women in respect to risk reduction of Zika infection.
  • During the first week of infection, a person can spread Zika virus by being bitten by a mosquito that subsequently bites another person exposing them to blood containing Zika virus.
  • Most cases of Zika virus are asymptomatic; if symptoms are present, they may include fever, malaise, maculopapular rash, conjunctivitis, headache, and arthralgia.
  • There is no specific treatment or vaccine for Zika virus.
  • There has been mosquito-borne transmission of Zika virus in the continental US; the first confirmed case was August 1, 2016 in Miami, Florida.

Summary of CDC recommendations for the care of the pregnant woman (CDC, 2017): 

Major Recommendations
  • Pregnant women should not travel to areas with risk of Zika infection.
  • Pregnant women should use condoms/barrier protection with any sexual partner that lives in or has traveled to areas with risk of Zika.
Prenatal Care
  • Screen for potential Zika virus exposure at all prenatal visits. Examples of screening tools and testing algorithms can be found on the CDC website.
  • If exposure screening is positive, screen for symptoms (fever, rash, arthralgia or conjunctivitis) and/or fetal abnormalities on ultrasound.
  • Symptomatic women with possible Zika exposure should undergo serologic and/or urine testing for Zika virus.
  • Zika virus testing of asymptomatic women with potential Zika exposure varies based on region of travel.
 Zika virus testing includes:
  • Zika virus nucleic acid testing (NAT) (i.e. RNA) in urine and serum
  • Serum Zika virus and dengue virus immunoglobulin M (IgM)
    • If IgM is positive, equivocal, presumptive or possible, must confirm with serum plaque reduction neutralization test (PRNT) which tests viral specific neutralizing antibodies to Zika.
Management of pregnant women with Zika virus infection
  • Consider serial ultrasound every 3-4 weeks to evaluate for fetal abnormalities
  • Amniocentesis on a case by case basis
Management of pregnant women with potential exposure and no serologic evidence of Zika infection
  • Ultrasound to evaluate for fetal abnormalities.
    • If fetal abnormalities present, consider repeating Zika virus NAT and IgM testing.
    • If no fetal abnormalities, continue routine prenatal care and risk management for Zika virus exposure.
Postnatal recommendations in women with positive or presumptive Zika virus infection during pregnancy
  • Live birth: infant serum and urine testing for Zika virus NAT and Zika/Dengue IgM as well as Zika virus NAT and immune-histochemical (IHC) staining of umbilical cord and placenta; test CSF if available.
  • Fetal losses: Zika virus NAT and IHC staining of fetal tissues.
  • Breastfeeding is recommended. Zika virus has been found in breastmilk but there have not been reports of infection associated with breastfeeding; the benefits are thought to outweigh the theoretical risks of transmission via breast milk.
When a pregnant woman passes the Zika virus to her fetus during pregnancy, it can lead to congenital Zika syndrome (CDC, 2017b). While the full extent of potential health effects from Zika virus is unknown, we know that congenital transmission can lead to brain abnormalities including severe microcephaly, eye abnormalities, congenital contractures (clubfoot or arthrogryposis), hypertonia restricting movement soon after birth and hearing loss (CDC, 2017a, CDC, 2017b). There is guidance from the CDC for healthcare providers on neuroimaging of infants  with congenital Zika syndrome as well as specific guidance for the management of infants with Zika virus infection for the first 12 months, regardless of the presence of birth defects. The CDC is also responsible for the development of Zika Care Connect, which provides a network of referral sources and specialty healthcare services helping to facilitate access to resources for families affected by Zika virus.

Zika virus is a classic example of an emerging infectious disease in the US. The response from the CDC and WHO has been critical in making the public aware of this threat and successfully mobilizing resources to provide healthcare providers with the most current, scientifically-based evidence available. Nurses are often the first clinical contact a patient will have with the healthcare system.  We are in a position to educate and decrease fears associated with Zika virus, which was an unknown threat to most in the US less than 2 years ago. A major focus of education should be prevention, including educating patients on taking measures to prevent being bitten by mosquitos and efforts to reduce risk by informing patients of travel precautions to areas with risk of Zika infection for pregnant women, women of reproductive age and women and their partners trying to conceive. With this, we can contribute in public health efforts to prevent the spread of an emerging virus which poses serious health risks and the potential for catastrophic effects on newborn morbidity and mortality.

Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases, Division of Vector-Borne Diseases, (2017a). Zika Virus. Retrieved from: https://www.cdc.gov/zika/index.html June 2017.
Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases, Division of Vector-Borne Diseases, (2017b). Zika, CDC Interim Response Plan, May 2017. Retrieved from: https://www.cdc.gov/zika/public-health-partners/cdc-zika-interim-response-plan.html
Martines, Roosecelis Brasil et al. (2016). Pathology of congenital Zika syndrome in Brazil: a case series. The Lancet, 388(10047), 898-904.


Posted: 6/23/2017 11:18:52 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

Systemic Vascular Resistance and Pulmonary Vascular Resistance: What’s the Difference?

In a previous blog post, we discussed preload and afterload. You may recall, preload is the amount of ventricular stretch at the end of diastole. Afterload is the pressure the myocardial muscle must overcome to push blood out of the heart during systole. The left ventricle ejects blood through the aortic valve against the high pressure of the systemic circulation, also known as systemic vascular resistance (SVR).1 The right ventricle ejects blood through the pulmonic valve against the low pressure of the pulmonary circulation, or pulmonary vascular resistance (PVR).1

Let’s dig a little deeper into these concepts.

Systemic vascular resistance (SVR)*

Systemic vascular resistance (SVR) reflects changes in the arterioles2, which can affect emptying of the left ventricle. For example, if the blood vessels tighten or constrict, SVR increases, resulting in diminished ventricular compliance, reduced stroke volume and ultimately a drop in cardiac output.1 The heart must work harder against an elevated SVR to push the blood forward, increasing myocardial oxygen demand. If blood vessels dilate or relax, SVR decreases, reducing the amount of left ventricular force needed to open the aortic valve. This may result in more efficient pumping action of the left ventricle and an increased cardiac output.2 Understanding SVR will help the bedside clinician treat a patient’s hemodynamic instability. If the SVR is elevated, a vasodilator such as nitroglycerine or nitroprusside may be used to treat hypertension. Diuretics may be added if preload is high. If the SVR is diminished, a vasoconstrictor such as norepinephrine, dopamine, vasopressin or neosynephrine may be used to treat hypotension. Fluids may be administered if preload is low.

SVR is calculated by subtracting the right atrial pressure (RAP) or central venous pressure (CVP) from the mean arterial pressure (MAP), divided by the cardiac output and multiplied by 80. Normal SVR is 700 to 1,500 dynes/seconds/cm-5.

Here’s an example:
If a patient's MAP is 68 mmHg, his CVP is 12 mmHg, and his cardiac output is 4.3 L/minute, his SVR would be 1,042 dynes/sec/cm-5.
Conditions that can increase SVR include1,2:
  • Hypothermia
  • Hypovolemia
  • Cardiogenic shock
  • Stress response
  • Syndromes of low cardiac output
Conditions that can decrease SVR include1,2:
  • Anaphylactic and neurogenic shock
  • Anemia
  • Cirrhosis
  • Vasodilation

Pulmonary vascular resistance (PVR)*

Pulmonary vascular resistance (PVR) is similar to SVR except it refers to the arteries that supply blood to the lungs. If the pressure in the pulmonary vasculature is high, the right ventricle must work harder to move the blood forward past the pulmonic valve. Over time, this may cause dilation of the right ventricle, and require additional volume to meet the preload needs of the left ventricle.1
PVR can be calculated by subtracting the left atrial pressure from the mean pulmonary artery pressure (PAP), divided by the cardiac output (CO) and multiplied by 80. To obtain the left atrial pressure, a pulmonary artery catheter (PAC) is needed to perform a pulmonary artery occlusion pressure (PAOP), also known as pulmonary artery wedge pressure (PAWP). Normal PVR is 100 – 200 dynes/sec/cm-5.

Here’s an example:
If a patient's mean PAP is 16 mmHg, his PAOP is 6 mmHg, and his cardiac output is 4.1 L/minute, his PVR would be 195 dynes/sec/cm-5.
Factors that increase PVR include1:
  • Vasoconstricting drugs
  • Hypoxemia
  • Acidemia
  • Hypercapnia (high partial pressure of arterial carbon dioxide [PaCO2])
  • Atelectasis
 Factors that decrease PVR include1:
  • Vasodilating drugs
  • Alkalemia
  • Hypocapnia (low PaCO2)
  • Strenuous exercise
The accuracy of SVR and PVR depends on the direct pressure measurements and indirect cardiac outputs from a pulmonary artery catheter which are subject to error. However, SVR can provide critical information when differentiating various types of shock and PVR is useful when diagnosing the severity of pulmonary hypertension.3 Understanding these parameters will help the bedside clinician better manage medications and hemodynamic instability.
*You may also see systemic vascular resistance index (SVRI) or peripheral vascular resistance index (PVRI) reported; these measurements are calculated by substituting cardiac index (CI) for CO in the equations.

1. Breitenbach, J. (2010). Putting an end to perfusion confusion. Nursing Made Incredibly Easy!. 5(3): 50 60
2. Gowda, C. (2008). Don’t be puzzled by cardiovascular concepts. Nursing Made Incredibly Easy!. 6(4): 27-30.
3. Silvestry, F. (2015). Pulmonary artery catheterization: interpretation of hemodynamic values and waveforms in adults. Uptodate. Retrieved on April, 17, 2017 from https://www.uptodate.com/contents/pulmonary-artery-catheterization-interpretation-of-hemodynamic-values-and-waveforms-in-adults
Myrna B. Schnur, RN, MSN 



Posted: 5/25/2017 10:11:09 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Diseases & Conditions

Transmission-based isolation precautions for common pathogens

As a follow-up to our previous post on isolation guidelines, here is a list of transmission-based precautions recommended for common pathogens. 

Megan Doble, MSN, RN, CRNP
Centers for Disease Control (CDC), 2016. Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. Available at: https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm#

Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee, (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

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Posted: 4/9/2017 5:43:04 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions Patient Safety

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