Sepsis is a dysregulated response to acute infection which can lead to multi-organ failure, septic shock, and even death if not treated appropriately. Unfortunately, sepsis is one of the leading causes of death in hospitalized patients worldwide. However, early recognition and swift management can save lives. That means you can make the difference.
Our favorite subject, Pathophysiology!!
Once the host is exposed to the offending microorganism, the inflammatory response is activated. Once exposed, the body recognizes the microorganism as a foreigner and triggers a systemic reaction. Transcription factors are the first to be started and up-regulate or down-regulate genes responsible for the inflammatory response. Next, the release of multiple cytokines deploys immune cells to the infection site and removes the offending infection or damaged host cells.
Dysregulation of the inflammatory response
The exact reasons why the host immune response becomes dysregulated are unknown. However, some factors that affect this dysregulation could include; genetics, environmental factors, comorbidities, age, sex, nutritional status, immunosuppression, and pathogen load. Typically, inflammatory mediators stay within a specific localized boundary; however, in sepsis, the overflowing of pro-inflammatory mediators becomes systemic and causes an uncontrolled and autonomous response.
Please Show me the Signs.
Sadly, there is no distinct presentation of sepsis or a specific lab that we can look at that determines, “You have sepsis.” Therefore, it is up to you, the bedside warrior, to have a high index for suspicion, looking at your clinical assessment in conjunction with laboratory findings to diagnose sepsis.
Some common signs and symptoms of sepsis can include:
Nursing recognition of sepsis
In nursing, no matter where you practice, early recognition is key to survival. Hypotension is a late sign of sepsis and means that the patient is already in shock when this occurs. Think about symptoms that come before hypotension that you can recognize. Look for fevers or hypothermia, tachycardia, chills, or rigors. Listen to the family. If they tell you that something is not right with their loved one, please listen to them. The systemic inflammatory response is not perfect when diagnosing sepsis, but it can trigger you to think about what to do next.
If you see these signs, speak up, don’t be afraid to reach out to the clinician and let them know your concerns. I know getting a hold of that LIP (licensed independent practitioner) can potentially be intimidating, but be confident in your knowledge, and if you think something deserves a second look, ask for it. You can suggest potential workups such as lactate or blood cultures and potentially resuscitation strategies
Lactate has gained a significant role in the evaluation of septic shock and is fairly cheap to obtain. The Surviving Sepsis Campaign advises that lactate is >/= 4.0 is associated with an increase in mortality rate.
Surviving Sepsis Campaign
The campaign was launched in 2002 with updates in 2018 with collaborative efforts to reduce sepsis mortality. These evidence-based bundles were put together and created at a 25% relative risk reduction in mortality rates.
To further aid in the diagnosis of your patient, we need to obtain blood cultures. As bedside nurses, it is vital that we maintain aseptic techniques to minimize contamination. Contaminated blood cultures can be confusing when it comes to antibiotic treatment and can cause a delay inappropriately targeting therapy for your patient.
You need to draw the cultures from two separate sites, not take the easy route and get both from the same stick. This could skew results in the case of contamination and confuse management. Make sure to clean your site with a chlorhexidine thoroughly, and it is crucial to let the area dry completely. Perform complete hand hygiene and don clean gloves before obtaining your blood. As for your venipuncture bottles, you will want to draw using the aerobic bottle followed by anaerobic. Ensure the caps from the culture bottles are taken off and cleaned thoroughly with alcohol/chloraprep beforehand. As nurses, we are responsible for maintaining aseptic techniques and adequate hand hygiene.
Antibiotic administration should not be delayed if there is difficulty in obtaining cultures. The goal is to have antibiotics administered within one hour. Kumar et al. completed one of the most significant studies describing the correlation between early antibiotic usage and mortality. The study showed that there was an average increase in mortality by 7.6% for every one hour of delayed antibiotic administration for patients with septic shock. If you are supposed to administer more than one antibiotic and have limited IVs, ask about which one has more broad coverage and administer that first (typically cefepime, piperacillin-tazobactam, etc.).
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.
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.
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.
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.
- Early recognition is critical with bedside clinical assessment followed by laboratory findings. If you suspect something, say something to your team.
- Ensure adequate IV access and maintain aseptic technique
- Early antibiotic administration (within 1 hour) is the most vital; try and obtain cultures before antibiotic administration, DO NOT DELAY if unable to obtain the cultures
- Balanced IV crystalloid for initial fluid resuscitation to goal MAP > 65 mmHg
- If unable to maintain MAP with initial IV fluid resuscitation, consider early initiation of vasopressors
- If vasopressor requirements continue to increase, initiate hydrocortisone
Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock [published correction appears in JAMA. 2008 Oct 8;300(14):1652. Chaumet-Riffaut, Philippe [corrected to Chaumet-Riffaud, Philippe]]. JAMA. 2002;288(7):862-871. doi:10.1001/jama.288.7.862
Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med. 2014;370(17):1583-1593. doi:10.1056/NEJMoa1312173
Arina P, Singer M. Pathophysiology of sepsis. Curr Opin Anaesthesiol. 2021;34(2):77-84. doi:10.1097/ACO.0000000000000963
Keh D, Trips E, Marx G, et al. Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial. JAMA. 2016;316(17):1775-1785. doi:10.1001/jama.2016.14799
Kumar A, Safdar N, Kethireddy S, Chateau D. A survival benefit of combination antibiotic therapy for serious infections associated with sepsis and septic shock is contingent only on the risk of death: a meta-analytic/meta-regression study. Crit Care Med. 2010;38(8):1651-1664.
Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Crit Care Med. 2015;43(1):3-12. doi:10.1097/CCM.0000000000000723
Keeley A, Hine P, Nsutebu E. The recognition and management of sepsis and septic shock: a guide for non-intensivists. Postgrad Med J. 2017;93(1104):626-634. doi:10.1136/postgradmedj-2016-134519
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304-377. doi:10.1007/s00134-017-4683-6
Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111-124. doi:10.1056/NEJMoa071366
Sepsis. (n.d.). Retrieved May 05, 2021, from https://www.who.int/news-room/fact-sheets/detail/sepsis
Venkatesh B, Finfer S, Cohen J, et al. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. N Engl J Med. 2018;378(9):797-808. doi:10.1056/NEJMoa1705835