Sepsis & Septic Shock

Initial resuscitation:

According to the campaign, IV fluid administration is used to treat sepsis-induced hypoperfusion. They make a strong recommendation for 30 mL/kg of IV BALANCED crystalloid (i.e., Lactated Ringer’s or e.g. Plasmalyte), based on the low quality of evidence. This administration should be within the first 3 hours of recognition. As bedside nurses, we need to make sure we have multiple large-bore IVs. We also need to have a keen awareness of why (Ab)Normal Saline may not be the best thing for your septic patient. A balanced crystalloid is a preferred solution in these situations. If the order is for normal saline, ask the clinician why (because occasionally there is a good reason to avoid a balanced solution), and see if changing to a balanced fluid is possible or necessary.

Continue to reassess hemodynamics frequently, including SBP (MAP), HR, RR, temperature, capillary refill, and urinary output. Maintaining a mean arterial pressure of 65 mmHg is used to help guide our therapy and potentially prevent organ failure. 

Vasoactive medications:

If persistent hypotension exists and the patient cannot maintain a MAP of 65 mmHg, then vasopressors should be initiated to support MAP > 65 mmHg. According to the surviving sepsis guideline, norepinephrine is the recommended first-choice vasopressor. Be on the lookout for upcoming articles about vasopressors and peripheral vasopressors.

SEPSISPAM trial compared a higher MAP goal of 80-85 mmHg to a low MAP goal of 65-70 mmHg, and there was no reduction in 28-day mortality with a higher MAP goal. Therefore, MAP > 65 mmHg is an excellent endpoint to target. However, there may be other physiologic reasons to select a higher or lower MAP target, so be sure to collaborate with your LIPs on specific goals for each patient. 

Corticosteroids:

If fluid resuscitation and vasopressor therapy are inadequate at maintaining our endpoint perfusion goal of MAP > 65 mmHg, IV corticosteroids are encouraged to be given. In addition, IV hydrocortisone is recommended at 200 mg daily total, or 50 mg every 6 hours. Steroid administration can be a nurse-driven recommendation if you see that the patient is not responding appropriately to other therapies.

Initially, the Annane trial showed a decrease in 28-day mortality among patients who had septic shock and adrenal insufficiency and received hydrocortisone and fludrocortisone. However, follow-up trials such as the CORTICUS, ADRENAL, and HYPRESS, showed no mortality benefit but may be associated with decreased time to reversal of shock, time to extubation, and decreased LOS. Therefore, it is ideal to start this therapy EARLY to help reduce the clinical deterioration even further.

Additional Care:

As the bedside warrior, it is crucial to be meticulous in double-checking the clinician orders for VTE prophylaxis and stress ulcer prophylaxis. Monitor to see if there is any need for transfusion of blood products, blood glucose control, or even advanced respiratory support. Ensure that nutrition has been addressed with the team and the physician or APP has set goals of care with the patient or family. 

Furthermore, do you think that there has been adequate control of the source of infection? You are constantly with the patient and know before anyone else when the clinical status deteriorates or fails to improve. Let the clinician know if you think there is another possible source for infection.

Here are a few mnemonics to remember important aspects of the care of all ICU patients.

You, the bedside warrior, can make the difference. Double-check all orders and make sure nothing gets missed. Speak up, advocate for the patient; you play an important role on the team that will save this patient’s life.