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

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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

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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. Respiratory rate >20 breaths/min Abdomen, acute infection Bloods (including lactate) White cells <4 or >12g/L Wound infection If sepsis is suspected, full blood count, New altered mental state Skin/soft tissue inflammation clotting, renal function, liver function tests, c-reactive protein and arterial blood Blood glucose >7.7 (not diabetic) Endocarditis gas (to ascertain lactate level) should be Urinary tract or kidney infection taken. Low haemoglobin will reduce the Brain/meningitis/encephalitis delivery of oxygen to tissues so should be Obstetric or gynaecological urgently identified and treated, while a raised white cell count is a strong indicator

If yes, consider the following question the following consider If yes, infection of infection and is used as part of the initial Bone or joint infection screening for sepsis. A raised lactate, If the previous considerations indicate sepsis, commence the Sepsis Six care bundle though not specific to sepsis, provides and contact the doctor and critical care outreach team clear evidence of metabolic compromise and development of severe sepsis. Monitoring changes in lactate, and increase the risk of neutropenic sepsis so identifying improvement or deterioration, this should be considered in all patients Box 3. Signs of organ is linked to sepsis prognosis and is a good who become unwell following these treat- dysfunction indicator of the impact of treatment. ments (National Institute for Health and Severe sepsis Clinical Excellence, 2012). National early ● Central nervous system: Acutely Blood cultures warning scores (Royal College of Physi- altered mental status Two sets of blood cultures are recom- cians, 2012) and robust escalation proto- ● Cardiovascular system: Systolic <90 mended to improve microbial identifica- cols help identify and manage deteriora- or mean <65mmHg tion and sensitivity and, therefore, antibi- ● tion. Nurses need to understand what Respiration: SpO2 >90% only with otic choice. Cultures should be taken from resources are available in their organisa- new/more oxygen separate sites at the same time and should tion to help identify patients whose health ● Renal: Creatinine >177µmol/L or include one from each intravenous device is deteriorating. urinary output <0.5ml/kg/hr for 2 hrs in place for more than 48 hours. Cultures ● Hepatic: Bilirubin >34µmol/L should also be taken from other sources, Sepsis management ● Bone marrow: Platelets <100 for example sputum or urine. The majority of research evidence on ● Hypoperfusion: Lactate >2mmol/L sepsis is limited to severe sepsis and septic ● Coagulation: international normalised Urinary output shock – there is little on uncomplicated ratio >1.5 or partial thromboplastin time Fluid balance is a good indicator of circu- sepsis. Patients with sepsis need imme- >60 seconds lating volume and renal function, and diate intervention to determine severity therefore essential for good sepsis man- and prevent deterioration to severe sepsis. agement and the prevention of acute The use of care bundles is recom- started. McNeill et al (2008) found that few kidney injury. Insertion of a urinary cath- mended by the SSC and other international AMUs in the UK were able to resuscitate eter is the “gold-standard” for accurate sepsis forums. Care bundles bring together patients using the SSC care bundles. measurement of urinary output but may a small number of interventions that, Daniels et al (2010) developed the increase infection risk. when undertaken together and reliably, “Sepsis Six” care bundle, which was shown improve patient outcomes (Institute for to improve delivery of reliable care across a Oxygen Healthcare Improvement, 2012). SSC guid- range of clinical settings; endorsed by the Contrary to recent guidance for oxygen ance presents two bundles for severe sepsis College of Emergency Medicine and the therapy (O’Driscoll et al, 2008), patients and septic shock, with actions to be deliv- SSC, it is now used in many UK hospitals. with sepsis need high-flow oxygen until ered within three hours and six hours of Sepsis Six (Box 4) consists of three investi- there is clear evidence (from the blood gas) identification (previously known as the gations and three interventions that all that no hypoperfusion exists. Careful con- “Resuscitation and Management bundles”) patients with sepsis should receive within sideration needs to be given to those with (Dellinger et al, 2013). Daniels et al (2010) one hour of identification. Most of the chronic lung disease who may not tolerate note that, although the SSC bundles are actions can be started by nursing staff high levels of oxygen. internationally recognised, they have ele- while waiting for a medical response, and ments that require critical-care skills that aid prompt, effective decision-making. All Fluids are not always available in emergency patients with severe sepsis should be Fluid resuscitation is essential to prevent departments or acute medical units reviewed by critical care staff for further hypotension and improve cardiac output (AMUs), where they are most likely to be interventions. and therefore tissue perfusion. Many

16 Nursing Times 22.01.14 / Vol 110 No 4 / www.nursingtimes.net For articles on critical care, go Nursing to Times.net nursingtimes.net/criticalcare patients with sepsis are significantly dehy- drated so high levels of fluid resuscitation Box 5. national and international resources are often needed. The SSC currently rec- ● Surviving Sepsis Campaign: www.survivingsepsis.org ommends 30ml/kg of crystalloids for ● The UK Sepsis Trust: www.sepsistrust.org patients with hypotension or raised lactate ● Global Sepsis Alliance: www.globalsepsisalliance.com (>4mmol) (Dellinger et al, 2013). Lower vol- ● Sepsis and VTE NHS Education for Scotland: www.knowledge.scot.nhs.uk/ umes of fluid, given in intermittent sepsisvte/sepsis.aspx boluses, should be considered in uncom- ● 1000 Lives Plus (Wales): www.1000livesplus.wales.nhs.uk plicated sepsis and reviewed regularly for ● Sepsis Kills (Australia): www.cec.health.nsw.gov.au/programs/sepsis efficacy. Lower volumes should also be considered for those with active heart or renal failure. Delivering all elements of Sepsis Six help of simple tools and robust escalation within one hour of identification sets a sig- systems, it is possible for all staff to inter- Antibiotics nificant challenge in busy clinical areas. vene early to prevent harm and signifi- Broad-spectrum antibiotics should be Similar to the “golden hour” described in cantly reduce mortality. NT given within one hour of sepsis being iden- good trauma, stroke or heart-attack care, tified, having checked patient allergies. teams need to coordinate roles and respon- References Bone RC et al (1992) Definitions for sepsis and Antibiotic choice will depend on the prob- sibilities so all elements of care are com- organ failure and guidelines for the use of able source of infection, local policy and pleted efficiently (Nguyen and Smith, innovative therapies in sepsis. The ACCP/SCCM may involve discussion with microbiology. 2006). The team lead should be responsible Consensus Conference Committee. American College of Chest Physicians/Society of Critical Antibiotic therapy should be reviewed for the timeliness of interventions, clari- Care Medicine. Chest; 101: 6, 1644-1655. daily to reduce toxicity, risk of resistance fying roles and creating a plan of care, Chege F, Cronin G (2007) Emergency care staff and cost (Dellinger et al, 2013). whether for referral, escalation or even can improve survival rates from sepsis. Accident end-of-life. Organisations have and Emergency Nurse; 15: 157-160. Czura CJ (2011) Merinoff Symposium 2010: sepsis Management plan approached the work differently: some - speaking with one voice. Molecular Medicine; 17: It is essential to evaluate the response to have created sepsis teams, others sepsis 1-2, 2-3. treatment and an ongoing management coordinators, or use tools that make reli- Daniels R (2011) Surviving the first hours in sepsis: getting the basics right (an intensivist’s perspective). plan. This should include level of observa- able identification and treatment easier Journal of Antimicrobial Chemotherapy; 66: 2, ii11-ii23. tion, review schedule and an escalation across all teams. Daniels R et al (2010) The sepsis six and the severe plan. Clear escalation supports decision sepsis resuscitation bundle: a prospective observational cohort study. Emergency Medicine making for the whole team, setting out Sepsis care in the future Journal; 28: 507-512. who should be contacted and when. A plan Sepsis prevalence is increasing, though it Dellinger RP et al (2013) Surviving sepsis is needed for those who may not respond is unclear whether this is the result of campaign: international guidelines for effectively and who need more invasive better diagnosis or due to population management of severe sepsis and septic shock. Critical Care Medicine; 41: 2, 580-637. monitoring or intervention, usually pro- change. The work of the SSC and other Institute for Healthcare Improvement (2012) Using vided in a high-dependency or intensive global forums has generated increasing Care Bundles to Improve Health Care Quality. care environment. Treatment goals will be interest in reducing the number of deaths tinyurl.com/IHI-bundles McClelland H (2007) Can care bundles improve to optimise cardiac output measures, oxy- caused by sepsis. With an ever-increasing quality in emergency care? Accident and genation and tissue perfusion and to workload and the introduction of health- Emergency Nursing; 15: 119-120. measure the response to treatment. care-based targets, alongside staffing McNeill G et al (2008) Can acute medicine units in the UK comply with the Surviving Sepsis Consideration needs to be given to shortages and a lack of appropriate beds, Campaign’s six-hour care bundle? Clinical those patients who are unlikely to respond there is much pressure on health staff to Medicine; 8: 2, 163-165. to treatment and whose priority will be perform at higher levels of efficiency and National Institute for Health and Clinical good end-of-life care. Open and frank to recognise patients who are potentially Excellence (2012) Neutropenic Sepsis: Prevention and Management of Neutropenic Sepsis in Cancer discussions with the patient and family unwell or whose health is deteriorating Patients. CG151. nice.org.uk/cg151 about treatment will help them under- while still providing high-quality care Nguyen HB, Smith D (2006) Sepsis in the 21st stand the severity of the condition and its (McClelland, 2007). century: recent definitions and therapeutic advances. American Journal of Emergency expected outcome. Resources are now available for pre-hos- Medicine; 25, 564-571. pital and community settings (Box 5), O’Driscoll BR et al (2008) On behalf of the British which will further improve timeliness of Thoracic Society. Guideline for emergency oxygen Box 4. The Sepsis Six diagnosis and treatment. Research is aimed use in adult patients. Thorax; 63 (Suppl VI): vi1–vi68. care bundle Porth MC (2005) Pathophysiology: Concepts of at finding blood markers that are sensitive Altered Health States. Philadelphia PA: Lippincott ● Deliver high-flow oxygen to sepsis progression and effective treat- Williams & Wilkins. ● Test blood cultures ments for severe sepsis and septic shock. Royal College of Physicians (2012) National Early Warning Score (NEWS): Standardising the ● Administer antibiotics Assessment of Acute-illness Severity in the NHS. ● Measure serum lactate and full blood Conclusion tinyurl.com/RCP-EarlyWarning count Sepsis is a leading cause of death and Slade E et al (2003) The Surviving Sepsis Campaign: raising awareness to reduce mortality. ● Start intravenous fluids harm. Nurses are pivotal in spotting Critical Care; 7, 1-2. ● Commence accurate urine output patients who are unwell or deteriorating, Survive Sepsis Organisation (2009) Survive measurement and in initiating life-saving treatments. Sepsis: The Official Educational Programme of the Clear guidance on identification and evi- Surviving Sepsis Campaign. Sutton Coldfield: Survive Sepsis. Source: Daniels et al (2010) dence-based interventions is available to Woodrow P (2012) Intensive Care Nursing. support effective and safe care. With the London: Routledge.

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