Managing patients with sepsis in the general ward environment
Julie Nassau, MA, BSc, RN.
Nurse Consultant, Critical Care Outreach, Barnet Hospital, Barnet, Hertfordshire
The care and management of the septic patient is dependent on a skilled workforce who appreciate that prompt and expert care will influence the eventual outcome. The incidence of sepsis is rising (ICNARC, 2001) and it is be coming more commonplace for these patients to begin their initial treatment in ward areas, and to remain there with aggressive management from the medical and nursing teams.
Substantial numbers of organisms can potentially cause sepsis (Box 1). Sepsis has in the past primarily been caused by Gram-negative bacteria, for example Escherichia coli. However, the incidence of sepsis from Gram-positive bacteria, for example methicillin-resistant Staphylococcus aureus and fungi is increasing (Cohen and Abraham, 1999). This is thought to be due to an increasing number of patients who are elderly, the increased use of invasive surgery, an increase in immuno-compromised patients and the increasing number of antibiotic-resistant bacteria (Friedman et al, 1998).
The American College of Chest Physicians (ACCP) and the US Society of Critical Care Medicine (SCCM) defined sepsis as: ‘The presence of systemic inflammatory response syndrome (SIRS) with the addition of a confirmed or presumed (that is the presence of commonly recognised signs of infection without an identifiable pathogen being isolated) microbiological infection’ (Bone et al, 1992).
For the patient with sepsis the priority is to control life-threatening abnormalities of organ function. Management includes treatment of the causative infection, restoration of tissue perfusion and support of failing organs (Clarke, 1997). Immediate treatment is with oxygen, and fluid resuscitation. Treatment needs to begin promptly in the accident and emergency department or ward. Careful fluid monitoring and vital sign measurements are imperative. This will include temperature, pulse, blood pressure, respiratory rate, oxygen saturation, consciousness level and urine output. Careful utilisation of a fluid balance chart should be used. The frequency of observations depends on the severity of the patient’s condition. However, these patients are very sick and observations should therefore be reviewed at least hourly. To facilitate fluid management a central venous catheter may be inserted. Post-insertion a portable chest X-ray should be ordered. X-ray departments are unsafe environments for an acutely sick patient as there is less monitoring equipment and staff available to monitor the patient’s condition. To aid accurate urine measurement an indwelling urinary catheter will be needed (Pepperell, 2002). These measurements must not only be recorded but should also be reviewed frequently within defined parameters. If these parameters are not met then an urgent medical review is required.
The aim of treatment is to maintain and support the homeostasis of the patient:
Sepsis is a devastating illness that needs early recognition and prompt treatment from the multidisciplinary team. It is possible to manage the early stages at ward level. These patients do, however, require a significant input from the nursing team at a time when nursing resources are scarce. This needs to be recognised by managers of wards when allocating budgets.
Alexander, J.W. (1993) Prevention of bacterial translocation with early enteral feeding: a feasible approach? In: Faist, E., Meakins, J.L., Schildberg, F.W. (eds). Host Defence and Dysfunctions in Trauma, Shock and Sepsis. Berlin: Springer-Verlag.
Angus, D.C., Linde-Zwirble, W.T., Lidcker, J. et al. (2001) Epidemiology of severe sepsis in the United States. Critical Care Medicine 29: S109-S116.
Bongard, F.S., Sue, D.Y. (2002) Current Critical Care Diagnosis and Treatment (2nd edn). New York, NY: MacGraw-Hill.
Bone, R.C., Balk, R.A., Cerra, F.B. (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM consensus conference committee. American College of Chest Physicians/Society of Critical Medicine. Chest 101: 6, 1644-1655.
Clarke, G.M. (1997) Severe sepsis. In: Oh, T.E. (ed.). (1997) Intensive Care (4th edn). Oxford: Butterworth Heinemann.
Cohen, J., Abraham, E. (1999) Microbiologic findings and correlations with serum tumour necrosis factor-a in patients with severe sepsis and septic shock. Journal of Infectious Diseases 180: 116-121.
Department of Health. (2001) Comprehensive Critical Care: A review of adult intensive care services. London: Stationery Office.
Friedman, G., Silva, E., Vincent, J-L. (1998) Has the mortality of septic shock changed with time? Critical Care Medicine 26: 12, 2078-2086.
Intensive Care National Audit and Research Centre. (2001)Case Mix Programme Database. London: ICNARC.
Morgan, R.J.M., Williams, F., Wright, M.M. (1997) An early warning scoring system for detecting developing critical illness. Clinical Intensive Care 8: 2, 100.
Paterson, R.L., Webster, N.R. (2000) Sepsis and the systemic inflammatory response syndrome. Journal of the Royal College of Surgeons 45: 178-182.
Pepperell, E. (2002) Producing catheterisation guidelines for patients who have oliguria. Professional Nurse 18: 1, 27-29.
Vincent, J.L., Abraham, E., Annane, D. et al. (2002) Reducing mortality in sepsis: New Directions in Critical Care 6: (suppl), S1-S18.
Wheeler, A.P., Bernard, G.R. (1999) Current concepts: treating patients with severe sepsis. New England Journal of Medicine 340: 207-214.
Wiles, J.B., Cerra, F.B., Segal, J.H. Border, J.R. (1980) The systemic response: does the organism matter? Critical Care Medicine 8: 55-60.