Sepsis

34 l Nursing2010 l April www.Nursing2010.com

 alert
Avoiding the shock
Recognize the early warning signs and follow these
potentially lifesaving steps.
By Kelly A. Powers, BSN, RN, and Patricia L. Burchell, BSN, RN, SANE-A
EARLIER TODAY, Irene Smith,
75, was admitted for I.V. antibiotics
to treat a complicated urinary
tract infection. Her medical
history includes hypothyroidism,
mild-to-moderate aortic stenosis,
Parkinson disease, osteoporosis, and
osteoarthritis. When you enter her
room at the beginning of your shift,
you find that she’s dusky, lethargic,
and tachypneic. You check her vital
signs: heart rate, 125 beats/min; BP,
87/52 mm Hg; respirations, 38; and
temperature, 38.6° C (101.5° F).
You call for the rapid response team
(RRT).
Ms. Smith is at risk for severe
sepsis, which kills about 215,000
people in the United States each
year, out of the more than 750,000
people who develop the condition.
Deaths from sepsis outnumber those
from breast, colorectal, pancreatic,
and prostate cancer combined.1
Early recognition of sepsis and
early goal-directed therapy can
sometimes halt the progression of
sepsis to severe sepsis and septic
shock. This article will follow Ms.
Smith’s case, which shows how rapid
response and aggressive care can
improve patient outcome in a critical
situation.
www.Nursing2010.com
_ _
2.3
ANCC
CONTACT HOURS
Understanding sepsis
Sepsis starts with a systemic
inflammatory response syndrome
(SIRS) that alters capillary
endothelium, increasing nitric
oxide production and impairing
vasoregulation.2 The interplay of
inflammatory cells and mediators
leads to a cascade of endothelial
injury, global tissue hypoxia,
microthrombi formation (due to
decreased levels of activated protein
C, which promotes fibrinolysis),
and abnormal oxygen use. Without
treatment, this cascade can lead to
organ dysfunction and failure and
death.
SIRS is a clinical response to an
infectious or noninfectious insult. A
patient with SIRS will have at least
two of these signs:
• Core temperature below 96.8° F
(36° C) or above 100.4° F (38° C).
• Heart rate greater than 90 beats/min.
• Respiratory rate greater than 20 or
Paco2 less than 32 mm Hg (normal
range, 35 to 45 mm Hg).
• White blood cell (WBC) count less
than 4,000 cells/mm3 or greater than
12,000 cells/mm3 (normal range,
4,500 to 10,500 cells/mm3) or greater
than 10% immature neutrophils
(normal range, 0% to 3%).1
Sepsis is the presence of SIRS ac-
companying an infection. Severe
sepsis is sepsis plus evidence of
end-organ dysfunction as a result
of hypoperfusion.3 (Indications of
organ dysfunction include lactic aci-
dosis, oliguria, and acute change in
mental status.) Septic shock is severe
sepsis with persistent hypotension
despite fluid resuscitation and acute
circulatory failure resulting in tissue
hypoperfusion. (See Defining sepsis
for clinical criteria.4)
Patients who have a greater risk of
developing sepsis are those age 65 or
older and those under age 1; patients
with chronic illness; those who take
immunosuppressant agents; or those
with infection due to surgery or an
invasive procedure. Patients over age
65 have a higher infection risk due
to impaired immunity, decreased
mobility, skin breakdown, dementia,
decreased gag and cough reflex, and
poor bladder emptying.1
The national estimated mortality for
sepsis is 30% to 50% for severe sepsis
and 50% to 60% for septic shock,
higher if the patient develops acute
respiratory distress syndrome and
respiratory failure.1,5 Common compli-
cations of septic shock include myo-
cardial dysfunction, acute renal failure
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-
bolic acidosis. The patient may re-
port shortness of breath or appear
slightly anxious. Subtle changes in
the patient’s vital signs or level of
consciousness may be the only warn-
ing that the patient is in trouble. An
older adult may demonstrate mild
disorientation or agitation that may
progress to obtundation or coma.
Assessing your patient
Baseline vital signs and a complete
history of current symptoms are the
starting point for evaluating a patient
for sepsis. Are vital signs within
normal range? What symptoms
precipitated hospitalization? Did
signs and symptoms include nausea,
vomiting and diarrhea, fever, chills,
or cough? What type of medical
problems has the patient had in
the past? This information will
help caregivers assess the patient’s
current signs and symptoms and
may pinpoint a potential source of
infection.
During the physical assessment,
begin by evaluating the patient’s
general condition. Assess the airway,
breathing, circulation, and mental
status. Pay particular attention to
the patient’s skin color and tem-
perature. Check for pallor, mottling,
and other signs of poor tissue perfu-
sion, such as delayed capillary bed
refill. A patient’s skin is often warm
to the touch in early sepsis, due to
increased CO and peripheral vaso-
dilation; this is referred to as warm
shock. As septic shock progresses,
the patient’s skin will become cooler
due to the depletion of intravascular
volume and decreasing CO. The pa-
tient’s extremities will feel cool and
clammy and you’ll notice decreased
capillary refill; this is referred to as
cold shock. Petechiae or purpura,
which can be associated with DIC,
are ominous signs.
Helping Ms. Smith
The RRT arrives and starts
administering a bolus of 0.9%
sodium chloride solution via
Ms. Smith’s existing peripheral I.V. site.
They establish a second peripheral I.V.
www.Nursing2010.com
line and obtain blood specimens for
a complete blood cell (CBC) count ,
comprehensive metabolic panel, and
lactate level. Blood cultures, a DIC
screen, and a type and screen may
be obtained later, pending further
assessment and lab results.
After receiving 2 L of I.V. 0.9%
sodium chloride solution, Ms Smith’s
clinical status remains unchanged.
Her urinary tract infection, fever,
tachycardia, tachypnea, leukocy-
tosis, hyperlactatemia, and limited
response to the fluid bolus lead the
healthcare provider to diagnose her
with sepsis. A central venous access
device (CVAD) is placed for admin-
istering vasopressors and additional
fluids and medications, as well as for
providing central venous pressure
(CVP) monitoring.
Rapid interventions
Treatment for a patient suspected of
having sepsis should be started as
quickly as possible, ideally within
the first hour of presentation. Much
like the golden hour for trauma
patients, the first hour of caring for
a patient with sepsis is critical.
Obtaining lab results is a priority.
A CBC count will demonstrate leuko-
cytosis indicating an acute inflamma-
tory process and possible infection, as
well as a low hemoglobin level. He-
moglobin is the main component of
red blood cells (RBCs) that transports
oxygen. Decreased hemoglobin levels
can indicate anemia. The comprehen-
sive metabolic panel, which includes
blood urea nitrogen, creatinine, and
liver enzymes, can indicate renal
or hepatic dysfunction, which can
indicate severe sepsis. If infection is
suspected (or documented, as in our
case study) and the patient meets two
or more SIRS criteria, a serum lactate
level also needs to be obtained.
An elevated serum lactate level can
indicate tissue hypoperfusion. Serum
lactate is a marker of anaerobic me-
tabolism, which occurs when tissue
oxygenation demands exceed sup-
ply. Elevated lactate levels (over 2.5
mmol/L) indicate widespread tissue
hypoperfusion and are associated
with increasing risk of death.10,11
Next, start an I.V. fluid bolus of
0.9% sodium chloride solution, as
prescribed. If the CBC count shows
a value that meets the SIRS criteria
(a WBC count greater than 12,000
cells/mm3 or less than 4,000 cells/
mm3 or greater than 10% immature
neutrophils), establish an additional
venous access and obtain blood
specimens for additional lab tests, in-
cluding two or more blood cultures,
type and screen, and a DIC panel.
Insert an indwelling urinary catheter
and obtain a urine specimen for a
urinalysis and culture. Also obtain
samples for sputum cultures.
If the patient remains hypotensive
despite fluid boluses, prepare for
CVAD insertion.
The Surviving Sepsis Campaign’s
resuscitation bundle of interven-
tions calls for administering broad-
spectrum antibiotics within 3 hours
of ED admission and 1 hour of
non-ED admission.1 Because you’ll
likely administer several antibiotics
in rapid succession, administer the
antibiotics with the shortest infusion
times first.
The goals of fluid resuscitation
in the first 6 hours include a CVP
of 8 to 12 mm Hg, a mean arterial
pressure (MAP) of 65 mm Hg or
greater, a urine output of 0.5 mL/
kg/hour or greater, and a central
venous oxygen saturation of 70%
or greater or mixed venous oxygen
saturation (SVO2) of 65% or greater.4
In mechanically ventilated patients,
a higher targeted CVP of 12 to 15
mm Hg is recommended, to account
for positive-end expiratory pressure
and increases in intrathoracic pres-
sure.1 If the patient can’t maintain a
systolic BP greater than 90 mm Hg
or a MAP of 65 mm Hg or greater
after fluid resuscitation, start an infu-
sion of norepinephrine or dopamine
(the initial vasopressors of choice) as
prescribed via the CVAD and titrate
it to meet a target MAP of 65 mm Hg
or greater.
For the patient who remains hy-
potensive despite fluid resuscitation
and norepinephrine administration of
more than 5 to 10 mcg/min, the next
step is to administer vasopressin.1
April l Nursing2010 l 37
Obtain an SVO2 sample from the
CVAD to check for hypoperfusion
and impaired oxygenation. Check the
patient’s hematocrit level if the SVO2
value isn’t over 65% despite other
parameters having responded to fluid
resuscitation (that is, CVP is 8 mm Hg
or greater, urine output is greater than
0.5 mL/kg/hour, and MAP is 65 mm
Hg or greater). If the patient’s SVO2
can’t be brought up to target by these
interventions, the healthcare provider
will consider further fluid resuscita-
tion and packed RBCs if needed to
bring the hematocrit to at least 30%.
A dobutamine infusion may also be
prescribed.4
Obtain a repeat SVO2 reading 30
minutes after initiating the dobuta-
mine infusion. Reevaluate the patient
if the value is still less than 65%.
Treating Ms. Smith
Here’s how the interventions
described above would proceed with
Ms. Smith. As prescribed, you start
for aggressive care and treatment with
a sequence of multiple antibiotics.
Over the next 72 hours, her blood
work results show improvement: im-
mature neutrophils decrease from 30%
to 1%, lactate level decreases from
8.1 to 2.5 mg/dL, and WBC count
decreases from 35,200 to 13,500
cells/mm3. Ms. Smith’s clinical status
continues to improve. She’s moved to
a step-down unit and then back to a
general medical unit. Upon discharge,
she’s transferred to a rehabilitation
care facility. After 2 weeks, she returns
home and resumes her usual activity.
Caring for a patient with sepsis is
challenging and often requires mul-
tiple resources, such as emergency or
critical care physicians and nurses,
pharmacists, and respiratory thera-
pists. The first line of treatment is to
identify and eliminate the underlying
infection. If your facility has an RRT,
contact the team early in the process.
Transfer your patients to an ICU as
soon as possible.
REFERENCES
1. Implementing the Surviving Sepsis Campaign.
e
http://www.survivingsepsis.org.
2. Cheek DJ, McGehee-Smith H, Cunneen J, :
Cartwright M. Sepsis: taking a deeper look.
Nursing. 2005;35(1):38-42.
3. Filbin MR. Shock, septic. http://emedicine.
medscape.com/article/786058-overview.
4. Dellinger RP, Levy MM, Carlet JM, et
al., for the International Surviving Sepsis
Campaign Guidelines Committee. Surviving
Sepsis Campaign: international guidelines for
management of severe sepsis and septic shock:
2008. Crit Care Med. 2008;36(1):296-327.
5. Fauci A, Braunwald E, Kasper DL, Hauser SL.
Harrison’s Principles of Internal Medicine, 17th ed.
New York, NY: McGraw Hill; 2008.
6. Vandijck D, Blot S, Decruyenaere J. Update
on the management of infection in patients with
severe sepsis. Dimens Crit Care Nurs. 2008;27(6):
244-248.
7. Xigris (drotrecogin alfa [activated]). http://www.
sepsis.com/overview.jsp.
8. Shorr AF, Micek ST, Jackson WL, Jr., Kollef MH.
Economic implications of an evidence-based sepsis
protocol: can we improve outcomes and lower costs?
Crit Care Med. 2007;35(5):1257-1262.
9. Mackenzie I, Wilson I. The management of
sepsis. Update in Anaesthesia. 2001. http://www.
nda.ox.ac.uk/wfsa/html/u13/u1308_01.htm.
10. Jones AE, Puskarich MA. Sepsis-induced tissue
hypotension. Crit Care Clin. 2009;25(4):769-779.
11. Bakker J, Jansen T. Don’t take vitals, take a
lactate. Intens Care Med. 2007;33(11):1863-1865.

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

> For more than 4 additional continuing education articles related to

multisystem patient care topics, go to Nursingcenter.com/CE. <
Earn CE credit online:
Go to http://www.nursingcenter.com/CE/nursing and
receive a certificate within minutes.

Sepsis alert: Avoiding the shock
TEST INSTRUCTIONS
• To take the test online, go to our secure Web site
at http://www.nursingcenter.com/ce/nursing.
• On the print form, record your answers in the
test answer section of the CE enrollment form on
page 39. Each question has only one correct an-
swer. You may make copies of these forms.
• Complete the registration information and
course evaluation. Mail the completed form and
registration fee of $21.95 to: Lippincott Williams
& Wilkins, CE Group, 2710 Yorktowne Blvd.,
Brick, NJ 08723. We will mail your certificate
in 4 to 6 weeks. For faster service, include a
fax number and we will fax your certificate
within 2 business days of receiving your
enrollment form.
• You will receive your CE certificate of earned
contact hours and an answer key to review your
results. There is no minimum passing grade.
• Registration deadline is April 30, 2012.
INSTRUCTIONS
DISCOUNTS and CUSTOMER SERVICE
• Send two or more tests in any nursing journal published by Lippincott Williams &
Wilkins together by mail, and deduct $0.95 from the price of each test.
• We also offer CE accounts for hospitals and other healthcare facilities on nursingcenter.
com. Call 1-800-787-8985 for details.
PROVIDER ACCREDITATION
Lippincott Williams & Wilkins, publisher of Nursing2010 journal, will award 2.3 contact hours
for this continuing nursing education activity.
Lippincott Williams & Wilkins is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s Commission on Accreditation.
Lippincott Williams & Wilkins is also an approved provider of continuing nursing
education by the District of Columbia and Florida #FBN2454. This activity is also provider
approved by the California Board of Registered Nursing, Provider Number CEP 11749 for
2.3 contact hours.
Your certificate is valid in all states.
The ANCC’s accreditation status of Lippincott Williams & Wilkins Department of
Continuing Education refers only to its continuing nursing educational activities and does
not imply Commission on Accreditation approval or endorsement of any commercial
product.
k

38 l Nursing2010 l April www.Nursing2010.com