Sepsis

34 l Nursing2010 l April www.Nursing2010.com

 alert
Avoiding the shock
Recognize the early warning signs and follow these
potentially lifesaving steps.
2.3
ANCC
By Kelly A. Powers, BSN, RN, and Patricia L. Burchell, BSN, RN, SANE-A CONTACT HOURS

EARLIER TODAY, Irene Smith, Understanding sepsis Sepsis is the presence of SIRS ac-
75, was admitted for I.V. antibiotics Sepsis starts with a systemic companying an infection. Severe
to treat a complicated urinary inflammatory response syndrome sepsis is sepsis plus evidence of
tract infection. Her medical (SIRS) that alters capillary end-organ dysfunction as a result
history includes hypothyroidism, endothelium, increasing nitric of hypoperfusion.3 (Indications of
mild-to-moderate aortic stenosis, oxide production and impairing organ dysfunction include lactic aci-
Parkinson disease, osteoporosis, and vasoregulation.2 The interplay of dosis, oliguria, and acute change in
osteoarthritis. When you enter her inflammatory cells and mediators mental status.) Septic shock is severe
room at the beginning of your shift, leads to a cascade of endothelial sepsis with persistent hypotension
you find that she’s dusky, lethargic, injury, global tissue hypoxia, despite fluid resuscitation and acute
and tachypneic. You check her vital microthrombi formation (due to circulatory failure resulting in tissue
signs: heart rate, 125 beats/min; BP, decreased levels of activated protein hypoperfusion. (See Defining sepsis
87/52 mm Hg; respirations, 38; and C, which promotes fibrinolysis), for clinical criteria.4)
temperature, 38.6° C (101.5° F). and abnormal oxygen use. Without Patients who have a greater risk of
You call for the rapid response team treatment, this cascade can lead to developing sepsis are those age 65 or
(RRT). organ dysfunction and failure and older and those under age 1; patients
Ms. Smith is at risk for severe death. with chronic illness; those who take
sepsis, which kills about 215,000 SIRS is a clinical response to an immunosuppressant agents; or those
people in the United States each infectious or noninfectious insult. A with infection due to surgery or an
year, out of the more than 750,000 patient with SIRS will have at least invasive procedure. Patients over age
people who develop the condition. two of these signs: 65 have a higher infection risk due
Deaths from sepsis outnumber those • Core temperature below 96.8° F to impaired immunity, decreased
from breast, colorectal, pancreatic, (36° C) or above 100.4° F (38° C). mobility, skin breakdown, dementia,
and prostate cancer combined.1 • Heart rate greater than 90 beats/min. decreased gag and cough reflex, and
Early recognition of sepsis and • Respiratory rate greater than 20 or poor bladder emptying.1
early goal-directed therapy can Paco2 less than 32 mm Hg (normal The national estimated mortality for
sometimes halt the progression of range, 35 to 45 mm Hg). sepsis is 30% to 50% for severe sepsis
sepsis to severe sepsis and septic • White blood cell (WBC) count less and 50% to 60% for septic shock,
shock. This article will follow Ms. than 4,000 cells/mm3 or greater than higher if the patient develops acute
Smith’s case, which shows how rapid 12,000 cells/mm3 (normal range, respiratory distress syndrome and
response and aggressive care can 4,500 to 10,500 cells/mm3) or greater respiratory failure.1,5 Common compli-
improve patient outcome in a critical than 10% immature neutrophils cations of septic shock include myo-
situation. (normal range, 0% to 3%).1 cardial dysfunction, acute renal failure

www.Nursing2010.com April l Nursing2010 l 35

_ _
and chronic renal dysfunction, dis- a significant burden on the healthcare • treatment of the infection with
seminated intravascular coagulation system.7 In one study, median total appropriate antimicrobial therapy
(DIC), and liver failure. Prolonged hospital costs per patient dropped • resuscitation and hemodynamic
tissue hypoperfusion can cause long- from $21,985 to $16,103 after a support with I.V. fluids and
term neurological complications. sepsis protocol was implemented.8 vasopressors
The practice guidelines recom- • full organ support (such as renal
Taking a proactive approach mended by the Surviving Sepsis replacement therapy or mechanical
In 2008, the international Surviving Campaign call for a group, or “bun- ventilation)
Sepsis Campaign updated its dle” of related interventions that, • modulation of the inflammatory
guidelines for managing severe when executed together, result in response with recombinant human
sepsis and septic shock.4 Key better outcomes than when imple- activated protein C
objectives of this endeavor were to mented individually.1,4 By being vigi- • sedation and analgesia as needed
build awareness of sepsis, improve lant for the signs of early sepsis and • optimal nutrition.6
early detection, educate healthcare acting quickly to halt its progression,
professionals caring for patients patient mortality from sepsis can be Identifying sepsis
with sepsis, and increase the use of reduced by as much as 16%.1 Recognizing sepsis isn’t always
appropriate interventions.6 Treating The mainstays of this early goal- easy. Many patients can have vital
patients with severe sepsis costs directed therapy, which we’ll de- signs that fit the SIRS criteria. For
hospitals nearly $17 billion per year, scribe in detail later, include: example, patients with influenza, a
gastrointestinal virus, or a urinary
Defining sepsis4 tract infection may have fever,
An adult patient with sepsis has a documented or suspected infection, plus some of tachypnea, and leukocytosis, but
the systemic manifestations of infection outlined below: generally these patients improve
General variables with the first steps of the early goal-
• Fever (core temperature above 38.3° C) directed therapy for sepsis (fluid
• Hypothermia (core temperature below 36° C) and antimicrobial administration).
• Heart rate greater than 90 beats/min or more than 2 standard deviations above Remember that a patient who meets
the normal value for age the criteria for SIRS isn’t always
• Tachypnea septic, and that patients can develop
• Altered mental status
sepsis late in the course of a hospital
• Significant edema or positive fluid balance (greater than 20 mL/kg over 24 hours)
stay. Be vigilant at all times for early
• Hyperglycemia (plasma glucose of 140 mg/dL or greater) in a patient without
diabetes
signs of sepsis.
Two of the earliest signs of sepsis
Inflammatory variables are a narrow pulse pressure and
• Leukocytosis (WBC count over 12,000 cells/mm3)
tachycardia. Tachycardia and hypo-
• Leukopenia (WBC count below 4,000 cells/mm3)
tension are almost universal findings
• Normal WBC count with more than 10% immature forms (or “bands”)
• Plasma C-reactive protein level more than 2 standard deviations above the normal
in patients with sepsis. Early on, in
value patients who’ve received partial or
• Plasma procalcitonin level more than 2 standard deviations above the normal value full fluid resuscitation, tachycardia
and hypotension are associated with
Hemodynamic variables
high cardiac output (CO) and low
Arterial hypotension (systolic BP less than 90 mm Hg; MAP less than 70 mm Hg;
or a systolic BP decrease of more than 40 mm Hg in adults or less than 2 standard
peripheral vascular resistance. Pa-
deviations below normal for age) tients will have warm extremities and
bounding pulses. In contrast, patients
Organ dysfunction variables
who haven’t been significantly resus-
• Arterial hypoxemia (Pao2/Fio2 of 300 or less)
citated, or who didn’t seek medical
• Acute oliguria (urine output less than 0.5 mL/kg/hour for at least 2 hours, despite
adequate fluid resuscitation)
care until late in the course of illness,
• Creatinine level increase of more than 0.5 mg/dL will have a low CO and high systemic
• Coagulation abnormalities, such as an International Normalized Ratio greater than vascular resistance. These patients
1.5 or activated partial thromboplastin time more than 60 seconds will have cold extremities, diapho-
• Ileus (absent bowel sounds) resis, and weak, thready pulses, and
• Thrombocytopenia (platelet count less than 100 × 103/mm3) will need urgent resuscitation.9
• Hyperbilirubinemia (plasma total bilirubin greater than 4 mg/dL) Tachypnea is common in patients
Tissue perfusion variables with sepsis, but its significance may
• Hyperlactatemia (above the upper limit of lab normal) not be clearly understood. As tis-
• Decreased capillary refill or mottling. sue hypoperfusion progresses, the
patient’s respiratory rate increases

36 l Nursing2010 l April www.Nursing2010.com

in an effort to compensate for meta- line and obtain blood specimens for Next, start an I.V. fluid bolus of
bolic acidosis. The patient may re- a complete blood cell (CBC) count , 0.9% sodium chloride solution, as
port shortness of breath or appear comprehensive metabolic panel, and prescribed. If the CBC count shows
slightly anxious. Subtle changes in lactate level. Blood cultures, a DIC a value that meets the SIRS criteria
the patient’s vital signs or level of screen, and a type and screen may (a WBC count greater than 12,000
consciousness may be the only warn- be obtained later, pending further cells/mm3 or less than 4,000 cells/
ing that the patient is in trouble. An assessment and lab results. mm3 or greater than 10% immature
older adult may demonstrate mild After receiving 2 L of I.V. 0.9% neutrophils), establish an additional
disorientation or agitation that may sodium chloride solution, Ms Smith’s venous access and obtain blood
progress to obtundation or coma. clinical status remains unchanged. specimens for additional lab tests, in-
Her urinary tract infection, fever, cluding two or more blood cultures,
Assessing your patient tachycardia, tachypnea, leukocy- type and screen, and a DIC panel.
Baseline vital signs and a complete tosis, hyperlactatemia, and limited Insert an indwelling urinary catheter
history of current symptoms are the response to the fluid bolus lead the and obtain a urine specimen for a
starting point for evaluating a patient healthcare provider to diagnose her urinalysis and culture. Also obtain
for sepsis. Are vital signs within with sepsis. A central venous access samples for sputum cultures.
normal range? What symptoms device (CVAD) is placed for admin- If the patient remains hypotensive
precipitated hospitalization? Did istering vasopressors and additional despite fluid boluses, prepare for
signs and symptoms include nausea, fluids and medications, as well as for CVAD insertion.
vomiting and diarrhea, fever, chills, providing central venous pressure The Surviving Sepsis Campaign’s
or cough? What type of medical (CVP) monitoring. resuscitation bundle of interven-
problems has the patient had in tions calls for administering broad-
the past? This information will Rapid interventions spectrum antibiotics within 3 hours
help caregivers assess the patient’s Treatment for a patient suspected of of ED admission and 1 hour of
current signs and symptoms and having sepsis should be started as non-ED admission.1 Because you’ll
may pinpoint a potential source of quickly as possible, ideally within likely administer several antibiotics
infection. the first hour of presentation. Much in rapid succession, administer the
During the physical assessment, like the golden hour for trauma antibiotics with the shortest infusion
begin by evaluating the patient’s patients, the first hour of caring for times first.
general condition. Assess the airway, a patient with sepsis is critical. The goals of fluid resuscitation
breathing, circulation, and mental Obtaining lab results is a priority. in the first 6 hours include a CVP
status. Pay particular attention to A CBC count will demonstrate leuko- of 8 to 12 mm Hg, a mean arterial
the patient’s skin color and tem- cytosis indicating an acute inflamma- pressure (MAP) of 65 mm Hg or
perature. Check for pallor, mottling, tory process and possible infection, as greater, a urine output of 0.5 mL/
and other signs of poor tissue perfu- well as a low hemoglobin level. He- kg/hour or greater, and a central
sion, such as delayed capillary bed moglobin is the main component of venous oxygen saturation of 70%
refill. A patient’s skin is often warm red blood cells (RBCs) that transports or greater or mixed venous oxygen
to the touch in early sepsis, due to oxygen. Decreased hemoglobin levels saturation (SVO2) of 65% or greater.4
increased CO and peripheral vaso- can indicate anemia. The comprehen- In mechanically ventilated patients,
dilation; this is referred to as warm sive metabolic panel, which includes a higher targeted CVP of 12 to 15
shock. As septic shock progresses, blood urea nitrogen, creatinine, and mm Hg is recommended, to account
the patient’s skin will become cooler liver enzymes, can indicate renal for positive-end expiratory pressure
due to the depletion of intravascular or hepatic dysfunction, which can and increases in intrathoracic pres-
volume and decreasing CO. The pa- indicate severe sepsis. If infection is sure.1 If the patient can’t maintain a
tient’s extremities will feel cool and suspected (or documented, as in our systolic BP greater than 90 mm Hg
clammy and you’ll notice decreased case study) and the patient meets two or a MAP of 65 mm Hg or greater
capillary refill; this is referred to as or more SIRS criteria, a serum lactate after fluid resuscitation, start an infu-
cold shock. Petechiae or purpura, level also needs to be obtained. sion of norepinephrine or dopamine
which can be associated with DIC, An elevated serum lactate level can (the initial vasopressors of choice) as
are ominous signs. indicate tissue hypoperfusion. Serum prescribed via the CVAD and titrate
lactate is a marker of anaerobic me- it to meet a target MAP of 65 mm Hg
Helping Ms. Smith tabolism, which occurs when tissue or greater.
The RRT arrives and starts oxygenation demands exceed sup- For the patient who remains hy-
administering a bolus of 0.9% ply. Elevated lactate levels (over 2.5 potensive despite fluid resuscitation
sodium chloride solution via mmol/L) indicate widespread tissue and norepinephrine administration of
Ms. Smith’s existing peripheral I.V. site. hypoperfusion and are associated more than 5 to 10 mcg/min, the next
They establish a second peripheral I.V. with increasing risk of death.10,11 step is to administer vasopressin.1

www.Nursing2010.com April l Nursing2010 l 37

Obtain an SVO2 sample from the for aggressive care and treatment with REFERENCES
CVAD to check for hypoperfusion a sequence of multiple antibiotics. 1. Implementing the Surviving Sepsis Campaign.
e
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medscape.com/article/786058-overview.
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Campaign Guidelines Committee. Surviving
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Hg or greater). If the patient’s SVO2 continues to improve. She’s moved to management of severe sepsis and septic shock:
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on the management of infection in patients with
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sepsis.com/overview.jsp.
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nda.ox.ac.uk/wfsa/html/u13/u1308_01.htm.
Treating Ms. Smith infection. If your facility has an RRT,
10. Jones AE, Puskarich MA. Sepsis-induced tissue
Here’s how the interventions contact the team early in the process. hypotension. Crit Care Clin. 2009;25(4):769-779.
described above would proceed with Transfer your patients to an ICU as 11. Bakker J, Jansen T. Don’t take vitals, take a
Ms. Smith. As prescribed, you start soon as possible. lactate. Intens Care Med. 2007;33(11):1863-1865.

an infusion of cefepime, a broad- By recognizing sepsis early and Kelly A. Powers and Patricia L. Burchell are registered
nurses in the ED at Christiana Care Health System in
spectrum, cephalosporin antibiotic. treating it promptly, you may be able Newark, Del.
The RRT nurse stays with Ms. Smith to prevent the patient from progress- The author has disclosed that she has no financial
until she’s transferred to an ICU bed ing to septic shock. ■ relationships related to this article.

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