Detour Off The Sepsis Road: Early Recognition is Key
Submitted by Angela Buckles, RN, CNS-S, Murray State University
Sepsis is the systemic inflammatory response to infection (Howell & Tisherman, 2006). The pathophysiology of sepsis is complex and typically involves the following components: inflammatory, procoagulant, antifibrinolytic, and microvascular (Wheeler, 2007). The occurrence of sepsis has increased dramatically. In the 1970’s, the US estimated 164,000 cases (Neviere, 2009). At present, the US reports approximately 750,000 cases a year and estimates 1 million cases by 2020 (O’Brien, Ali, Aberegg, & Abraham, 2007). With a mortality rate of 30%, an estimated 250,000 annual deaths, and hospital costs exceeding $16 billion, sepsis has become a burden (O’Brien et al, 2007, Kaplow & Hardin, 2007). It is imperative to increase the awareness and early recognition of sepsis. This article will review the definition, pathophysiology, and the current treatment plan for sepsis. Utilization of the Synergy Model and a case study will illustrate how early identification of sepsis can lead to improved patient outcomes.
The definition of sepsis ranges from the start of the systemic inflammatory response to multiple organ failure. Knowledge of the different stages of sepsis gives healthcare personnel the ability to intervene and choose appropriate treatment interventions. The following definitions are from Neviere, 2009. Systemic inflammatory response syndrome (SIRS) is clinically identified by the presence of two or more of the following:
- Temperature > 38.5 degrees C or < 35 degrees C
- Heart rate > 90 beats/min
- Respiratory rate > 20 breaths/min or PaCO2 < 32 mmHg
- WBC > 12,000 cells/mm3, < 4000 cells/mm3, or > 10 percent immature band forms
Sepsis occurs when the clinical signs of SIRS are present along with a visible infection or culture-proven infection. Severe sepsis occurs with sepsis plus at least one of the following signs of organ hypoperfusion or dysfunction:
- Areas of mottled skin
- Capillary refilling requires three seconds or longer
- Urine output <0.5 mL/kg for at least one hour, or renal replacement therapy
- Lactate > 2 mmol/L
- Abrupt change in mental status
- Abnormal electroencephalographic (EEG) changes
- Platelet count <100,000 platelets/mL
- Disseminated intravascular coagulation
- Acute lung injury or acute respiratory distress syndrome (ARDS)
- Cardiac dysfunction, as defined by echocardiography or direct measurement of the cardiac index
Septic shock exists when severe sepsis is present plus one or both of the following:
- Systemic mean blood pressure is < 60 mmHg (or <80 mmHg if the patient has baseline hypertension) despite adequate fluid resuscitation
- Maintaining the systemic mean blood pressure > 60 mmHg (or > 80 mmHg if the patient has baseline hypertension) requires dopamine > 5 mcg/kg per minute, norepinephrine < 0.25mcg/kg per minute, or epinephrine < 0.25mcg/kg per minute despite adequate fluid resuscitation.
Multiple organ failure occurs with the presence of altered organ function and when homeostasis cannot be maintained without intervention. Multiple organ dysfunction syndrome (MODS) is the severe end of the sepsis spectrum. MODS is classified as primary or secondary:
- Primary MODS is the result of a well-defined insult in which organ dysfunction occurs early and can be directly attributable to the insult itself.
- Secondary MODS is organ failure not in direct response to the insult itself, but as a consequence of a host response.
It’s imperative for SIRS and severe sepsis to be recognized as early as possible. Progression to septic shock and MODS results in poor patient outcomes (Kaplow & Hardin, 2007). Identifying populations susceptible to developing sepsis leads to early recognition and better outcomes. According to Kaplow and Hardin, 2007, the following patients are at risk:
- Ages less than 1 year and greater than 85 years
- Severe community-acquired pneumonia
- Intra-abdominal surgery
- Chronic diseases such as cardiovascular disease, renal disease, and diabetes
- Urinary tract infection
The pathophysiology of sepsis is complex and involves many factors. For the purpose of this article, a simplified version will be explained using the inflammatory, procoagulant, and antifibrinolytic process. Cytokines are released during the inflammatory response. The cytokines cause other proinflammatory mediators, such as myocardial depressant factor to be released. This results in a decrease in the ejection fraction, a decrease in response to fluid resuscitation, and a decrease in blood pressure. The endothelium becomes procoagulant in response to the cytokines. This causes damage to the endothelium and leads to capillary leakage. When capillary permeability is disrupted, fluid shifts into the cells and the inflammatory process is further activated. This continuous cycle makes achieving homeostasis difficult (Kaplow & Hardin, 2007).
Thrombin production is promoted by the endothelium injury induced by the cytokines. A decline of protein C and antithrombin III results in procoagulation. Thrombin changes fibrinogen into fibrin and when combined with platelets, clots are formed. These clots can block microvasculature and negatively impact cell and organ function (Kaplow & Hardin, 2007).
Endothelial injury results in substances being produced to impair fibrinolysis. When fibrinolysis is impaired, the balance between clot formation and clot removal is disrupted. This imbalance can lead to disseminated intravascular clotting (DIC). DIC ultimately leads to MODS (Kaplow & Hardin, 2007).
Early identification of sepsis results in better patient outcomes. Septic patients can be seen in the outpatient and inpatient setting (O’Brien et al, 2007). The presentation of symptoms varies; however, some common symptoms exist for each body system. The following table illustrates the common symptoms seen for each body system:
|General||Fever, chills, fatigue, malaise, rigors, warm pink periphery|
|Central Nervous System||Confusion, anxiety, disorientation, apprehension, agitation, obtunded, comatose|
|Cardiovascular||Tachycardia, increase pulse pressure, hypotension|
|Pulmonary||Hyperventilation, respiratory alkalosis, shortness of breath, tachypnea, hypoxemia, acute lung injury|
|Gastrointestinal & Genitourinary||Nausea, vomiting, decreased albumin, jaundice, oliguria|
|Hematologic||Increased or decreased WBCs, increased INR, increased PTT, DIC, thrombocytopenia|
|Metabolic/Endocrine||Increased glucose production, insulin resistance, lactic acidosis, electrolyte abnormalities (Kaplow & Hardin, p. 622, 2007)|
Once sepsis is recognized, treatment needs to begin immediately. Four phases have been identified to help with diagnosis and treatment of sepsis (O’Brien et al, 2007). Stage one is the Resuscitation Phase which involves assessing the above mentioned signs and symptoms. Assessing vital signs, white blood cell count (WBC), and a differential are key steps in this first stage. Within one hour of the suspicion of sepsis, obtain appropriate cultures and administer broad spectrum antibiotics. Vasopressors should be administered if fluids do not improve hypotension. The airway should be evaluated and managed with intubation if necessary. The Resuscitation Phase should be completed within 6 hours (O’Brien et al, 2007).
Initial Management is the next phase in the treatment of sepsis. This phase should be completed within 24 hours of the presentation of sepsis. Further diagnostic testing is performed to detect likely pathogens and sites of infection. Once the source is determined, it needs to be controlled. Some examples include removal of infected central lines and surgical debridement of wounds. The plan of care and outcomes also need to be discussed with the patient and family (O’Brien et al, 2007).
The Maintenance Phase begins 24 hours after the presentation of sepsis. The goal of this phase is to prevent nosocomial complications and restore premorbid functioning. Avoid nososomial infections through good hand washing and restrictive transfusion practices. Review cultures and customize antibiotic therapy to improve outcomes and prevent antibiotic resistance. Apply appropriate stress ulcer and thromboembolism prophylaxis (O’Brien et. al, 2007).
The Recovery Phase is the final stage. Goals of care should be discussed with the patient and family. Prevention measures such as immunizations and good hand washing should be instilled in the patient and family. The appropriate follow up services should be offered (O’Brien, 2007). Positive patient outcomes can be achieved by following the treatment guidelines and applying the Synergy Model to the plan of care.
The Synergy Model
The American Association of Critical-Care Nurses’ (AACN) created the Synergy Model. This model fosters the development of nurse competencies to optimally meet the individual needs of patients (Kaplow & Hardin, 2007). When the competencies and needs are met, improved outcomes result for the patient, family, and the healthcare system (Mullen, 2002). The model consists of eight patient characteristics and eight nurse characteristics.
The patient characteristics exist on a continuum and the patient may fluctuate depending upon the illness (Curley, 1998).
The following are the patient characteristics (Mullen, 2002):
- Resiliency: Capacity to return to previous level of functioning
- Stability: The ability to maintain a steady state
- Complexity: The entanglement of 2 or more systems (body, family, therapies)
- Predictability: Expecting a certain illness trajectory or outcome
- Vulnerability: Susceptibility to stressors that may effect outcomes
- Participation in Decision-Making: How much the patient and family participate in decision making
- Participation in Care: How much the patient and family can participate in care
- Resource Availability: Resources (personal, financial, social, etc) the patient and family bring to the current situation.
The nurse competencies also exist on a continuum and range from novice or competent to expert nurse. Each nurse may be stronger or weaker in certain areas. The key to the model is to assess the patients’ needs and match the nurse that’s strong in that particular competency to ensure optimal patient outcomes.
The following are the eight nurse competencies (Mullen, 2002):
- Clinical Judgment: Clinical reasoning and critical thinking skills
- Caring Practices: Creating a therapeutic environment based on the unique needs of the patient and family
- Advocacy and Moral Agency: Working on another’s behalf; resolving ethical concerns
- Collaboration: Working with others in a way that encourages each person’s contribution toward patient goals
- Systems Thinking: Recognizing and incorporating differences into care
- Response to Diversity: Recognizing the interrelationships of healthcare systems
- Clinical Inquiry: The ongoing questioning and evaluation of practice
- Facilitator of Learning: Using self to facilitate patient and family learning
The concepts of the Synergy Model and the current recommendations for recognition and treatment of sepsis will be applied to the following case study.
The Case Study
A.R. was a 39 year-old female married with two teenage boys. They lived in a rural community that didn’t have many healthcare resources, including a hospital. A.R. was a math teacher at the local high school and her husband worked in construction. Her past medical history includes hypertension, diverticulitis, acid reflux, and allergies. Past surgical history includes a hysterectomy and a colon resection for diverticulitis. Social history is negative for smoking, drinking, and drug abuse. Current medications include Lisinopril 10mg daily, Protonix 40mg daily, and Claritin 10mg daily.
A.R. came to the nearest emergency room (ER) for severe abdominal pain. The ER physician diagnosed her with an acute colon due to ruptured diverticuli. The patient was admitted to a general surgeon and underwent a colectomy. After the operation, the patient was admitted to the surgical unit. Three days later, the patient was still recovering and was anticipating discharge to home in a couple more days. A.R. was ambulating in the hall, tolerating a full liquid diet, and reporting a pain of 2 while on a patient controlled analgesia (PCA) pump. Her incision was intact with staples and some redness and swelling was noted. On the third post-operative night, the nightshift nurse noticed the patient’s condition started to change.
At 1 am, Nikki, the nightshift nurse, noted the patient’s oxygen level was at 93% on 2 liters nasal cannula. Previously, the oxygen saturation was 99%. A.R. complained of feeling a little short of breath but contributed that to her anxiety. She was worried about all the tasks waiting for her at home. Nikki increased her oxygen to 3 liters and A.R. stated she felt better. Her oxygen saturation came up to 98%. Her lungs were clear to auscultation. She maintained a heart rate of 98, a blood pressure of 115/55, and a respiratory rate of 19.
At 2 am, Nikki went back to check on A.R. She stated she still felt a little short of breath, but she was doing okay. She maintained her oxygen saturation of 95% on 3 liters and a respiratory rate of 21. At 4 am, A.R. asked for assistance to the restroom. Upon ambulating to the restroom, A.R. became diaphoretic, pale, and very weak. Nikki put her back in the bed and asked her to use the bedpan. She called the physician with the patient’s latest vital signs and condition. Now her heart rate was 105, blood pressure 95/42, and respiratory rate 23, temperature 99.8 F. The physician attributed these findings to the Morphine PCA pump. He instructed Nikki to notify him for any further changes and to bolus her with one liter of normal saline. Nikki continued to check on the patient throughout the night. A.R. maintained her vital signs but still continued to have shortness of air.
At 7am, Betty, the dayshift nurse, takes over A.R.’s care. Nikki tells her to watch her closely because she feels that something is wrong. She stated she wanted to call the surgeon back but didn’t because her vital signs remained the same. After Betty finished with report at 7:45 am, she went to check on A.R. Betty immediately called the rapid response team (RRT) and notified the surgeon. A.R. was confused, vomiting, pale, and diaphoretic. Her oxygen saturation was 89% on 3 liters, heart rate was 122, blood pressure was 75/30 manually, respiratory rate was 28, and temperature was 102.3 F. Her lungs were clear and her incision had begun to drain a small amount of brown drainage. The surgeon was in the middle of a case and stated he would check on the patient as soon as possible. Betty asked him for an order for a complete blood count (CBC) and basic metabolic panel (BMP) since no am labs were ordered. She also asked for a normal saline bolus.The nurse competencies also exist on a continuum and range from novice or competent to expert nurse. Each nurse may be stronger or weaker in certain areas. The key to the model is to assess the patients’ needs and match the nurse that’s strong in that particular competency to ensure optimal patient outcomes.
At 7:55 am, the RRT nurse was on the floor and obtained report from Betty. At this time, A.R. stated that she didn’t know what was wrong, but she did not feel well. Betty hung the normal saline bolus and drew the blood out of A.R.’s central line. The RRT nurse continued to assess A.R. Per protocol, the RRT nurse began to administer Dopamine. A.R.’s blood pressure was down to 70/30 and was becoming hard to auscultate. After the blood pressure did not improve with fluids or Dopamine, Levophed was initiated. The cardiac monitor showed sinus tachycardia at 135 bpm. A.R. began to vomit again and become confused. Betty leaves the RRT nurse to tend to A.R. while she pages the surgeon again. While coming back from the nurses’ station, Betty sees A.R’s mom and husband in the hallway. Betty tells them that A.R.’s condition has changed and that she has an intensive care (ICU) nurse helping to get her stabilized. A.R.’s mom and husband become extremely upset and Betty asks another nurse to help the RRT nurse while she speaks with the family.
At 8:30 am the surgeon arrives and transfers the patient to the ICU. At this time, A.R. is maxed out on Dopamine and Levophed. Her blood pressure is 65/30, heart rate 145, respiratory rate 31, oxygen saturation 90% on 100% nonrebreather, temperature 101.9 F. The CBC came back and showed a WBC of 21. Two days prior the WBC was 8. Her potassium was 5.6. The surgeon ordered several antibiotics and spoke with the family about taking her back to surgery to drain her abdominal wound. He also felt that the source of infection could be from her central line catheter. At 8:45 am the patient arrived in ICU. Betty gave report to the ICU nurse and then went to speak with the family in the waiting room. Betty apologized for not calling them and they said they understood. A.R.’s mom stated that she appreciated Betty doing everything she could to try to stabilize her daughter.
At 9:30 am, Betty realized she forgot to send some of A.R.’s medications down to the ICU. When Betty brought the medications to ICU she saw that A.R.’s room was empty and she assumed they took her to surgery. Betty saw the ICU nurse and told her she had medications for A.R. The ICU nurse told Betty that won’t be necessary because A.R. had passed away. She went into ventricular tachycardia upon arrival to the operating room (OR). When the OR staff transferred her to the OR table, she went into ventricular fibrillation and they were not able to resuscitate her.
Septic patients can change very quickly and it’s important to recognize the signs and symptoms as soon as possible. Early recognition leads to better outcomes and reduces the mortality rate. The next section discusses the case study and how the Synergy Model and the treatment plan could have improved the outcome of this patient.
Application of Evidence-based Practice and Synergy Model
In the above case study, early recognition of sepsis was not apparent. This patient was in septic shock before interventions started to take place. Vital signs were assessed and some pertinent lab data were obtained. Once treatment began, it was appropriate. The RRT nurse started with fluid resuscitation and then added vassopressors. By starting Dopamine first, she followed evidence-based practice guidelines established in Surviving Sepsis Campaign (Kaplow & Hardin, 2007).
According to the Synergy Model, A.R. was in the middle of the continuum for resiliency at the beginning of the illness. She mounted a moderate response, had some degree of compensation, and had moderate reserves. This quickly changed and by the morning she was minimally resilient. A.R. had moderate vulnerability because she was somewhat susceptible and somewhat protected. She was moderately stable because she was able to maintain a steady state for a period of time; however, by the morning she was minimally stable. A.R. was moderately complex because she had an entanglement of two or more systems and her family was moderately involved. A.R. had many resources such as her own knowledge base, her family, and work friends. She exhibited full participation in her care and decision making; however, by morning she was not able to make decisions for herself. A.R. demonstrated moderate predictability. She was doing well, but then became ill. She was an abdominal surgical patient and that’s one of the groups that are at risk for sepsis complications (Kaplow & Hardin, 2007).
A.R. was in the middle of the continuum and then quickly changed to critical by morning. She needed a nurse that was strong in clinical judgment, advocacy, systems thinking, and collaboration. Nikki and Betty were both strong in clinical judgment. Nikki realized something was wrong and notified the surgeon. Betty realized the situation was deteriorating and called the surgeon and RRT nurse. Both Nikki and Betty were strong in advocacy because they advocated the patient’s needs to the surgeon and RRT nurse. Both nurses were strong in caring practices because they not only met the current needs of the patient; they both looked at future needs and problems. Nikki and Betty were in the middle of the continuum with collaboration. Nikki collaborated with the surgeon about A.R.’s plan of care. She also showed openness by discussing her actions and concerns with Betty at the change of shift. Betty showed collaboration by working with the surgeon and the RRT nurse (Kaplow & Hardin, 2007).
Betty demonstrated facilitator of learning by speaking with the family about A.R’s condition. Nikki showed some clinical inquiry by realizing that A.R.’s condition was changing. Betty showed clinical inquiry by knowing that the situation had deteriorated and A.R. needed a change in her level of care.
Both nurses intervened appropriately with the needs of the patient; however, early recognition of sepsis might have improved the patient’s outcomes. Drawing a CBC earlier at the start of the change in condition might have lead to an earlier diagnosis of sepsis and a better outcome. A.R. might have benefited from Nikki and Betty being stronger advocates.
Sepsis will continue to be a major clinical disease process. Healthcare workers need to be educated on early recognition and treatment interventions. The Surviving Sepsis Campaign outlines recognition and treatment protocols while the Synergy Model helps to identify patients’ needs and nurses’ competencies. By utilizing both of these tools, healthcare workers can help identify sepsis early and improve patient outcomes.
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