Aggressive treatment of Sepsis

The earliest treatment of sepsis treatment is PREVENTING the infection in the first place.

Initiatives  are being used to help prevent infection. Initiatives includes bundles such as the central line insertion bundles and foley catheter insertion bundle.

However despite our great care- patients can present with or develop sepsis.

Once sepsis has been identified early- we are ready for the next step: Treatment

Nurses play a key role in treatment of sepsis. 



Within three hours the following items must be completed:

• Obtain lactate level
• Obtain pan cultures- blood culture, urine culture and obvious wound cultures. If obtaining cultures takes longer than 45 minutes to start antibiotics without obtaining all cultures.
• Obtain a blood culture from lines greater than 48 hours old to rule out line infection.
• One blood culture should always be drawn peripherally.
• Administer broad spectrum antibiotics.
• Administer large amounts of crystalloid fluid (Normal Saline used most commonly) quickly- 30ml/kg at a minimum for hypotension or lactate level ≥4mmol/L.
• IV fluids boluses should continue if patient responds hemodynamically.
• Monitor glucose levels- initiate critical care glucose protocols. Maintain glucose levels less then 180 mg/dl.
• Imaging studies maybe used to help determine source of infection.

Within six hours the following items must be completed:

• Vassopressors for hypotension after fluid volume has been replenished.
• Norepinephrine first choice vassopressor
• Repeat lactate level- goal is to be normalized.

 



Mean arterial pressure (MAP) ≥ 60mmg Hg

CVP reading greater the 8- 12 mmHg

Central venous oxygen saturation (ScvO2)  reading greater > 70%

Urine output ≥ 0.5ml//kg/hr

Special Considerations

Pediatrics require special consideration. See the attached link for further information on pediatric sepsis care.
Providing patients and families with education regarding sepsis is very important. Families and patients must understand the severity of the illness. Sepsis can lead to multi-organ failure.  Treatment of sepsis needs to be aggressive. Discussion with families and patients should include palliative care/end of life care decisions and the patient’s wishes regarding aggressive treatment.
 
Providing aggressive treatment is another key part of Surviving Sepsis.
 
 

 

 

Early Identification of Sepsis

Sometimes when bad things happen, it can lead to changes to help prevent poor outcomes in the future.   This is true for sepsis care in New York State.  NYS is the first state to apply mandated laws for hospitals to set in place protocols for sepsis care. The NYS push comes from a 12 year old boy who died as a result of early warning signs of sepsis being missed. Click here to read more about Rory and how his parents have been advocates to prevent this from happening again.

As part of the NYS regulations hospitals must have protocols in place to help identify early warning signs of sepsis- (8) hospitals shall have in place evidence-based protocols for the early recognition and treatment of patients with severe sepsis and septic shock that are based on generally accepted standards of care as required by subdivision (a) of section 405.4 of this Part. Patients who are identified and treated earlier have improved survival outcomes from sepsis (Tazbit, 2012).

 One way to complete this is to use a tool called Modified Early Warning System or MEWS for short.  MEWS is a tool which assists healthcare personnel to identify the early signs of sepsis. MEWS takes key vital signs/assessments and alerts practitioners when the there is a change in vital signs. Changes in vital signs may be subtle; therefore practitioners are less likely to pick up the slight changes.

Here is what a MEWS adult score card can look like:

Pediatric monitoring can be more difficult to the varying vital signs for every age group.  Here is a sample for the pediatric monitoring tool.

 

Facilities who are using electronic health records (EHR) can integrate the monitoring tools into the EHR to continuously monitor patients for changes. The healthcare system that I currently work for has built this into our EHR and practitioners are given a best practice alert for changes in the MEWS. The nursing staff is alerted when there is a change in the MEWS score with a protocol for the response.

Whether using the adult or pediatric monitoring tool it is always important to remember the early warning systems are tools to help us care for the patients, but we must always use critical thinking and good assessment skills. Nurses should notify the physician with changes in patients or a gut feeling something is not right. Tools cannot always pick up subtle changes that the human-human interface can.



 

Tazbir, J. (2012). Early Recognition and Treatment of Sepsis in the Medical-Surgical Setting... [published erratum appears in MEDSURG NURS; 2012 Sep-Oct; 21(5): 270]. MEDSURG Nursing, 21(4), 205-209.



Signs and Symptoms of Sepsis

Last week I discussed that early recognition of sepsis is important to surviving sepsis. This week lets discuss the signs and symptoms of what patients with sepsis looks like.





Upon first assessment of the patients with possible sepsis may present with:

Heart rate greater then 90, increases respiratory rate, cool mottled skin, low oxygen levels, and altered mental status. Click here to see a complete list of signs and symptoms for sepsis.



Every patient may present differently with sepsis, a complete assessment is key in identifying sepsis early!



Lab work that will most likely be ordered will include, complete blood count (CBC), complete metabolic panel (CMP), APTT, PT, arterial blood gas (ABG) and lactate level.



The following video will help clear definitions found related to shock.

Sepsis can effect all age groups.  Education for new parents should include what to look for. Click here to identify early signs and symptoms for newborns with possible sepsis.

Early recognition leads to early treatment. Next week I will discuss options for treatment protocols.

The Severity of Sepsis

The number of patients who are admitted with sepsis has been steadily increasing over the last decade. Patients who are admitted with sepsis are 7 times more likely to die during the hospitalization. These are scary statistics. To see more sepsis statistics visit the CDC website.

In order to increase the survival a large campaign has been initiated to to look at evidence based practices. One resource for evidnece based medicine is  survivingsepsis.org. As care providers it is important that signs and symptoms of sepsis are recognised early. Early recognition and treatment improves outcomes. Protocols create standard treatment plans and decrease variation from best practices.