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.
Since the publication of the Department of Health’s Comprehensive Critical Care (DoH, 2001), there has been an increased likelihood that the septic patient will be cared for, at least initially, in a general ward, with the back-up of a critical care outreach team supporting the ward staff. Critical care outreach teams are groups of intensive care-trained nurses and perhaps medical staff and professionals allied to medicine who aim to support ward staff in the care of acutely sick patients, with the goal of preventing unnecessary admissions to the intensive care unit (DoH, 2001).
Sepsis frequently arises in the ward setting. Approximately 100 000-300 000 patients develop bacteraemia each year in the USA (Bongard and Sue, 2002). Data from the USA estimates that severe sepsis accounts for 215 000 deaths per year, a mortality rate of 29% (Angus et al, 2001). The actual total is probably higher as this figure does not account for those deaths in which sepsis might have been a contributing cause, for example myocardial infarction (Vincent et al, 2002).
Sepsis is the consequence of an uncontrolled systemic response to an infection by the host (Wiles et al, 1980), which can lead to acute organ dysfunction, multi-organ failure and eventual death. The process is often rapid and can result in a sudden deterioration in the patient’s condition. It is imperative that nurses are aware of the presenting signs and the immediate treatment protocols required in order to facilitate effective treatment.
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).
Definition of sepsis
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).
In order to end the confusion, the ACCP and the SCCM clarified the diagnosis of sepsis into definite steps in a pathway (Figure 1) (Bone et al, 1992). This was an international consensus and has been adopted world-wide. As is clear from the flow chart the term septicaemia is no longer used.
Sepsis displays itself in a number of non-specific ways, which can make diagnosis difficult. The patient’s signs and symptoms must be considered alongside his or her current and previous medical history (Box 2).
A full medical examination should take place with routine investigations as shown in Box 3. Note should be made of travel, exposure to animals, exposure to biohazards, medication and underlying disease, all of which predispose the patient to potential life-threatening disease. Systemic inflammatory manifestations may occur from the introduction of an infectious organism into the body. The point of entry may be discrete, such as an insect bite, not immediately obvious, such as a dog having licked an open sore, or overt, as in a postoperative patient wound infection.
Frequently the patient with sepsis develops multi-organ dysfunction syndrome. This is a progressive altering of an organ’s function such that homeostasis cannot be maintained without intervention. Mortality is directly related to the type or number of organs affected; the failure of the renal system has the worst prognosis (ICNARC, 2001).
Aim of therapy
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.
With the advent of critical care outreach teams, use may be made of an ‘early warning scoring tool’ (Figure 2) to trigger a response from these teams, who can support ward teams (DoH, 2001).
Central to the care of a septic patient is first-class communication. A management plan should be agreed between the multidisciplinary team to ensure optimum care, with defined parameters and goals of treatment. With prompt, well-handled medical management, Vincent et al (2002) suggests that some septic patients now no longer need the facilities of the intensive care unit. The emergence of critical care outreach teams, collaborative help and support during the initial care of these patients in the ward can prevent admission to intensive care units and if necessary these teams can expedite the safe transfer of the patient to a higher level care unit.
The aim of treatment is to maintain and support the homeostasis of the patient:
- Haemodynamic support. Volume replacement is with crystalloid or gelatine-based plasma expanders. The majority of medical staff prefer crystalloid to colloid for the initial resuscitation (Bongard and Sue, 2002). Inotrope agents, epinephrine, norepinephrine, may be used once full fluid resuscitation is completed (Clarke, 1997). However, these require close monitoring of the patient and are more suited to use in a high-dependency unit
- Prompt treatment with antibiotics can reduce the overall mortality from sepsis by 10-15% (Wheeler and Bernard, 1999)
- Renal support. Dopamine or frusemide may be required. However, frusemide can cause hypotension and can be nephrotoxic (Clarke, 1997)
- Support of coagulopathies. This can be achieved, for example, by correcting clotting abnormalities with fresh frozen plasma, platelets and vitamin K (Vincent et al, 2002).
- Early surgical debridement of wound (Paterson and Webster, 2000)
- Respiratory support. High-flow oxygen, non-invasive ventilation should be used to maintain normal oxygen saturation (>95%)
- Physiotherapy should be used if there are clinical signs of a chest infection (Clarke, 1997)
- Nutritional support. Sepsis induces a hypercatabolic state. Nutritional support may be accomplished through, preferably, nasogastric feeding, or parenteral feeding. Early feeding has been associated with reduced mortality (Alexander, 1993)
- Management of hyperglycaemia. Resistance to insulin is common (Bongard and Sue, 2002).
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.