Sepsis is a major cause of morbidity and mortality in hospitals today. It has been defined as ‘the body’s response to an infection when organisms invade the body’ (Baudouin 2008). It’s an infection which is caused by micro organisms or bacteria’s that invade the body. Sepsis can lead to acute organ dysfunction followed by multi-organ failure and death. In the early stages of sepsis the immune response can be characterised as a systemic inflammatory response syndrome (SIRS) (Chamberlain 2008). This is the body’s response to a variety of severe clinical insults. It is characterised by the presence of two or more of the following features: Temperature >38Â°C or <36Â°C, Heart rate > 90/min, Respiratory rate > 20/min or PaCO2 <4.3kPa, White cell count > 12 x 109/l altered mental status, blood glucose>7.7mmol/l in absence of diabetes (LTHTR Sepsis Care Pathway 2009).Sepsis is defined as SIRS in response to infection (I, Mackenzie 2001).
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The surviving Sepsis campaign was launched in October (2002) aiming to increase awareness of sepsis, severe sepsis and septic shock among healthcare staff and the general public, develop evidence based guidelines for the management of severe sepsis and ensure that guidelines are put to practice globally. In the Nice Clinical guideline 50- acutely ill patients in Hospital they made key recommendations to ensure early identification of the acutely ill patient and prevent deterioration of condition thus reduce patient mortality, morbidity and length of stay, to reduce ICU admissions and re admission.
Initial management of a critically ill patient includes:
- Immediate assessment of the airway, breathing and circulation
- Baseline observations HR, RR, BP, O2 sats, capillary refill, EWS and AVPU to assess level of consciousness
- A brief history
- A limited examination of the relevant systems of the body.
- A secondary assessment after stabilisation of the patient including a more thorough history, detailed examination by system and appropriate investigations. The golden hour an early window of opportunity immediate resuscitation with oxygen and fluids prevents secondary injury to organs as a result of hypoxemia and hypovalaemia helping to reduce mortality and morbidity. The timing of clinical intervention is essential to the survival of septic patients (Chamberlain 2008).
Respiratory failure is common and may develop at any stage so repeated assessments are necessary. A depressed conscious level is the most common cause of airway obstruction (I, Mackenzie 2001). A clear airway does not indicate effective breathing. Failure of gas exchange may be caused by lung problems (pneumonia, lung collapse, pulmonary oedema), failure of the mechanics of ventilation. Respiratory failure is suggested by signs of respiratory distress including dyspnoea, increased respiratory rate, use of accessory muscles, cyanosis, confusion, tachycardia, sweating. The diagnosis is made clinically but may be confirmed by pulse oximetry and arterial blood gases. Patients with a depressed conscious level may not react normally to hypoxia and signs of respiratory failure may be difficult to detect. Patients with inadequate ventilation, gas exchange or both require ventilatory support. This usually necessitates intubation and mechanical ventilation although in some patient’s gas exchange and oxygenation can be improved by the application of continuous positive airway pressure (CPAP) by face mask or non-invasive ventilation. As per LTHTR sepsis care pathway (2009) high flow oxygen to be given to maintain a target of >94% using a non rebreath mask. Oxygen to be reduced when patient stable. In critically ill patients, high concentration oxygen should be administered immediately and this should be recorded afterwards in the patient’s health record (BTS guideline for emergency oxygen use in adult patients 2008).
Tachycardia and hypotension are almost universal findings in the septic patient and result from a number of cardiovascular problems. In early sepsis, and in patients who have been partially or fully fluid resuscitated, the low blood pressure and high heart rate are associated with a high cardiac output and a low peripheral vascular resistance with warm peripheries and bounding pulses. In contrast, patients who have not been significantly resuscitated or have presented late in the course of their illness have a low cardiac output and high systemic vascular resistance. These patients are peripherally cold, sweaty, with weak, thready pulses and they need urgent resuscitation. However resuscitation aims to restore circulating volume, cardiac output and reversal of hypotension (I, Mackenzie 2001).
Initially infuse i/v crystalloid or colloid rapidly guided by the clinical response. The optimal resuscitation fluid however, remains the subject of debate. Fluid resuscitation of severe sepsis may consist of natural or artificial colloids or crystalloids. Fluid challenge should be administered and repeated based on response (increase in blood pressure and urine output) and tolerance (V, Jean-louis 2004). Administering large volumes of fluid to patients with known cardiac disease or myocardial dysfunction related to their acute illness is a problem. Ronco, C et al (2004) argued that it is the quantity of fluid given rather than the type of fluid explaining that more crystalloid is needed to achieve the same effect as colloid but colloids are more expensive and carry their own risks. Adequacy of fluid infusion can be facilitated by repeated fluid challenges in which a pre defined amount of fluid e.g. 250 or 500mls is in fused over a set time. Sherman et al (2007) states that aggressive volume resuscitation and administering broad spectrum antibiotics should be given early to all septic patients using 2-4litres of normal saline. All patients should be monitored closely to see the response to resuscitation (urine output mental status, BP). If the patients blood pressure is <90mmhg or lower than >40mmgh lower than the patients normal BP fluid challenges nacl 0.9% 500ml given over 5-10mins (ALERT 2003). LTHTR Sepsis Care Pathway 2009 states if patient hypotensive give up to 3 boluses of 500ml (0.9% Saline) to maintain MAP>65/systolic 100mmgh. Urinary catheter hourly urine measurements.
Perform investigations to confirm or clarify problems that are clinically evident, or to look for complications that are likely. Bloods including FBC, coagulation screen, U&E, Liver function, Amylase, cardiac enzymes, Glucose, lactate and ABG’s. Other tests may include a blood glucose, ECG and chest x-ray. You may consider sending samples for microbiology to confirm the presence of infection, i.e. blood cultures should be taken, sputum if suspecting chest infection and mid-stream urine (MSU) or catheter specimen of urine f suspecting urine infection. Blood cultures are only to be taken when there is clinical need to do so and not as routine (DOH 2007). Indepth search for the source of sepsis with rapid institution of appropriate antibiotic therapy. Delayed or initially ineffective antibiotic therapy has been shown to be associated with worse prognosis and if it is important that all likely microbial culprits are covered by the empiric antibiotic which can be altered when culture results are available (Ronco, C et al 2004).
Monitoring is not dependent on expensive equipment, but it requires the continuous presence of trained nursing staff. Clear documentation aids the assessment of subtle changes in the patient’s clinical state. Patients with severe SIRS / sepsis should have observations recorded hourly. Record body temperature, pulse, blood pressure, urine output, CVP, respiratory rate and SpO2 (if available). Accurate fluid balance is essential. An accurate Early Warning Score is essential as per LTHTR trust protocol along with every set of observations taken. EWS used widely throughout the trust it acts as an assessment of recognising deterioration in patients an identifies at risk patients. It requires the charting of observations such as systolic BP, HR, RR on a regular basis each is given a score from 0-3 and then added together to give an EWS. This is then used to trigger further assessment of the patient by senior nursing or medical staff and referral to critical care outreach who support nurses at ward level to tackle early detection and treatment to prevent intensive care admissions. Early detection and recognition of a patient that is deteriorating is vital (DOH 2007).
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The initial antibiotic prescription is a ‘best guess’, and will depend on the clinical picture of the patient, local patterns of antibiotic resistance and the local availability of antibiotics. It should be broad enough to cover the most likely pathogens, but not so broad as to encourage antibiotic resistance. The advice of a local microbiologist or infectious diseases specialist is valuable. Surviving Sepsis Campaign (2008) states the choice of antibiotics should be guided by the susceptibility of likely pathogens in the community and the hospital, as well as any specific knowledge about the patient, including drug intolerance, underlying disease, the clinical syndrome.Â The regimen should cover all likely pathogens since there is little margin for error in critically ill patients. There is ample evidence that failure to initiate appropriate therapy promptly (i.e., therapy that is active against the causative pathogen) has adverse consequences on outcome. Although restricting the use of antibiotics, and particularly broad-spectrum antibiotics, is important for limiting super infection and for decreasing the development of antibiotic resistantÂ pathogens, patients with severe sepsis or septic shock warrant broad-spectrum therapy until the causative organism and its antibiotic susceptibilities are defined. Shermon et al (2007) states that early use has been clearly demonstrated to reduce the mortality in sepsis an if no known source of infection is present then give broad spectrum antibiotic therapy to cover aerobic and anaerobic infections. LTHTR Sepsis Care Pathway (2009) states antibiotics to be given in first hour and all antibiotics to be reviewed after 48hours.
Medical staff have been implicated in the spread of infectious agents between patients. All staff must wash their hands before and after attending to a patient. Equipment should not be shared between patients if possible, but where this is necessary the equipment should be thoroughly cleaned between patients. Staff should protect themselves and their clothes from becoming contaminated with biological material by wearing disposable aprons and gloves. Visitors should be discouraged from moving between patients. Wounds, including drain sites and intravenous cannulae sites, should be inspected, cleaned and dressed at regular intervals. Intravenous cannulae and central lines should be removed as soon as practical. Ensure correct documentation is filled in i.e. Vascular access device tool, wound charts and care plans as per trust protocol.
In conclusion sepsis remains a major cause of morbidity and mortality in hospitals today. Many authors have looked at best practice in the early recognition and treatment of sepsis. It is vital that nurses and clinicians recognise and treat critically ill patients for the best outcome to reduce the risk of deterioration and potential cardiac arrests. NPSA (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients. Within LTHTR trust and other trusts there are many policies in ensuring this with the early recognition policy, early warning scores to help assist the staff on recognising the deteriorating patient and sepsis care pathway to assist with the treatment of the deteriorating patient. With the use of these policy’s and the help of critical care outreach teams within the trust early recognition and treatment within the golden hour reduces the morbidity and mortality thus educing admissions into the intensive care unit. It appears that there remains much discussion into which fluid works best during fluid resuscitation. Trust protocols should be followed. Recognition of ‘at risk’ patients can only be achieved by appropriate and timely assessment and monitoring. Nice made key recommendations in patients at risk policy, assessment and monitoring, response, critical care and staff competencies the LTHTR policy ‘Procedure for the timely recognition and response for patients at risk of deterioration’ encompasses these key recommendations. There is no predictive scoring system which gives accurate predictions of outcome for individual patients. Survival from an episode of severe sepsis is dependent the patient’s age, previous health and the time delay before the onset of medical intervention, as well as the appropriateness and quality of medical care. Few countries have limitless resources, and so difficult decisions face all intensive care doctors when deciding between the potential benefits for one critically ill patient and need for provision of healthcare to several less critically ill patients (I, Mackenzie 2001).
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