An evidence-based approach to a patient with sepsis

Introduction

This essay will focus on the evidence-based approach to a patient with sepsis. Sepsis is defined as a systemic inflammatory response to infection (Polat et al., 2017). The importance of an evidence-based approach in nursing practice cannot be overstated. Indeed, evidence-based practice has been demonstrated to improve clinical outcomes, increase patient safety and even reduce healthcare costs (Considine and McGillivray, 2010, Peterson et al., 2008, Fineout-Overholt et al., 2005). An evidence-based approach requires knowledge of the robustness of the various types of studies sourced from the literature, as well as an adoption of a critically analytical mindset (Burns et al., 2011). To that end, relevant and up-to-date references shall be cited throughout this essay which contends with Mr. K, a 55-year-old gentleman. Mr. K's name and patient identifiers have been redacted and anonymized. This is in keeping with the guidelines put forth by the Nursing and Midwifery Council (NMC); the NMC stipulates that patient privacy and confidentiality should be upheld by nurses (NMC, 2015).

Mr. K has a medical history of chronic hypertension, hyperlipidaemia, type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD). He is a chronic smoker and occasionally consumes alcohol socially. He has no relevant surgical history. Mr. K has been admitted twice in the past year for acute exacerbations of COPD. Although he has been prescribed with a short-acting beta agonist (SABA) , long-acting beta agonist (LABA), anti-cholinergic and inhaled corticosteroid, he is non-compliant with his prescribed pharmacotherapy and has defaulted on his pulmonology outpatient follow-up visits multiple times.

History & Physical Examination

History taking is a crucial component of clinical decision making (Kassirer et al., 2010). A targeted history in the emergency department reveals that Mr. K has experienced chest pain for the past three days that is associated with a purulent cough. The chest pain was sharp in nature and well-localized to the left lower thoracic region. There was no associated radiation. However, there was some nausea without vomiting. Although he has had a chronic cough for years, he verbalized (with difficulty) that the nature of his sputum had changed to become more viscous and purulent. He also described his cough as being more severe and frequent than usual, and had difficulty breathing as well. There was no associated haemoptysis. Mr. K reported that he had felt feverish and had experienced chills and rigors during the preceding night.

In the emergency department, Mr. K's vital signs were as follows:

• Temperature - 39.1 degrees Celsius
• Heart Rate: 140 beats per minute
• Blood Pressure: 90/50 mmHg
• Respiratory Rate: 28 breaths per minute
• Oxygen Saturation: 86% on room air
• Glasgow Coma Scale: 15

On inspection, Mr. K appeared to be toxic. He was in moderate respiratory distress as evidenced by his recruitment of accessory muscles of inspiration (e.g. sternocleidomastoid muscles) and the adoption of a seated tripod position. He could not complete full sentences during the history taking delineated above. He did not appear to be peripherally or centrally cyanosed. On auscultation, Mr. K's heart sounds were normal without any murmur or pericardial rub. There was reduced air-entry over the left middle-lower lung field which was associated with crepitations. The abdominal system and the systemic review of other organ systems was unremarkable. Based on the history and physical examination, Mr. K appeared to have an acute exacerbation of COPD secondary to pneumonia, which was further complicated by sepsis and impending septic shock.

Pneumonia, Sepsis & Septic Shock

Based on his vital signs alone, Mr. K had an extremely high NEWS (National Early Warning Score) score of 14. This warranted an emergency assessment by a rapid response team with critical care competencies. Indeed, the NEWS score is a well-validated tool which replaced a plethora of early warning systems throughout the United Kingdom (Jones, 2012). The NEWS score is associated with clinical outcomes and mortality and can predict a patient's likelihood of being admitted into the intensive care unit (Abbott et al., 2015). Patients with a NEWS score exceeding 6 should be monitored on an hourly basis minimally (NEWS, 2017). To that end, Mr. K was transferred from the P2 (priority 2) area of the emergency department to the P1 (priority 1) area and worked up extensively. Although the main differential diagnosis was that of pneumonia, an acute coronary syndrome (ACS) still had to be excluded in view of Mr. K's chest pain. This is especially so as COPD is associated with an increased risk of cardiovascular disease; Mr. K also had other independent risk factors such as diabetes and hypertension (Rothnie and Quint, 2016). A 12-lead electrocardiogram was performed and revealed no signs of ACS (e.g. T-wave inversions, reciprocal changes, ST-elevations/depressions).

While this investigation was performed, several nursing interventions were undertaken in accordance with the ABCDE approach. This approach is a widely adopted framework in emergency medicine and rapidly assesses the patient's airway, breathing, circulation, disability and exposure (Smith and Bowden, 2017). First, Mr. K's airway was deemed to be patient as he was capable of verbalizing. Second, supplemental oxygen was administered to him in order to reduce his effort of breathing by means of improving his oxygen saturation. It was prudent to ensure that his oxygen saturation remained between 88% and 92% (NICE, 2016), in order to avoid blunting his hypoxic drive (Brill and Wedzicha, 2014). As his respiratory distress was observed to improve shortly after this, a decision was made not to intervene with invasive ventilation (i.e. rapid sequence intubation). Third, in view of Mr. K's borderline blood-pressure, two large-bore intravenous cannulae were set over his antecubital fossae. 500 ml of normal saline was rapidly infused in order to address Mr. K's circulatory decompensation.

Sepsis and septic shock have a mortality of 30% and 50% respectively (Song et al., 2016). Shock is defined as an acute physiological perturbance which results in systemic signs and symptoms secondary to hypoperfused organ systems (Bonanno, 2011). Septic shock is further defined as a systemic inflammatory response to infection (Polat et al., 2017). In view of this, the Surviving Sepsis Guidelines (SSG) were enacted. The SSG mandate that a specific bundle be implemented by healthcare workers within one hour. This bundle consists of the early recognition of sepsis, obtaining blood cultures, administering intravenous broad-spectrum antibiotics, obtaining serum lactate and administering vasopressors if indicated (Milano et al., 2018). To that end, the establishment of circulatory access via intravenous cannulae was paramount. The same access was used to administer intravenous antibiotics. Prior to that, blood cultures and serum lactate (together with other haematological tests that assessed end-organ perfusion and ischaemia) were obtained.

Septic Workup

Once Mr. K was stabilized, a full septic workup was commenced. A plain chest radiograph revealed lobar pneumonia in the left lung. A point-of-care urinalysis did not reveal any nitrites or leukocytes to suggest a urinary tract infection. At the same time, an arterial blood gas was obtained in order to assess Mr. K's acid-base status. Patients with acute exacerbations of COPD typically present with respiratory acidosis secondary to hypercapnia (Bruno and Valenti, 2012). A further one litre of normal saline was administered to Mr. K intravenously as an infusion in order to maintain his mean arterial pressure above 60mmHg. Mr. K's capillary glucose was also checked to ensure that he was not hyperglycaemic nor hypoglycaemic. Severe hyperglycaemia at admission is associated with an increased 30-day mortality in both diabetics and non-diabetics (van Vught et al., 2016). Mr. K's anti-hypertensive medications were temporarily suspended in view of his septic shock, and his oral hypoglycaemic agents (e.g. metformin) were titrated according to his glycaemic state. An oral steroid (prednisolone) was prescribed as there is strong evidence for its utility in severe exacerbations of COPD (Wedzicha et al., 2017).

Management

Mr. K was subsequently transferred to the high-dependency ward for frequent monitoring. His family was updated of his diagnosis and apprised of his progress throughout his high-dependency and subsequent general ward stay. Mr. K was managed by a multi-disciplinary team including a medical social worker, a pulmonologist, a dietician and a pharmacist. His intravenous antibiotics were eventually oralised to Augmentin (co-amoxiclav) as his blood cultures grew Streptococcus pneumoniae. In taking a patient-centred approach, Mr. K's financial situation was taken into consideration. Hence, a referral was made to a medical social worker in order to provide Mr. K and his family with the appropriate financial counselling.

Conclusion

Mr. K presented with an acute exacerbation of COPD which was secondary to lobar pneumonia and further complicated by sepsis and septic shock. He required an escalation to P1 within the emergency department in view of a severe NEWS score. He also required the institution of the SSG. Several evidence-based nursing interventions were undertaken. These include the obtaining intravenous access, delivering supplemental oxygen, obtaining blood cultures and other associated haematological tests as well as administering fluid resuscitation amongst others. Nurses should endeavour to practice evidence-based medicine throughout their daily clinical practice in order to achieve optimal patient outcomes. This case study has demonstrated the utility of an evidence-based practice in clinical decision making, as well as in rationalizing decisions undertaken by the medical team.

References

Abbott, T. E., Vaid, N., Ip, D., Cron, N., Wells, M., Torrance, H. D. and Emmanuel, J. (2015) 'A single-centre observational cohort study of admission National Early Warning Score (NEWS)', Resuscitation, 92, pp. 89-93.

Bonanno, F. G. (2011) 'Clinical pathology of the shock syndromes', J Emerg Trauma Shock, 4(2), pp. 233-43.

Brill, S. E. and Wedzicha, J. A. (2014) 'Oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease', International journal of chronic obstructive pulmonary disease, 9, pp. 1241-1252.

Bruno, C. M. and Valenti, M. (2012) 'Acid-base disorders in patients with chronic obstructive pulmonary disease: a pathophysiological review', J Biomed Biotechnol, 2012, pp. 915150.

Burns, P. B., Rohrich, R. J. and Chung, K. C. (2011) 'The levels of evidence and their role in evidence-based medicine', Plastic and reconstructive surgery, 128(1), pp. 305-310.

Considine, J. and McGillivray, B. (2010) 'An evidence-based practice approach to improving nursing care of acute stroke in an Australian Emergency Department', J Clin Nurs, 19(1-2), pp. 138-44.

Fineout-Overholt, E., Melnyk, B. M. and Schultz, A. (2005) 'Transforming health care from the inside out: advancing evidence-based practice in the 21st century', J Prof Nurs, 21(6), pp. 335-44.

Jones, M. (2012) 'NEWSDIG: The National Early Warning Score Development and Implementation Group', Clinical medicine (London, England), 12(6), pp. 501-503.

Kassirer, J. P., Wong, J. B. and Kopelman, R. I. (2010) 'Learning clinical reasoning'.

Milano, P. K., Desai, S. A., Eiting, E. A., Hofmann, E. F., Lam, C. N. and Menchine, M. (2018) 'Sepsis Bundle Adherence Is Associated with Improved Survival in Severe Sepsis or Septic Shock', West J Emerg Med, 19(5), pp. 774-781.

National Early Warning Score (NEWS) ' Standardising the assessment of acute-illness severity in the NHS', Available Online: https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2, Accessed On: 9 Nov 2019

National Institute for Health and Care Excellence (NICE) 'Chronic obstructive pulmonary disease in adults', Available Online: https://www.nice.org.uk/guidance/qs10/chapter/Quality-statement-6-Emergency-oxygen-during-an-exacerbation, [Accessed On: 9 Nov 2019]

Nursing and Midwifery Council (2015) 'The Code, Professional standards of practice and behaviour for nurses, midwives and nursing associates', Available Online: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf, Accessed On: 9 Nov 2019

Peterson, E. D., Bynum, D. Z. and Roe, M. T. (2008) 'Association of evidence-based care processes and outcomes among patients with acute coronary syndromes: performance matters', J Cardiovasc Nurs, 23(1), pp. 50-5.

Polat, G., Ugan, R. A., Cadirci, E. and Halici, Z. (2017) 'Sepsis and Septic Shock: Current Treatment Strategies and New Approaches', The Eurasian journal of medicine, 49(1), pp. 53-58.

Rothnie, K. J. and Quint, J. K. (2016) 'Chronic obstructive pulmonary disease and acute myocardial infarction: effects on presentation, management, and outcomes', European heart journal. Quality of care & clinical outcomes, 2(2), pp. 81-90.

Smith, D. and Bowden, T. (2017) 'Using the ABCDE approach to assess the deteriorating patient', Nurs Stand, 32(14), pp. 51-63.

Song, J. E., Kim, M. H., Jeong, W. Y., Jung, I. Y., Oh, D. H., Kim, Y. C., Kim, E. J., Jeong, S. J., Ku, N. S., Kim, J. M. and Choi, J. Y. (2016) 'Mortality Risk Factors for Patients with Septic Shock after Implementation of the Surviving Sepsis Campaign Bundles', Infection & chemotherapy, 48(3), pp. 199-208.

van Vught, L. A., Wiewel, M. A., Klein Klouwenberg, P. M., Hoogendijk, A. J., Scicluna, B. P., Ong, D. S., Cremer, O. L., Horn, J., Bonten, M. M., Schultz, M. J. and van der Poll, T. (2016) 'Admission Hyperglycemia in Critically Ill Sepsis Patients: Association With Outcome and Host Response', Crit Care Med, 44(7), pp. 1338-46.

Wedzicha, J. A. E. C.-C., Miravitlles, M., Hurst, J. R., Calverley, P. M., Albert, R. K., Anzueto, A., Criner, G. J., Papi, A., Rabe, K. F., Rigau, D., Sliwinski, P., Tonia, T., Vestbo, J., Wilson, K. C. and Krishnan, J. A. A. C.-C. (2017) 'Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline', Eur Respir J, 49(3).