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Sepsis affects 18 million people worldwide each year (Slade et al 2003). Sepsis remains life threatening and mortality rate remains high approximately 40-50 % (Opport et al2005). We, nurses in all areas of practice, will care for septic patients during our professional carreer.Many nurses receive little training in how to identify sepsis or how important early and aggressive treatment to help prevent the condition. I am very interested to discuss about sepsis, because I have looked after many patients with sepsis. The aim of this essay is to raise awareness of sepsis, so that nurses will have a greater understanding of this condition and feel more confident in the identification and treatment.
The definition of sepsis is the presence of Systemic Inflammatory Response Syndrome (SIRS) criteria in the patients with a new infection. Once sepsis becomes complicated by a dysfunction in one or more organs, this defines severe sepsis. Bacteria cause 90% cases of sepsis. They are two types, gram negative and gram positive. Escherichia coli, Klebsiella, Enterobactor, Pseudomonas aeruginosa, Serratia, Proteus and Bacteroides fragilis are the gram-negative bacteria. Staphylococcus aureus, Streptococcus pneumonia, Alpha and beta-hemolytic streptococci are the gram-positive bacteria (Edwards 2001). Gram-negative bacterial infection causes most cases of sepsis. Viruses or fungi can also cause sepsis, particularly Candida spp (Cohen et al 2004).
The surviving sepsis campaign (formed in2002) is an international collaboration to improve the diagnosis, management and treatment of sepsis. The main aims of the campaign are:
- To increase the awareness of sepsis, severe sepsis and septic shock among health care staff and the public.
- Develop evidence-based guidelines for the management of severe sepsis.
- Ensure that the guidelines put into practice to create a global standard of care for patients with sepsis.
- Reduce the mortality from sepsis worldwide by 25 percent in the five years following the publication of evidence-based guidelines in 2004 (Dellinger et al 2004).
It is essential that nurses are aware of the evidence-based guidelines as our role is crucial to the success of the campaign. Nurses are in an ideal position to identify the first signs of a patient developing sepsis, and the sooner treatment begins the less likely the condition is to spread and result in organ dysfunction or failure (Ahrens and Tuggle 2004).
Infection is a major reason for patients admitted to hospitals and some patients may develop infections while in hospital (DH2003). Infection can found in any system of the body. The most common sources of infection that can lead to sepsis are:
- Respiratory tract: community-acquired pneumonia or health care-associated pneumonia.
- Intra-abdominal-cavity: infection might result from diverticulitis, appendicitis, perforated bowel, and ischemic or necrotic bowel.
- Central nervous system-such as meningitis.
- Genitourinary system: urosepsis is an infection, which might result from an obstruction in the urinary system, or catheter related infection.
- Skin: wound infections, cellulitis or necrotizing infections of the skin and soft tissues with rapid destruction of tissue, such as necrotizing fasciitis.
- Intravascular Catheters: any invasive catheters (central venous catheter or peripheral canulae.
Many organ systems may affect during the sepsis syndrome.
- Respiratory system: As the effects of of sepsis progress, acute respiratory distress syndrome (ARDS) may occur. During sepsis, there is a decrease in the performance of the ventillatory muscles, which leads to hypercapneic ventillatory failure and respiratory arrest These happens when metabolic demands on the ventillatory muscles. Tachypnoea,hypoxia and respiratory alkalosis are associated with the early onset of ARDS, followed after 48 hours by pulmonary infiltrates and respiratory failure (Mortelliti & Manning). Sepsis leads to an increase in lung permeability, the sequestration of polymorphonuclear neutrophils and respiratory failure. These affect the function of respiratory system (Nagase, Uzumi & Ishii).
- Cardio vascular system: The dysfunction of cardio vascular system is also observed in patients with sepsis, where both the heart and blood vessels show hypersensitivity. An increased amount of pro-inflammatory cytokines and vasoactive substances is present during sepsis. Following the increase in pro-inflammatory cytokines, production of nitric oxide is increase in both the vascular endothelium and smooth muscle. This leads to a fall in systemic vascular resistance, thereby hypotension (Patterson & Webster).
- Renal Dysfunction: Normally, the kidney regulates perfusion and glomerular filtration via autoregulation, which is dependent on the afferent and efferent arterioles. Autoregulation of the kidney, is affected during sepsis.
- Coagulation system: Sepsis often associated with a disorder of coagulation secondary to the cytokine-mediated activation of the coagulation pathway. This secondary disorder, known as disseminated intravascular coagulation (DIC). It causes bleeding and micro vascular thrombi, both implicated in multiple organ failure and soft-tissue damage (Meijers & Bouma).
Diagnosis can base on the presence of fever and other abnormalities of vital signs, as well as the presence of one or more organ dysfunctions that are not the original site of infection or trauma (Ahamed). Sepsis syndrome is characterized by; alteration in body temperature regulation, tachycardia, lowered systemic vascular resistance, respiratory alkalosis, leococytosis, leucopenia and some form of organ dysfunction(Chistman, Holden and Blackhell).It does not discriminate between different ages, underlying disease, genetic background, infecting micro-organisms or sites of infection. Sepsis can occur in people who were previously healthy. The infecting organism may be a temporary defect in the host’s defense. Defects may be located in specific or non-specific cellular barriers, humoral immunity barriers and physical barriers such as the skin or mucous membranes and reflexes such as cough and peristalsis (Maskin, Fountain and Spinedi et al).
In understanding the changes that happen to the body in severe sepsis, it is helpful to remind ourselves of the changes that occur during the normal immune response. Cells damaged by infection from bacteria, viruses, chemical agents or trauma produce the same non-specific defensive response of inflammation. Regardless of the cause, inflammation has three basic phases; vasodialatation and increased permeability of blood vessels; emigration of phagocytes; and tissue repair (Tortora and Grabowski, 2000). Vasodilatation brings more blood to the damaged area, and the increased permeability allows phagocytes and antibodies to pass out from the circulation. The clotting cascade is also activated. Clot formation is part of the normal immune response, and may be the body’s attempt to confine any invading organism to one area of body (Ahrens and Vollman, 2003). This inflammatory response and activation of the clotting system is to repair damaged tissues and prevent further damage.
Clinical assessment is important in patients with sepsis. Any patients who triggers early warning score, should be assessed initially using the ABCDE approach. This systemic approach ensures that the life threatening problems are assessed and managed in order of importance. The Resuscitation Council 2006 also recommends that clinical staff should follow ABCDE approach when assessing and treating critically ill patients. It is sensible to adopt this systemic approach to the assessment of sepsis patient (ABC of sepsis).
Airway: An assessment should be made of the patency of airway. If patient is alert and talking, there is less chance of an airway problem.
Breathing: The body’s demand for oxygen rises in sepsis. As demand outstrips supply, lactic acidosis occurs. These processes combine to elevate the respiratory rate. The depth and pattern of respiratory rate should evaluate in addition to any asymmetry of chest movement. Listen for abnormal sounds include expiratory wheeze, suggesting obstruction of the lower airway and crepitating suggest the secretion, pulmonary oedema or consolidation. If a respiratory problem is identified, attention should be given to oxygen therapy and to the possible need for bronchodilators and physiotherapy. The response to therapy should be assessing repeatedly. Pulse oximetry is mandatory, and ABG and chest X-ray is helpful.
Circulation: Attention should pay to the colour of the skin, particularly peripherally. Pallor is suggestive of hypo perfusion and may suggest a low cardiac output. Heart sound should auscultate to seek murmur. Feel for the peripheral skin temperature. In decompensated sepsis, where the cardiac output begins to fall, the peripheries may appear cool. Capillary refill time is useful test of perfusion. The heart rate and rhythm should asses by palpitation of peripheral pulses.
Disability: Sepsis can produce confusion, agitation and reduced conscious level due to reduced cerebral perfusion. Fluid resuscitation can restore cerebral function. It is important to check blood sugar because; hypoglycemia can also produce these signs and is readily correctable. The conscious level can quickly asses and communicate using the AVPU scale.( A-Alert,V-responds to voice,P-responds to pain,U-unresponsive).
Exposure: The patient should be examined from head to toe seeking the source of sepsis. Consideration should be given to the patient’s dignity during this assessment, and it should be recognized that exposure can cause rapid temperature loss. Therefore, it is essential to check peripheral temperature.
When treating patients with sepsis, the first hour known as the ‘golden’ hour because the treatment given or not given during that time can have significant impact on the survival (ACS 1997).To be able to treat patients in the `golden hour` we must first be able to recognize it confidently. Studies have shown that patients admitted to intensive care unit from the wards are often not referred early enough. Sometimes receive suboptimal care, which can increase patient’s mortality (McQuillan et al1998).Vincent et al 2002 suggest that some patients with sepsis are recognized late and are not treated appropriately before transfer to ICU.
In March 2004, the Surviving Sepsis Campaign produced comprehensive guidelines on the management of patients with severe sepsis. Initial treatment within one hour of diagnosis is,
Give supplemental oxygen therapy, via facemask, to achieve SpO2>94%.
Obtain blood specimen lactate, full blood count, urea and electrolytes, glucose, liver function tests, coagulation screen and blood culture two sets. Samples from sputum, urine, wound swab etc as appropriate.
Blood cultures should be taken before antibiotics are given to identify any microorganisms that may be in the blood and it should from a peripheral vein and from any invasive catheters that the patient may have in situ.Blood cultures are not always positive in patient with sepsis.
Cohen et al (2004) suggest that care should take when obtaining blood cultures to prevent them becoming contaminated and giving a false positive result.
Administer intravenous broad-spectrum antibiotics. In severe sepsis antibiotics should be given within one hour of diagnosis (Dellinger et al, 2004). Giving prompt antibiotic therapy may reduce mortality by 10-15 percent, compared with patients in whom antibiotic therapy is delayed (Wheeler & Bernard, 1999).
Any septic patient who has a lactate level above 4mmol/L should be considered to have severe sepsis even if the blood pressure is within the normal range.
If patient is hypotensive, fluid resuscitate up to 3boluses of 500ml normal saline to maintain MAP>65/systolic 100mmhg (Trust’s sepsis care pathway).
Consider catheterization to maintain fluid balance.
If the patient have signs of severe sepsis, needs referral to ICU. Signs of severe sepsis are; Systolic blood pressure below 90mmHg or MAP below 65mmHg, lactate above 2mmol/L, urine output below 0.5ml/kg/hr for 2 hours, INR above1.5, bilirubin above 34mol/L, platelets below 100mol/L, creatinine above 177mmol/L.
Some patients develop severe sepsis from infections they acquire while in hospital. One in ten NHS hospital patients are affected by healthcare associated infections(HCAIs) each year(DH2003).The most common of these infections are urinary infections as a result of indwelling urinary catheters and pneumonia.Therefore,nurses must make continued efforts to play an active part in reducing the number of HCAIs as this can potentially lead to fewer patients developing sepsis .
Ahrens and Tuggle (2004) suggest that it may also be beneficial to raise the public’s awareness of the Surviving Sepsis Campaign and the warning signs of developing sepsis. This may help to achieve the main aim of the campaign, which is to reduce mortality.Sepsis, is a common condition and can be fatal. A good knowledge of the signs and symptoms of sepsis is the key to prompt recognition. Every patient suspected having sepsis should have blood taken for a serum lactate level. In patients with severe sepsis, early aggressive treatment and adherence to evidence-based guidelines can help to save lives. In addition, efforts to reduce HCAIs can aid in the reduction of the incidence of sepsis.
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