Sepsis care: getting it right every time
Crucial facts on World Sepsis Day
Sepsis is a time critical condition, which can be life threatening. World Sepsis Day on 13 September, provides us with an opportunity to consider the impact of sepsis throughout the world.
In the UK, there are an estimated 150,000 cases of sepsis per year, resulting in 44,000 deaths. This equates to more deaths from bowel, breast and prostate cancer combined according to the Sepsis Trust, 2016.
This year two key events have shaped sepsis care in the UK and worldwide.
These are revised international consensus definitions for sepsis and septic shock, and the publication of the National Institute for Health and Care Excellence (NICE) guidance on outlining the recognition, diagnosis and early management of sepsis.
Sepsis has always been a challenge for healthcare professionals. The term ‘sepsis’ was first introduced by Hippocrates (460-370BC) and is derived from the Greek word ‘sipsi’ ('make rotten').
Today, we recognise sepsis is a worldwide killer and, since the publication of the seminal research by Rivers et al, providing early goal directed therapy to patients with sepsis in the emergency departments is vital.
Fifteen years on from this publication, there is a greater awareness among healthcare staff and the public of the dangers of sepsis; previously, sepsis was predominately diagnosed and managed in critical care units only.
This shift in knowledge has resulted in frontline staff within all areas being aware of sepsis and understanding that early treatment of the condition is vital.
There is no single solution for fighting sepsis as often the presentation and recognition will be different; it must be won patient by patient. In this short piece we aim to outline key four facts about sepsis which may help with the recognition and management of sepsis in a variety of clinical settings.
In defining the condition, sepsis and infection are terms that are often used interchangeably within practice. In addition, colloquial terms such as ‘blood poisoning’ or ‘septicaemia’ are also common terms used to describe sepsis. It should be noted that recent international and NICE publications no longer use the terms Systemic Inflammatory Response Syndrome (SIRS) and ‘severe sepsis’.
Sepsis is defined as ‘a life threatening organ dysfunction due a dysregulated host response to infection’. NICE defines septic shock is defined as ‘persisting hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of 65 mmHg or more and a serum lactate level of greater than 2 mmol/L despite adequate volume resuscitation’ (NICE, 2016). While these definitions and changes in terminology have been in response to recent evidence, they do not help with the early identification of sepsis at the bedside; subsequently clinical parameters are used to determine the severity of illness and potential organ dysfunction. Both NICE and international consensus definitions have developed a range of simple tools which can be used in a variety of environments (see further information box).
Sepsis is life threatening and causes tissue and organ damage. It can be a silent killer as sepsis may have a non-specific and non-localised presentation. A thorough assessment of the patient through history taking and the use of a structured approach (Airway, Breathing, Circulation, Disability and Exposure), recording full sets of vital signs combined with an early warning scoring tool should be employed.
If you suspect sepsis:
• Try to identify the source of infection.
• Consider whether the patient has any factors which increase the risk of sepsis.
• Assess and record any clinical concerns, for example; changes in mental status, respiratory rate and heart rate.
Early treatment is critical. Once diagnosed the environment in which you are working and local guidelines available for the treatment of this condition will determine how sepsis is to be treated. As a minimum this should include:
• Administration of antibiotics within 1 hour (if possible, blood cultures and any other specimens should be taken) but a delay in the administration of antibiotics should be avoided.
• Commencement of fluid resuscitation. After each bolus (determined by age) the patient should be re-assessed.
• Oxygen should be administered to prevent hypoxia.
• The source of infection should be isolated and treated accordingly.
In recent years a range of guidelines and resources regarding sepsis has been published, but this can be overwhelming for the practising nurse. The Royal College of Nursing and RCNi have both developed a useful repository of sepsis information from various organisations.
German Sepsis Society. (2016). Sepsis History
National Institute for Health and Care Excellence. (2016). Sepsis, recognition, diagnosis and early management. NICE Guideline NG51.
Rivers E et al. (2001). Early goal directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine. 345. 1368-1377
Sepsis Trust. (2016). Sepsis
Singer M et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 315. 8. 801-810.
About the authors
Chris Carter is associate nurse lecturer at Birmingham City University and is chair of the RCN's defence nursing forum
Kevin Crimmons is associate professor and head of adult nursing at Birmingham City University
Sue Viveash is associate nurse lecturer at Birmingham City University