Critical Care / Emergency / Trauma

Sepsis signposts: Can you spot them?

Sepsis. The word strikes fear into the heart of any nurse—or these days, viewers of certain TV shows. On one episode of the NBC series ER, staffers discussed early goal-directed therapy for a sepsis patient. In HBO’s The Sopranos, Tony Soprano developed sepsis after being shot by Uncle Junior. What’s next? Sepsis Survivor—a reality show pitting sepsis patients against each other?
Whether or not you’ve seen sepsis on TV lately, here’s a catch phrase we want you to remember: Sepsis—it’s not just for critical care units anymore. You may encounter patients with undiagnosed sepsis in any setting. Would you be able to recognize the signs and symptoms of this all-too-often fatal condition?
Severe sepsis and septic shock are a challenge for all healthcare professionals. Each year, an estimated 751,000 cases of severe sepsis and 215,000 sepsis-related deaths occur in the United States. The annual economic burden runs into the billions. That’s why every nurse must learn how to recognize the condition. The sooner you detect it, the greater your patient’s survival odds.

Cascading to a crisis
The response to infection occurs along a continuum that begins when a localized or generalized infection (or trauma, thermal injury, or sterile inflammatory process) triggers the systemic inflammatory response syndrome (SIRS). Clinically, SIRS occurs when the patient has two or more of the following:
• temperature above 100.4° F (38° C) or below 96.8° F (36° C)
• heart rate faster than 90 beats/minute
• hyperventilation (a respiratory rate faster than 20 breaths/minute or partial pressure of arterial carbon dioxide below 32 mm Hg)
• white blood cell (WBC) count above 12,000 cells/mm3 or below 4,000 cells/mm3.
SIRS may progress to sepsis, severe sepsis, septic shock, and multiple-organ dysfunction syndrome in a complex cascade of events. Stimulation of the inflammatory response activates the coagulation process, which impairs thrombolysis. Cytokines are released from WBCs during phagocytic activity and from the activated endothelium. Cytokine release, in turn, leads to proinflammation and procoagulation. Activation of the coagulation process causes impaired fibrinolysis.
This sequence of events throws inflammation, coagulation, and fibrinolysis into an imbalance that leads to widespread inflammation, microvascular thrombosis, endothelial injury, and systemic coagulopathy. This imbalance can impair tissue perfusion and cause organ-system dysfunction.
Once such dysfunction occurs, sepsis has become severe and progresses rapidly to septic shock and eventually multiple-organ dysfunction syndrome. Creatinine and liver enzyme levels rise, the partial pressure of arterial oxygen decreases, platelet and protein C levels fall, and D-dimer levels climb. Other findings that reflect sepsis include fast respiratory and heart rates, low blood pressure, decreased urine output, and low central venous pressure.

Recognizing sepsis
During assessment and monitoring, always consider the possibility of sepsis—and be aware that its signs and symptoms may be subtle. Suspect sepsis if your patient has:
• chills
• unexplained mental status changes
• decreased urine output
• petechiae
• purpura
• reduced skin perfusion
• skin mottling
• glycemic changes (such as hyperglycemia in a nondiabetic patient).
Remember—these are signs of organ dysfunction. (Mental status changes reflect brain dysfunction; decreased urine output indicates renal dysfunction; reduced skin perfusion and mottling signify skin dysfunction; and hyperglycemia reflects pancreatic dysfunction.) Organ dysfunction means sepsis has progressed to severe sepsis or septic shock.
Unfortunately, these early subtle changes are easy to overlook or to attribute to other causes (such as a new medication, lack of sleep, or unfamiliarity with the hospital environment). So be sure to consider the big picture by synthesizing all physical findings and determining whether the patient “looks” septic. Closely monitor vital signs, blood glucose level, WBC count, and urine output. Also monitor the serum lactate level, an early index of global tissue hypoxia; suspect a septic process if your patient’s lactate level exceeds 4 mmol/L.

Managing sepsis
Once you’ve identified a patient with sepsis, what should you do? With its variable causes and courses, sepsis is among the most challenging conditions to manage.
Many elements of sepsis care have been “bundled” based on recommendations of the Surviving Sepsis Campaign. Each bundle is a group of interventions that, when carried out together, leads to better outcomes than when implemented individually. Some bundle elements must be delivered in a critical care setting; others can be provided on virtually any hospital unit. Examples of bundle elements include providing prophylaxis for deep vein thrombosis and stress ulcers and determining if the patient meets criteria for recombinant human activated protein C therapy.
Be sure to monitor the patient’s capillary blood glucose level closely, because infection can cause glycemic changes even in a nondiabetic. Keeping the blood glucose level below 150 mg/dL promotes a more favorable outcome.
Antibiotic therapy must begin within the first hour after severe sepsis is diagnosed, once cultures have been obtained to identify the infection source. Implement infection control measures; for instance, remove an infected catheter and debride an abscess as appropriate and ordered.
If the patient is hypotensive, take care to administer the correct fluid volume—20 to 30 mL/kg. In severe sepsis or septic shock, measuring serum lactate levels can be helpful.When in doubt, suspect sepsis
With sepsis or septic shock, early recognition and treatment may be your patient’s only hope. Learn everything you can about sepsis so you can detect it quickly and provide timely interventions. Resources on sepsis assessment and management include the sepsis resuscitation bundle from the Institute for Healthcare Improvement (www.ihi.org/IHI/Topics/CriticalCare/Sepsis) and guidelines from the Surviving Sepsis Campaign (www.survivingsepsis.org).
Whatever your practice setting, stay alert for possible signs and symptoms of sepsis—because it’s not just for critical care units anymore.

Selected references
Dellinger R, Carlet J, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32:858-873.
Kleinpell R. Stop severe sepsis in its tracks. Nursing2007 Critical Care. 2006;1(1):20-26.
Levy M, Fink M, Marshall J, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250-1256.
Rivers E. Implementation of an evidence-based standard operating procedure and outcome in septic shock: what a sepsis pilot must consider before taking flight with your next patient. Crit Care Med. 2006;34:1247.
Society of Critical Care Medicine. Surviving Sepsis Campaign: severe sepsis bundles. Available at: http://ssc.sccm.org/node/89. Accessed August 15, 2007.
For a complete list of selected references, visit www.AmericanNurse Today.com.

Melanie Atkinson, MSN, RN, CCRN, is a Critical Care Clinical Outcomes Coordinator at Northwest Community Hospital in Arlington Heights, Ill. Diane Ryzner, CNS, APRN, BC, CCRN, is a Clinical Nurse Specialist in the Orthopedic/Neurology unit at at the same hospital.


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