Sepsis Recognition

Sepsis is defined by the Surviving Sepsis Campaign (SSC) as “the presence (probable or documented) of infection together with systemic manifestations of infection” (Dellinger et al.,

Septic shock is the leading cause of death for patients in intensive care units and is the final stage in a continuum of infectious and inflammatory processes. This continuum begins with bacteremia, which is the presence of bacteria in the blood. Normally the body’s immune system can fight off a localized infection caused by a small amount of bacteria in the blood and the person will remain asymptomatic. However, a hospitalized patient could be immunocompromised, have a

Septic shock is a subset of severe sepsis and was defined as “sepsis-induced hypotension persisting despite adequate fluid resusci- tation” (see Fig. 12.1). While the quantity of fluid that qualifies as “adequate fluid resuscitation” is controversial, we believe septic shock is best defined as a “mean arterial pressure (MAP) less than 65 mmHg after a fluid challenge of 20 mL/Kg body weight (given 30–60 minutes) in patients with sepsis and in the absence of other causes for hypotension” (also see Chap. 14). According to the ACCP/SCCM defini- tions, three stages in the hierarchy of the host’s response to infection were recognized, namely, sepsis, severe sepsis and septic shock, with sepsis having the best prognosis and septic shock the worst. While the use of the SIRS criteria to define sepsis is some- what controversial [3–6], many consider sepsis to be best defined as the “systemic response to infection with the presence of some degree of organ dysfunction”

The progress of my project to develop a nurse driven sepsis screening tool and an algorithm for implementation on the intensive care unit (ICU) for early identification and prompt treatment of septic patients has progressed remarkably well. I have been productive in gathering current guidelines for sepsis with the aid of my preceptor who is a critical care nurse practitioner on the ICU. With his help, I have been able to assemble key pieces of research to create a sepsis screening tool, and a treatment algorithm with sepsis resuscitation bundles. Extensive research has been conducted to integrate evidence-based practice in my project. I have also spent time with the unit educator, critical care intensivists, and my colleagues in brainstorming and collecting ideas about my project.

The number of documented cases has been rising every year. “This may be due to the aging population, the increased longevity of people with chronic disease, the spread of antibiotic-resistant organisms, an upsurge in invasive procedures and broader use of immunosuppressive and chemotherapeutic agents” (National Institute of General Medical Sciences, 2014). The mortality rate for sepsis ranges from about thirty percent for patients with sepsis to fifty percent in patients who develop septic shock. Mortality rate varies as to how many organs have been affected. Twenty percent mortality for one organ failure, forty percent for two organs failing, sixty-five to seventy percent for three failed organs, and seventy-five to eighty-five percent when four or more organs have failed. The cost related to sepsis is about seventeen billion dollars per year (about twenty-two thousand dollars per patient), which is six times greater than the cost of patients without sepsis.

According to the National Institute of General Medical Sciences severe sepsis strikes about 750,000 people in the United States each year and kills an estimated 28 to 50 percent of those individuals. The most vulnerable populations for sepsis are the elderly and newborns. After completing the whole eleven segments, I learned that anyone with an infection may be at risk for developing sepsis. The whole scenario helped me how to screen for sepsis and how important is to recognize and respond appropriately to early signs of sepsis in hospitalized patients. Once sepsis is diagnosed, early and aggressive treatment can begin which greatly reduces mortality rates associated with sepsis. After completing the whole scenario I learned how to approach

There is a disease continuum with increasing severity if not treated or not responsive to treatment o Sepsis

et al., 2008). Sepsis is a frequent cause of admission to intensive care units (ICUs) and it

Sepsis, a potentially life-threatening complication of an infection, occurs when chemicals are released into the bloodstream to fight infection. These chemicals trigger inflammatory responses throughout the body (Mayo Clinic Staff, 2016). Sepsis can be triggered by any type of infection: bacterial, viral, or fungal. Contrary to popular belief, sepsis is responsible for a great number of deaths in the United States alone. Sepsis kills more than 258,000 Americans per year, is the number one cause of death in hospitals, and kills more Americans than prostate cancer, breast cancer, and acquired immunodeficiency syndrome (AIDS) combined. (Rory Staunton Foundation for Sepsis Prevention, n.d.) As cited in nursing journal, “Sepsis: Diagnostic and Therapeutic Challenges,” ‘One of the

With sepsis becoming a growing concern with each passing day, we must develop new ways to combat it aggressively. With EMS becoming a more advanced, educated, and integral member of the health care team; there must be an inclusion of them into the early and advanced treatment of sepsis. According to a research team in the Netherlands 3.3 out of every 100 patients encountered by EMS in the United States have severe sepsis diagnoses, compared to only 2.3 per 100 for myocardial infarction and 2.2 per 100 for stroke (Van der Wekken et al., 2016). This is massive considering it is not considered a time critical diagnosis like myocardial infarction and stroke already are. The Revised Sepsis Syndrome Classification and Prehospital Sepsis Alert Score are the potential solution to these issues and look to increase rapid recognition, advanced treatment, and decrease mortality from this destructive and aggressive pathological process.

Once the sepsis criteria are met, the diagnosis of sepsis is added to the patient’s inpatient diagnosis, identifying the source of the infection and treatment it of it begins. Physicians, Nurses Practitioners, and Physicians assistants can order diagnostic studies such as x-rays, CT scans, MRI’s and ultrasounds, antibiotics (intravenously), and fluid therapies can all be ordered to help in treating the sepsis.

In the early 1990s at a conference convened by the American College of Chest Physicians and the Society of Critical Care Medicine modern definitions of “sepsis” were termed in detail. At that time, “sepsis” was described as a systemic response to a physiologic insult including infections and other etiologies that lead to the development of further organ injury, ultimately culminating in multiple organ dysfunction syndromes.

During the second set of final clinical practice, I provided nursing care to the client with query sepsis and clostridium difficile as admitting diagnosis. The client had a history (Hx) of acute kidney infection (AKI) which led to dialysis. After resolving AKI, the patient went home, but soon returned to the hospital with severe diarrhea (5-6 episodes per day), confusion and symptoms of sepsis. Upon initial assessment, I found the patient oriented to name only, confused and lethargic, incontinent of urine and stool. The patient had bilateral crackles throughout the lung fields, gurgles upon exertion and tachypnea with respiratory rate 24-28. SpO2 level was within normal limits. The patient’s family reported that the current patient’s cognitive condition function was different from the baseline. The patient was difficult to arouse, with Glasgow Coma Scale (GCS) score 12-13. The heart rate was within normal limits, strong, irregular. Bilateral edema 2+ was present in lower legs, skin was warm to touch, pedal pulses palpable. The patient was on caloric count due to poor caloric intake. The family was frustrated because of recurrent hospitalization due to hospital-acquired infection and very concerned about possibility of poor outcome for the patient due to rapidly deteriorating general condition.

Timely administration of appropriate antibiotics is essential for decreasing hospital mortality in patients with sepsis12. Kumar et al. demonstrated that with each hour delay, there is a 7.6% decrease in survival. Moreover, delaying appropriate antibiotics can increase healthcare costs, length of stay and antimicrobial resistance13, 14. Traditional methods of microbial identification have time concerns. Most laboratories take 48-72 hours to determine microorganisms’ susceptibility testing10, 15. Kerremans et al. did a prospective randomized controlled trial over two years period included 1489 patients to determine the utility of rapid diagnostic testing against traditional methods15. The intervention group had 20 hours mean reduction for

Sepsis increased incidence has become a major problem in the healthcare. The reason for this is because the ways by which the infections are acquired are becoming more diverse and the mortality rate and the morbidity incidence is alarming. In the United States for instance, 750,000 infections get handled every year and they have led to not less than 200,000 fatalities every year. An analysis of the condition did show that there was a population based incidence of three per 1000 in severe