Sepsis Nursing Management in Emergency

Care
By: Diah Retno Wulan, S.Kep., Ns., M.Kep

Emergency & Critical Care Department

Faculty of Nursing & Health Science
University of Muhammadiyah Banjarmasin
Mortality remains 20% to 50% for those patients who progress
to severe sepsis or septic shock.
Sepsis has no boundaries and can affect any age, gender, or
race.
Severe sepsis and septic shock are responsible for one in
four deaths internationally and the incidence is increasing.

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Deaths resulting from sepsis exceed those from
myocardia infarction, breast cancer, and stroke.

Evidence-based studies indicate that early recognition,

diagnosis, and treatment of sepsis in the emergency
department (ED) will improve patient outcomes and
decrease mortality.

While not all patients with sepsis enter the hospital

through the ED, timely initiation of care can have a
positive impact on outcomes.

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DEFINITION ???

Sepsis is a progressive syndrome that leads to

dysfunction.

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The following list contains definitions of common terms used in the
diagnosis and classification of sepsis:

1. Infection: Microbial phenomenon characterized by an inflammatory

response to the presence of micro- organisms or the invasion of
normally sterile host tissue by those organisms.

1. Bacteremia: Presence of viable bacteria in the blood.

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 Systemic
3.Systemic inflammatory response syndrome (SIRS):
inflammatory response to a variety of severe
clinical
. insults, manifested by two or more of the following
conditions:

 Temperature greater than 38° C (100.4° F) or less than

36° C (96.8° F)
 Heart rate greater than 90 beats per minute

 Respiratory rate greater than 20 breaths per minute or

PaCO greater than 32 mm Hg
2
 White blood cell count greater than 12,000/mm3, less
than 4000/mm3, or more than 10% immature (band)
forms
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4. Sepsis: Presence of infection or suspicion of infection,
with two or more of the SIRS criteria.
.
5. Severe sepsis: Sepsis associated with organ dysfunction,
hypo-perfusion, or hypotension. Hypo-perfusion and
perfusion abnormalities may include, but are not limited
to, lactic acidosis, oliguria, or an acute alteration in mental
status.
6. Septic shock: Sepsis-induced shock with hypotension
despite adequate crystalloid resuscitation, along with the
presence of perfusion abnormalities that may include, but
are not limited to, lactic acidosis, oliguria, or an acute
alteration in mental status. Patients receiving inotropic or
vasopressor agents may not be hypotensive at the time
that perfusion abnormalities are measured.
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 .
Sepsis-induced hypotension: A systolic blood pressure less than 90 mm Hg,
7.
mean arterial pressure (MAP) less than 65 mm Hg, or a reduction of 40 mm
Hg from baseline in the absence of other causes for hypotension.

8. Multiple organ dysfunction syndrome: Altered organ function in an acutely ill

patient such that homeostasis cannot be maintained without intervention

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EARLY GOAL-DIRECTED THERAPY:
INITIAL RESUSCITATION AND THE FIRST SIX
HOURS

According to the Surviving Sepsis Campaign

guidelines, resuscitation goals should be
achieved during the first 6 hours. For this to
occur, early recognition and imple- mentation
of treatment toward specific targets or goals
are crucial. Volume resuscitation and
antibiotic administration should be priorities
of care after airway and breathing.
Depending on the status of the patient,
therapies may be instituted simultaneously.

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EVALUATION FOR SEVERE SEPSIS SCREENING TOOL
PIRO SCORE
MED SCORING AND PREDICTED MORTALITY
END POINT OF RESUSITATION

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Therapeutic Interventions

Begin resuscitation immediately in patients with hypo- tension or

elevated serum lactate greater than 4 mmoL/L. This may mean
establishing central venous access and hemodynamic monitoring
in the ED pending ICU admission.
Specific therapy guidelines include:
 Oxygen
• Septic patient should receive supplemental oxygen with the
goal of maintaining pulse oximetry readings of greater than
93%.
• Anticipate advanced airway management and possible rapid
sequence intubation.

- Intubation and mechanical ventilation may reduce the

work of breathing, which reduces oxygen demand.

 Measurement of venous oxygenation saturations may be

accomplished via central line or pulmonary artery catheters.
• SvO measures oxyhemoglobin in the pulmonary artery
2
whereas ScvO is obtained from the right atrium
E M E via
R G E Ntriple
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2
lumen catheter.
 Large-bore intravenous catheter for fluid resuscitation
• 250 to 1000mL boluses of crystalloid solution (normal saline)
every 15 minutes for hypotension.18
• Maintain MAP of 65 mm Hg.
• If MAP is less than 65 mm Hg, administer vasopressors
(dobutamine, norepinephrine, or dopamine).

 Insertion of a central venous pressure (CVP) line

• CVP pressures can guide resuscitation, with the goal being to
maintain CVP of 8 mm Hg.
• During insertion, ensure “time-out” documentation, proper infection
prevention precautions, and draping of the patient and personal
protective equipment for all staff involved in the procedure
according to hospital policy.

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 Source identification and control
• Establish the source or site of infection as rapidly
as possible (within first 6 hours of presentation)
and evaluate the amenability for source control
(e.g., abscess drainage, tissue debridement,
indwelling line or catheter removal).

 Transfusion with red blood cells may be considered

if the hemoglobin is less than 7 g/dL, the ScvO is
2
less than 70%, or the hematocrit is less than 30%.
Because the shock state results in inadequate
tissue perfusion, interventions should focus on
restoring oxygen-carrying capability.

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 Antibiotic administration within 1 hour of arrival
• Timely administration of antibiotics is crucial
and affects outcomes.
• A 1-hour delay may reduce survival by almost
8%.

 Consider administration of vasopressors to

maintain MAP greater than 65 mm Hg.
• The Surviving Sepsis Campaign Guidelines for
Management of Severe Sepsis and Septic
Shock9 recommend norepinephrine and
dopamine as the initial vasopressors of choice
to increase vascular tone and blood pressure.
• Optimize fluid replacement before starting
vasopressors.

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 Inotropic therapy, such as dobutamine, may
be initiated to increase cardiac output in
patients with myocardial dysfunction.30–32
Available data do not support the use of low-
dose dopamine for renal protection.

 Consider hydrocortisone when hypotension

is refractory to fluid resuscitation and
vasopressors.

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ONGOING EVALUATION

During the initial acute phase of sepsis and septic shock, the patient’s
condition is dynamic and interventions must be assessed rapidly to direct
further care initiatives. Closely monitor the patient’s global condition data
accumulated to provide a full picture of the patient’s condition. Closely
follow institutional protocols for vital sign assessment and document
patient response monitoring. It is important to look at trends, especially in

vital signs.

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PEDIATRIC CONSIDERATIONS

While sepsis mortality in the pediatric

population is declining, sepsis remains a
major cause of death in children. Early
recognition of pediatric sepsis is crucial
and should be based on clinical
presentation and history. It is essential for
the emergency nurse to know normal vital
signs for neonates, infants, and children.
The following may be present before
hypotension, which is an ominous sign:
 Hypothermia or hyperthermia
 Altered mental status
 Peripheral vasoconstriction with
capillary refill greater than 2 seconds
(“cold shock”) or peripheral
vasodilation (“warm shock”)

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SIRS criteria do apply to pediatrics, with several
Exceptions:

 Either temperature or leukocyte abnormalities must be present.

 Bradycardia may be a sign of SIRS in the neonate but not necessarily

in older children.

 Relying solely on blood pressure may be misleading, as children often

maintain a blood pressure while they are in a shock state.

Fluid resuscitation is a priority for the pediatric sepsis patient. The pediatric
patient in severe sepsis may require up to 40 to 60 mL/kg of crystalloids.
Inotropes may be added after fluid therapy to maintain heart rates and
blood pressures that are normal for age as well as capillary refill times of
less than 3 seconds. It is recommended that central circulation access be
obtained before giving inotropes to children. In cases where multiple organ
failure is present, be cautious to avoid fluid overload.

Blood pressure is not a reliable end point to resuscitation. Measure

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responses in terms of capillary refill, normalization ofUNIVERSITAS
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evaluation of central and peripheral pulses.

PATIENT AND FAMILY SUPPORT

Patient and family education and

support is critical during the initial
phase of treatment. Health care
professionals are often busy
providing care to reach therapeutic
goals in a specific window of time,
leaving families excluded. Frequent
brief updates from members of the
multidisciplinary team can be helpful
in keeping families informed, leading
to decreased anxiety.

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 Early goal-directed therapy is based on early
recognition and identification of infection, hypo-perfusion,
and organ dysfunction that can trigger the initiation of

specific pathways of care.

Thank you…
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