Sepsis is a common diagnosis, a

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1 CNE Objectives and Evaluation Form appear on page 209. Early Recognition and Treatment of in the Medical-Surgical Setting Janice Tazbir is a common diagnosis, a frequent cause of hospitalization, and a leading cause of death in the United States (Kochanek, Xu, Murphy, Miniño, & Kung, 2011). Becoming familiar with sepsis is essential for nurses in all settings. The scope of sepsis, including incidence, prevalence, and associated costs, will be reviewed. terminology and the increasing severity of sepsis on a continuum will be explained through clinical examples. Causes of sepsis, as well as a brief review of pathophysiology and early treatment recommendations, will be discussed. Background Approximately 24% of patients who develop severe sepsis or septic shock will do so on a medical-surgical unit (Sebat et al., 2005). was the principal reason for hospitalization in 836,000 hospital stays and the secondary diagnosis in an additional 829,500 hospital stays in 2009 (Elixhauser, Friedman, & Stranges, 2011). Levit, Stranges, Ryan, and Elixhauser (2008) tracked sepsis data from 1997 to 2006, noting that sepsis as a principal diagnosis increased 48%. The rate of hospitalization for sepsis as a primary or secondary diagnosis rose 70% from 2000 to 2008 (Hall, Williams, DeFrances, & Golosinskiy, 2011). Between 1997 and 2008, hospital stays for septicemia increased by 91% (Healthcare Cost and Utili - zation Project [HCUP], 2010). is present, or develops, in approximately 1 of every 23 hospital admissions (Elixhauser et al., 2011). The prevalence of sepsis outlines the enormity of this problem. Early recognition and treatment of sepsis reduces mortality (Dellinger et al., 2008). Nurses are a critical part of the health care team that provides evidence-based care to prevent, identify, and promptly treat sepsis in the hospital setting. Terminology Related to Definitions relevant to the discussion are included in Table 1 (Bone et al., 1992). They were developed as part of a consensus conference of critical care practitioners, and are still endorsed by the American College of Chest Physicians after 20 years. Understanding the definitions related to sepsis is paramount because if a nurse is unable to clinically correlate a defined condition with a patient s symptoms, signs of sepsis may go unnoticed. Figure 1 illustrates the sepsis continuum. Patients may begin with sepsis and quickly decompensate into septic shock. Systemic Inflammatory Response Syndrome (SIRS) Clinical inflammatory response from a non-specific insult, including two or more of the following: Temperature > 38 C or < 36 C Heart rate > 90 beats/minute Respiratory rate > 20/minute or PaO 2 < 32 mm Hg White blood cell count >12,000/mm 3 or < 4,000/mm 3, or > 10% immature neutrophils SIRS response with presumed/confirmed infection Severe associated with organ dysfunction: Perfusion abnormalities (altered mental status, lactic acidosis, oliguria, etc.) or Hypoperfusion (systolic blood pressure < 90 mm Hg or systolic blood pressure drop of 40 mm Hg) Septic Shock with perfusion abnormalities and Hypotension despite adequate fluid resuscitation Source: Bone et al., TABLE 1. Definitions Janice Tazbir, MS, RN, CS, CCRN, is Professor of Nursing, Purdue University Calumet, Hammond, IN. Note: The author and all MEDSURG Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article. July-August 2012 Vol. 21/No

2 SIRS Diagnosis of systemic inflammatory response syndrome (SIRS) is based on the presence of at least two of eight criteria (Bone et al., 1992). SIRS is an inflammatory response that is common in bacterial infections, but non-infectious causes may include burns, trauma, and hemorrhage. If a patient with any of these diagnoses is not improving, the nurse should remain vigilant for signs and symptoms of sepsis. occurs when a patient with SIRS has a presumed or confirmed infection (Bone et al., 1992). Infection can be presumed, for example, if a patient has a ruptured appendix, or if a surgical report indicates cultures are pending. The patient with sepsis that does not improve will develop severe sepsis. Severe sepsis is associated with organ dysfunction (Bone et al, 1992). It is present in 6%-15% of patients in the intensive care setting, and consumes almost half the resources (Dombroskiy, Martin, Sunderram, & Paz, 2007). Organ dysfunction manifests as perfusion abnormalities and may include new onset of mental status changes, lactic acidosis, and oliguria. Hypoperfusion can be noted clinically as a systolic blood pressure lower than 90 mm Hg or a systolic blood pressure drop of 40 mm Hg or more. Lastly, the patient with septic shock is recognized clinically as having severe sepsis and, despite receiving adequate fluid resuscitation, continues to have a blood pressure less FIGURE 1. Continuum Severe Septic Shock than 90 mm Hg. Once a patient is in septic shock, he or she has a 39%- 60% risk of mortality despite treatment (Sebat et al., 2005). Causes Body systems most frequently affected by sepsis are respiratory (28.4%), cardiovascular (28.4%), and renal (23.1%) (Dombroskiy et al., 2007). Scott (2009) reported 4.5 hospital-acquired infections for every 100 admissions. The U.S. De - partment of Health and Human Services (2009) indicated threefourths of all hospital-acquired infections can be associated with four types of infections: surgical site infections, central line-associated bloodstream infections, ventilatorassociated pneumonia, and catheterassociated urinary tract infections. Not every patient with a hospitalacquired infection develops sepsis, but the potential exists for this progression. Preventing infections thus can prevent sepsis. Additionally, the average patient is older with more co-morbid diseases, more invasive procedures are performed, and sicker patients are kept alive longer (HCUP, 2010). Approximately two-thirds of patients hospitalized for sepsis in 2008 were age 65 or older. In patients age 85 and older, the sepsis hospitalization was about 30 times that of younger patients. A patient hospitalized for sepsis is eight times more likely to die and half as likely to be discharged home when compared to patients with other diagnoses (Hall et al., 2011). In 2009, sepsis was the 11th leading cause of death in the United States (behind liver disease) with a reported 35,587 deaths (Kochanek et al., 2011). However, occurrence may be under represented. For example, if a patient who has cancer also gets sepsis, the cause of death may be reported as cancer instead of sepsis. Cost of is not only prevalent, but costly. As hospitals are not reimbursed for many preventable illnesses, including certain infections, nurses have a vested interest in infection prevention. Approximately 1,737,125 hospital-acquired infections occur per year in the United States, with an average cost per patient of $25,903 (Scott, 2009). costs were $15.4 billion in 2009 (Elixhauser et al., 2011). Pathophysiology of Severe and Septic Shock Septic shock is a form of distributive shock. There is abnormal distribution due to vasodilation, capillary leakage, maldistribution of blood flow, and the release of myocardial depressant factor (Bridges & Dukes, 2005). The vasodilation results from nitric oxide release and endothelium changes on blood vessel walls. As a result of vasodilation and capillary leakage, the patient exhibits a lower blood pressure that decreases perfusion to vital organs, such as the kidney and brain. Perfusion abnormalities, such as a decrease in urine output or deterioration of mental status, become apparent clinically. On the cellular level, hypoperfusion leads to a change to anaerobic metabolism. This alteration causes changes in the glycolic path and citric acid cycle metabolic pathways, causing high lactate levels and acidosis. As cells continue without oxygen, the sodium potassium pump is impaired, the lysosomal membrane ruptures, and cell death can occur (Porth & Matfin, 2009). 206 July-August 2012 Vol. 21/No. 4

3 Early Recognition and Treatment of in the Medical-Surgical Setting TABLE 2. Three-Part Problem Inflammation Coagulation Fibrinolysis In addition to these changes, coagulation defects occur (see Table 2). The capillary leakage described previously also activates the complement system, which causes additional inflammation and endothelial dysfunction (Bridges & Dukes, 2005). Endothelial damage promotes adhesion on vessel walls, allowing neutrophils to adhere to them. This damage activates tissue factor, the principal activator in coagulation. This causes thrombin to convert from soluble fibrinogen to fibrin. Fibrin clumps with platelets and forms clots that are circulated through the bloodstream. When the body makes clots, fibrinolysis typically helps destroys them. In sepsis, however, endothelial injury and inflammation inhibits fibrinolysis and clots remain in the bloodstream (Porth & Matfin, 2009). The increase in inflammation increases coagulation and inhibits fibrinolysis. The patient has low blood pressure and impaired flow to organs. As microthrombi further impair blood flow to organs, cells die from the lack of oxygen. The bacterium is not the ultimate cause of death in septic shock; instead, death results from organ hypoperfusion as a result of vasodilation, capillary leakage, and thrombus formation (Porth & Matfin, 2009). Early Treatment of Severe Early goal-directed therapy (EGDT) in the treatment of severe sepsis and septic shock has been understood as an effective way to reduce mortality since Rivers and co-authors (2001) found patients with severe sepsis or septic shock who received EGDT had 16.5% less mortality than patients who did not receive EGDT. Multiple studies have reproduced these findings (Levy et al., 2010; Micek et al., 2006; Nguyen et al., 2007; Shapiro et al., 2006; Shorr, Micek, Jackson, & Kollef, 2007). In 2008, Dellinger and co-authors initiated the Surviving Campaign as an international effort to provide best practice guidelines. In 2002, before the campaign was introduced formally, they identified the aim to reduce mortality associated with sepsis by 25% by 2009; this goal was not met. The second phase focused on creating treatment guidelines, including plans for initial resuscitation in the first 6 hours after occurrence. An overview of these guidelines follows. Overview of Guidelines Initial resuscitation should begin immediately in patients with hypo - tension or an elevated serum lactate (>4 mmol/l). Treatment should not be delayed pending intensive care admission. Time is crucial, so when the patient experiences severe sepsis or septic shock on the medical-surgical unit, aggressive treatment needs to begin immediately. Calling for a Rapid Response Team or for an intensive care bed would be appropriate, depending on the setting and structure. Basic goals for resuscitation include a central venous pressure (CVP) of 8-12 mm Hg, mean arterial pressure (MAP) of 65 mm Hg, urine output greater than ml/kg/hr, and mixed venous gas greater than 65%. Fluid resuscitation should begin with crystalloids or colloids to raise MAP and CVP. Initial diagnostics include obtaining two or more blood cultures (one percutaneously, one from each vascular device in place > 48 hours) and cultures from other sites as indicated. Antibiotics should be given intravenously as early as possible and always within the first hour of recognition. The source of the infection should be identified within the first 6 hours; if infection is from intravascular access, the device should be removed. The patient should be recognized as having severe sepsis or septic shock, fluids started, cultures completed, and antibiotics ordered and administered within 1 hour (Dellinger et al., 2008). These treatment guidelines require prompt sepsis identification and a team ap - proach to treatment. Recently, phase four of the Surviving Campaign prompted the review of over 30,000 patients with sepsis. Their treatment according to the guidelines was shown to be successful in reducing the mortality for sepsis. Leaders of the Sur - viving Campaign currently are reviewing guidelines and ways to further disseminate knowledge (Levy et al., 2010). Conclusion is deadly and costly, and can occur anywhere in the hospital. Prevention clearly is the best strategy. When severe sepsis and septic shock occur, early goal-directed therapy can decrease mortality; the most recent guidelines should be implemented whenever severe sepsis and septic shock are recognized (Dellinger et al., 2008). Nurses are a critical part of the health care team that provides evidence-based care to prevent, identify, and promptly treat sepsis in the hospital setting. REFERENCES Bone, R.C., Balk, R.A., Cerra. F.B., Dellinger, R.P., Fein, A.M., Knaus, W.A., Sibbald, W.J. (1992). Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The American College of Chest Physi - cians/society of Critical Care Medicine Conference Committee. Chest, 101(6), Bridges, E.J., & Dukes, S. (2005). Cardiovascular aspects of septic shock: Pathophysiology, monitoring, and treatment. Critical Care Nurse, 25(2), 14-16, 18-20, 22-24, Dellinger, R.P., Levy, M.M., Carlet, J.M., Bion, J., Parker, M.M., Jaeschke, R., Vincent, J.L. (2008). Surviving Campaign: International guidelines for management of severe sepsis and septic shock: Critical Care Medicine, 36(1), Dombrovskiy, V.Y., Martin, A.A., Sunderram, J., & Paz, H.L. (2007). Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: A trend analysis from 1993 to Critical Care Medicine, 35(5), Elixhauser, A., Friedman, B., & Stranges, E. (2011). Septicemia in U.S. hospitals, Retrieved from us.ahrq.gov/reports/statbriefs/sb122.pdf July-August 2012 Vol. 21/No

4 Hall, M.J., Williams, S.N., DeFrances, C.J., & Golosinskiy, A. (2011). Inpatient care for septicemia or sepsis: A challenge for patients and hospitals. Retrieved from briefs/db62.htm Healthcare Cost and Utilization Project (HCUP). (2010). HCUP facts and figures: Statistics on hospital-based care in the United States, Retrieved from figures/2008/toc_2008.jsp Levit, K., Stranges, E., Ryan, K., & Elixhauser, A. (2008). HCUP facts and figures, 2006: Statistics on hospital-based care in the United States. Retrieved from figures/har_2006.pdf Levy, M.M., Dellinger, R.P., Townsend, S.R., Linde-Zwirble, W.T., Marshall, J.C., Bion, J., Angus, D.C. (2010). The Surviving Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Critical Care Medicine, 38(2) Kochanek, K.D., Xu, J., Murphy, S.L., Miniño, A.M., & Kung, H.C. (2011). Deaths: Preliminary data for Retrieved from nvsr59/nvsr59_04.pdf Micek, S.T., Roubinian, N., Heuring, T., Bode, M., Williams, J., Harrison, C., Kollef, M.H. (2006). Before-after study of a standardized hospital order set for the management of septic shock. Critical Care Medicine, 34(11), Nguyen, H.B., Corbett, S.W., Steele, R., Banta, J., Clark, R.T., Hayes, S.R., Wittlkae, W.A. (2007). Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Critical Care Medicine, 35(4), Porth, C.M., & Matfin, G. (2009). Pathophysiology: Concepts of altered health states (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Tomlanovich, M. (2001). Early goaldirected therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine, 345(19), Scott, R.D. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved from hai/scott_costpaper.pdf Sebat, F., Johnson, D., Musthafa, A.A., Watnik, M., Moore, S., Henry, K., & Saari, M. (2005). A multidisciplinary community hospital program for the early and rapid resuscitation of shock in nontrauma patients. Chest, 127(5), Shapiro, N.I., Howell, M.D., Talmor, D., Lahey, D., Ngo, L., Buras, J., Lisbon, A. (2006). Implementation and outcomes of the multiple urgent sepsis therapies (MUST) protocol. Critical Care Medicine, 34(4), Shorr, A.F., Micek, S.T., Jackson, W.L., & Kollef, M.H. (2007). Economic implications of an evidence-based sepsis protocol: Can we improve outcomes and lower costs? Critical Care Medicine, 35(5), U.S. Department of Health and Human Services (HHS). (2009). HHS action plan to prevent healthcare-associated infections: Executive summary. Retrieved from hai/exsummary.html ADDITIONAL READING Picard, K.M., O Donoghue, S.C., Young- Kershaw, D.A., & Russell, K.J. (2006). Development and implementation of a multidisciplinary sepsis protocol. Critical Care Nurse, 26(3), July-August 2012 Vol. 21/No. 4

5 MSN J1214 Answer/Evaluation Form: Early Recognition and Treatment of in the Medical-Surgical Setting Deadline for Submission: August 31, 2014 OBJECTIVES COMPLETE THE FOLLOWING This test may be copied for use by others. Name: Address: City: State: Zip: (Home) Preferred telephone: (Work) AMSN Member Expiration Date: Check Enclosed Visa Mastercard Credit Card # Exp. Date This continuing nursing educational (CNE) activity is designed for nurses and other health care professionals who care for and educate patients and their families regarding early recognition and treatment of sepsis. For those wishing to obtain CNE credit, an evaluation follows. After studying the information presented in this article, the nurse will be able to: 1. Define the incidence, causes, and costs of sepsis. 2. Discuss the pathophysiology of severe sepsis and septic shock. 3. Describe guidelines for early treatment of severe sepsis. CNE Instructions Persons wishing to obtain CNE credit must read the article and complete the answer/evaluation form. Upon completion, a certificate for 1.3 contact hours will be awarded. Evaluations can be submitted two ways: 1. AMSN s Online Library: Complete your evaluation online and print your CNE certificate immediately. Simply go to and select MEDSURG Nursing Journal from My Library. Fee: AMSN Member: Free Regular: $ Persons without access to the Internet may photocopy and send the answer/evaluation form along with a check or credit card order payable to AMSN to MEDSURG Nursing, CNE Series, East Holly Avenue Box 56, Pitman, NJ Test returns must be post-marked by August 31, A CNE certificate will be provided by mail. Fee: AMSN Member: $10.00 Regular: $15.00 This independent study activity is co-provided by AMSN and Anthony J. Jannetti, Inc. (AJJ). Accreditation status does not imply endorsement by the provider or ANCC of any commercial product. AJJ is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation (ANCC-COA). Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, Provider Number, CEP Licensees in the state of CA must retain this certificate for four years after the CNE activity is completed. This article was reviewed and formatted for contact hour credit by Dottie Roberts, MSN, MACI, RN, CMSRN, OCNS-C, CNE, MEDSURG Nursing Editor; and Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director. ANSWER FORM 1. If you applied what you have learned from this activity into your practice, what would be different? Strongly Strongly Evaluation disagree agree 2. By completing this activity, I was able to meet the following objectives: a. Define the incidence, causes, and costs of sepsis b. Discuss the pathophysiology of severe sepsis and septic shock c. Describe guidelines for early treatment of severe sepsis The content was current and relevant The objectives could be achieved using the content provided This was an effective method to learn this content I am more confident in my abilities since completing this material The material was (check one) new review for me 8. Time required to complete the reading assignment: minutes I verify that I have completed this activity: Comments July-August 2012 Vol. 21/No

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