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Early Identification and Treatment of Sepsis 5 Key in This Article Keywords: Sepsis/Screening/Infection Nursing Practice Review ●This article has been double-blind Infection peer reviewed Sepsis is a medical emergency. Early identification and treatment are essential but many health staff are unable to recognise its signs and symptoms Early identification and treatment of sepsis 5 key In this article... points Anatomy of sepsis Sepsis is one Signs and symptoms that can help professionals identify sepsis 1of the leading Effective sepsis management strategies causes of death in hospital patients worldwide Author Heather McClelland is nurse present in patients and how best to Patients with consultant in emergency care, Alex Moxon manage sepsis to prevent death or long- 2severe sepsis is emergency department staff nurse; both term disability. will not respond to at Calderdale and Huddersfield Chege and Cronin (2007) described early fluid replacement Foundation Trust. evidence of treatment for sepsis as existing Sepsis can be Abstract McClelland H, Moxon A (2014) as far back as the early Chinese emperors. 3identified Early identification and treatment of However, it was not until 1991 that defini- during routine sepsis. Nursing Times; 110: 4, 14-17. tions of sepsis were agreed and later pub- observations so Sepsis is a potentially fatal condition and is lished (Box 1) (Bone et al, 1992). These nurses play a vital becoming increasingly frequent, yet health underpin more recent research and guid- role in spotting professionals are often unable to recognise ance from leading campaign groups such symptoms its symptoms. It is the body’s exaggerated as the Surviving Sepsis Campaign (SSC) All patients response to infection and, if left untreated, and Global Sepsis Alliance. SSC – a partner- 4with sepsis will lead to severe sepsis, multi-organ ship of international critical care, medical should have a failure and death. Nurses play a vital role in and emergency care societies – aims to management identifying patients with sepsis and raise awareness and provide guidance plan that includes starting essential treatment. This article based on the best available evidence. In the level of looks at how sepsis can be identified and UK, SSC guidance is being changed to observation, review effectively treated to improve survival. improve both the identification of patients schedule and an at risk of developing severe sepsis and the escalation plan epsis is one of the leading causes delivery of early treatment. Clear of death in hospital patients 5guidance on worldwide and severe sepsis What is sepsis? identification and Scauses around 37,000 deaths in the Although sepsis is mainly caused by bacte- evidence-based UK every year (Daniels, 2011). This is more rial infection, it can be caused by a viral, interventions is than breast and bowel cancer combined, yet fungal or even parasitic source (Fig 1). As available to awareness of the condition remains lim- the infection affects the body’s normal support effective ited. Despite various campaigns and the inflammatory response, physiologicaland safe care availability of good evidence for treatment, changes can be seen that aid diagnosis. the death rate associated with sepsis Systemic inflammatory response syn- remains high, mainly due to poor identifi- drome (SIRS) is a collection of signs that cation and delayed interventions. the body is reacting to a range of injuries Defined as “a life-threatening condition or illnesses (Box 2), and is not specific to that arises when the body’s response to infection. The body may respond by infection injures its own tissues and raising the heart or respiratory rate to organs” (Czura, 2011), sepsis can present in increase the amount of oxygen – by any patient and in any clinical setting. As altering body temperature or increasing such, all nurses need to be aware of its white cell production – to overcome infec- development, how it can be identified and tion. Raised blood sugars and new confu- the care patients need to survive. This sion or an altered mental state may be early article discusses the pathophysiological signs of metabolic stress or hypoxia (Sur- Sepsis occurs when tissue is damaged as Alamy changes caused by sepsis, how these vive Sepsis Organisation, 2009). Although the body attempts to fight infection 14 Nursing Times 22.01.14 / Vol 110 No 4 / www.nursingtimes.net For articles on infection control, Nursing go to Times.net nursingtimes.net/infection BOX 1. DEFINITIONS FIG 1. CAUsaL RELatiONSHIPS OF INFECTION, SEPSIS ● Systemic inflammatory response AND SYsteMIC INFLAMMatORY RESPONSE SYNDROME syndrome (SIRS) The systemic inflammatory response to a variety of severe clinical insults. The response is manifested by two or more of the following conditions: » Temperature >38°C or <36°C Bacteria Other » Heart rate >90bpm Infection » Respiratory rate >20 breaths/min or PaC0 <32mmHg SIRS 2 Fungi Sepsis » White blood cell count >12,000/mm3 Trauma <4,000/mm3, or >10% immature (band) forms Parasites ● Sepsis The systemic response to infection, manifested by two or more of Viruses Burns the following, as a result of infection: Other » Temperature >38°C or <36°C Pancreatitis » Heart rate >90bpm » Respiratory rate >20 breaths/min or Blood-borne infection Source: Bone et al (1992) PaC02 <32mmHg and white blood cell count >12,000 cells/mm3 <4,000 cells/mm3 or >10% immature pathways, leading to vasodilatation, vessel BOX 2. SYsteMIC (band) forms leakage and increased metabolic demands. INFLAMMatORY ● Severe sepsis is associated with This effect increases oxygen demand RESPONSE SYNDROME organ dysfunction, hypoperfusion or which, combined with intravascular losses, hypotension. Hypoperfusion and causes hypoperfusion and ischaemia at cel- ● Temperature >38.3°C or <36.0°C perfusion abnormalities may include lular levels (Porth, 2005). At this stage, there ● Heart rate >90bpm – but are not limited to – lactic acidosis, will be signs of severe sepsis and evidence of ● Respiratory rate >20 breaths/min oliguria or an acute alteration in mental organ dysfunction away from the primary ● White cell count <4 or >12g/L status source of infection (Box 3). ● New altered mental state ● Septic shock Sepsis-induced with In a patient with sepsis from a urinary ● Blood glucose >7.7mmol/L (not hypotension despite adequate fluid tract infection, some changes to renal diabetic) resuscitation, along with the presence function might be expected, but not of perfusion abnormalities that may abnormal blood clotting or lactate levels. include – but are not limited to – lactic Low blood pressure and dehydration is with two or more SIRS and a suspected acidosis, oliguria or an acute alteration commonly seen in patients with sepsis, infective source is deemed to have sepsis in mental status. Patients receiving but will generally respond to fluid replace- and needs further screening for signs of inotropic or vasopressor agents may ment. Patients with severe sepsis who do organ dysfunction (severe sepsis) and risk not be hypotensive at the time that not respond to this treatment are in septic of mortality. perfusion abnormalities are measured shock. If not actively managed, this leads Simple screening tools are widely used ● Sepsis-induced hypotension A to refractory hypotension, tissue to identify patients with sepsis (Fig 2). systolic blood pressure <90mmHg or a ischaemia, circulatory collapse and multi- Some organisations have successfully reduction of 2:40mmHg from baseline organ failure. implemented routine screening of all in the absence of other causes for Patients at greatest risk of sepsis often admissions; others screen in the emer- hypotension have multiple comorbidities so treatment gency department. It is important to ● Multiple organ dysfunction needs to be considered carefully. For remember that SIRS is not always caused syndrome (MODS) The presence of example, patients with chronic respiratory by infection and may be present for a range altered organ function in an acutely ill disease presenting with a chest infection of medical reasons. Good clinical assess- patient such that homoeostasis cannot may have abnormal vital signs because of ment, history taking and investigation will be maintained without intervention their long-term condition or because they ensure accurate diagnosis and help to esti- have developed sepsis and may not tolerate mate the severity of the illness. Adapted from Bone et al (1992) high-flow oxygen as part of the sepsis Certain populations are at greater risk treatment protocol. of sepsis and should be more closely these responses can have a range of causes, assessed and monitored for deterioration. when combined with infection, they could Identification of sepsis Young children, frail older people or those indicate sepsis. The condition is defined by Identifying sepsis early is key to survival with multiple comorbidities may not have the presence of two or more SIRS signs but is still the greatest challenge facing the same capacity to fight infection as the where infection is suspected or confirmed effective sepsis management (Slade et al, general population. Those with long-term (Woodrow, 2012). 2003). By undertaking routine clinical invasive devices, such as urinary catheters Sepsis causes complex dysfunction in observations, nurses play a vital role in or cannulae, are equally at risk. Chemo- the body’s inflammatory and coagulopathy identifying sepsis. Any patient presenting therapy and other anti-cancer treatments www.nursingtimes.net / Vol 110 No 4 / Nursing Times 22.01.14 15 Nursing Practice Review Each element of the Sepsis Six bundle FIG 2. CHFT SEPSIS SCREENING TOOL can create a significant challenge for clin- Sepsis confirmed by >2 clinical signs and indication of infective source ical teams so it is worth looking at each in detail. Staff should review each element 1. Are >2 of the following signs Yes 2. Is the history indicative of an Yes and reflect on its implication in everyday present? infection in any of these areas? practice. Organisations may use the Sepsis Temperature >38.3°C or <36°C Invasive device infection Six approach or have their own protocols Heart rate >90bpm Lungs/pneumonia so it is important to check local policies.
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