Many survivors of sepsis develop physical and psychological symptoms collectively known as post-sepsis syndrome. This article comes with a handout for a journal club discussion
Sepsis is a life-threatening condition arising from a dysregulated response to an infection. Many survivors experience a range of physical and psychological symptoms collectively known as post-sepsis syndrome. The effects of post-sepsis syndrome vary but can be devastating and life altering. Health professionals, particularly nurses, need to ensure that sepsis survivors are given appropriate information and that appropriate referrals are made upon discharge, so they can access help should they develop post-sepsis syndrome.
Citation: Sangan V (2019) Post-sepsis syndrome: overview of a relatively new diagnosis. Nursing Times [online]; 115: 8, 19-21.
Author: Verity Sangan is compliance and special projects manager, LV Care Group, St Helier, Jersey.
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Sepsis is a life-threatening organ dysfunction caused by the human body’s dysregulated response to an infection (Singer et al, 2016). Essentially, the body does not only attack the infection as per the normal immune response, but also begins to attack its own organs and tissues.
Sepsis, which has been deemed a global health priority by the World Health Organization (WHO, 2017), can further develop into septic shock. This is a subset condition in which circulatory and metabolic responses increase mortality rates; it is characterised by persistent hypotension and a raised lactate level (Singer et al, 2016). Box 1 gives definitions of both sepsis and septic shock.
Post-sepsis syndrome is the name given to a collection of symptoms that people may develop after sepsis, which vary in severity and have both personal and economic consequences. This article looks at the burden of post-sepsis syndrome in adults and children, explores its physical and psychological effects, and discusses nurses’ responsibilities towards patients and families.
Box 1. Definitions of sepsis and septic shock
Sepsis is defined by the concomitant presence of:
- Suspected infection
- Minimum of two points acquired through Sequential Organ Failure Assessment (SOFA) scoring
Septic shock is defined by the concomitant presence of:
- Mean arterial pressure of >65, requiring vasopressors to maintain
- Serum lactate level of >2mmol despite fluid resuscitation
Source: Singer et al (2016)
Post-sepsis syndrome is widespread; at least one in six sepsis survivors have severe and persistent impairments, which include at least one new functional limitation on their activities of daily living (Prescott and Angus, 2018). One study of sepsis survivors found that physical and cognitive decline in their health was still evident at least eight years after discharge from hospital (Iwashyna et al, 2010).
In general, the physical effects of post-sepsis syndrome are more prevalent than the psychological effects (Hofhuis et al, 2008). The areas in which sepsis survivors differ most from the general population are physical health, mental health and vitality (Hofhuis et al, 2008).
Studies have shown that up to 40% of people who are discharged from hospital after having sepsis will die within two years and at least 60% will be readmitted within one year (Prescott and Angus, 2018; Thompson et al, 2018; Shankar-Hari and Rubenfeld, 2016). Moreover, two years after discharge, survivors of sepsis had higher healthcare costs than other patients who had experienced critical illness (Thompson et al, 2018). Inpatient costs of treating sepsis account for only around 30% of the total cost of sepsis, as out-of-hospital healthcare and lost productivity cost far more than is generally acknowledged (Tiru et al, 2015).
The physical effects of post-sepsis syndrome can be devastating and patients may not be able to return to work as quickly as they had anticipated; this can have huge consequences for personal and family life, as well as posing a financial cost to society.
The effects vary between individuals – sometimes quite dramatically. Some will experience hidden physical effects, such as increased fatigue or lethargy. Others will develop more-obvious physical effects, such as reduced muscle strength, which could lead to muscle wasting and functional disability (Chao et al, 2014).
Hidden physical effects such as acute renal failure may be harder to spot and, therefore, more difficult to monitor. Acute renal failure and an acceleration of the progression of pre-existing conditions are common physical effects of post-sepsis syndrome; discharged patients need to be aware of this so they can monitor symptoms and know to seek help as necessary (Prescott and Angus, 2018; Elfeky et al, 2017).
Survivors of sepsis are also at risk from developing complications such as diabetes and cardiovascular diseases (Shankar-Hari and Rubenfeld, 2016).
It is impractical to equip survivors with detailed knowledge of every physical symptom they may or may not develop after surviving sepsis; however, patients, relatives and carers should be made aware of who to contact if the survivor starts experiencing symptoms about which they are concerned. Box 2 lists common symptoms of post-sepsis syndrome.
Box 2. Common symptoms of post-sepsis syndrome
- Lethargy/excessive tiredness
- Poor mobility/muscle weakness
- Breathlessness/chest pains
- Swollen limbs (excessive fluid in the tissues)
- Joint and muscle pains
- Anxiety/fear of sepsis recurring
- Insomnia (due to stress or anxiety)
- Post-traumatic stress disorder
Source: UK Sepsis Trust (2019)
The psychological effects of post-sepsis syndrome often go unseen, but they have the potential to be incredibly debilitating. Survivors of sepsis have been found to be at increased risk of:
- Developing anxiety and depression;
- Experiencing fatigue and problems with sleep (Huang et al, 2018).
In one study, anxiety was present in as many as 32% of sepsis survivors, while depression was present in 29%; those who developed mental health complications often found these to be a persistent problem in everyday life one year after discharge. Furthermore, the study found that 44% of sepsis survivors are likely to develop post-traumatic stress disorder (Prescott and Angus, 2018).
Female hospital inpatients have been found to be more likely to die as a result of sepsis than their male counterparts (Elfeky et al, 2017); this suggests there may be a greater proportion of male survivors of sepsis than female. It is generally acknowledged that men are less likely than women to seek support for mental health problems, so it may be even more relevant to ensure that men who survive sepsis are given information on the mental health issues they may develop in the months and years after discharge.
Post-sepsis syndrome in children
Sepsis is one of the top 10 killers of children and adolescents globally. Children under one year of age and those with conditions such as cancer are more susceptible to developing sepsis than their peers (WHO, 2018). Those who survive can also develop post-sepsis syndrome.
In infants, symptoms of post-sepsis syndrome may not be spotted until they reach school age and find themselves academically behind their peers, or until it appears that they are not developing normally (Als et al, 2013). Als et al (2013) also found that children with post-sepsis syndrome were more likely to have shorter attention spans, poorer memory and, consequently, lower IQs.
A small study that followed children for up to four years after sepsis found that:
- Their cognitive function was lower than average;
- They were slightly more likely to attend special education schools instead of entering mainstream education (Bronner et al, 2009).
Implications for practice
Research has found significant gaps in knowledge about sepsis among paramedics, nurses and doctors; however, that gap is reducing (Matthaeus-Kraemer et al, 2016; Yealy et al, 2015). Research has also demonstrated that large portions of the general public have an awareness of sepsis, but do not know about its potential after-effects (Huang et al, 2018).
A 10-year Taiwanese study found improved survival rates among those people who received rehabilitation therapies after a stay in the intensive care unit (ICU) for sepsis compared with those who did not receive such therapies (Chao et al, 2014). This clearly demonstrates that patients have not necessarily ‘recovered’ just because they are considered medically fit for discharge.
It is not obvious which patients will go on to develop post-sepsis syndrome; therefore, upon discharge, nurses should consider referring sepsis survivors to rehabilitation therapies such as physiotherapy and occupational therapy, for relevant follow-up. The outcomes for patients leaving critical care is, after all, determined as much by follow-up care as by that delivered in the critical care setting (Bion, 2012).
Sepsis is the most common non-cardiac reason for ICU admission (Holland and Moss, 2017) so ICU nurses in particular have a responsibility to ensure that relevant and accessible information, and advice are provided to patients and their families upon discharge. Patients need to be given:
- Realistic expectations about whether, and how quickly, they can expect to return to their previous level of functioning;
- Information about support services and relevant therapies.
As some patients will be discharged from non-ICU settings, appropriate discharge advice must be available in all areas (Johns et al, 2010).
When the patient is a child, nurses need to be attentive to the support needs of parents, as they – particularly mothers – can experience emotional strain as a result of their child having sepsis and/or being hospitalised in intensive care (Buysse et al, 2008).
After discharge, a multidisciplinary approach is needed to support patients who may be experiencing symptoms of post-sepsis syndrome. The role of nurses in community and primary care could include ensuring patients have access to the services that are relevant to their needs. This may include the involvement of their GP, allied health professionals or mental health services.
There is limited research on post-sepsis syndrome, its prevalence, signs and symptoms, treatment and care. Further research is required to gain more statistical information on the prevalence of the syndrome in different patient demographics, draw a more definitive list of symptoms experienced by sepsis survivors, and determine how best to educate health professionals on post-sepsis syndrome information delivery and management. Furthermore, there is scope for further research to investigate the risk factors that may indicate which patients are more likely to develop post-sepsis syndrome and to what severity.
In the meantime, it remains the responsibility of all health professionals, particularly nurses and those working in primary care, to increase their knowledge of post-sepsis syndrome so they can better support sepsis survivors and their families. Nurse educators and providers of sepsis education and training should seek to include information about post-sepsis syndrome in their training programmes to raise the profile of the condition. Support for survivors and information leaflets are available through organisations such as the UK Sepsis Trust, which healthcare organisations could use while further work is carried out on this relatively new diagnosis.
- Sepsis is a life-threatening condition arising from a dysregulated response to an infection
- Post-sepsis syndrome is a collection of symptoms that many survivors of sepsis develop
- Symptoms include fatigue, reduced muscle strength, anxiety and depression
- At the point of discharge, patients need to receive clear information on the problems they may face
- More research is needed on this relatively new diagnosis
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