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COVID-19 and sepsis: what do the similarities mean for nurses and patients?

As with sepsis, for many people, the after-effects of COVID-19 will require long-term support

As with sepsis, for many people, the after-effects of COVID-19 will require long-term support

  • People who have been seriously ill with COVID-19 may have a heightened risk of developing sepsis within the next year
  • The Global Sepsis Alliance said in April that based on the data available it could more definitely state that COVID-19 does indeed cause sepsis
  • Knowledge of sepsis and its sometimes lengthy recovery process can help nurses support patients recovering from COVID-19
Sepsis a life-threatening reaction to an infection Picture: iStock

At the beginning of the COVID-19 pandemic, the expectation was that patients who reached intensive care would need help to breathe, hence the rush to procure enough ventilators.

As with sepsis, for many people, the after-effects of COVID-19 will require long-term support

  • People who have been seriously ill with COVID-19 may have a heightened risk of developing sepsis within the next year
  • The Global Sepsis Alliance said in April that based on the data available it could ‘more definitely state that COVID-19 does indeed cause sepsis’
  • Knowledge of sepsis and its sometimes lengthy recovery process can help nurses support patients recovering from COVID-19
Sepsis – a life-threatening reaction to an infection Picture: iStock

At the beginning of the COVID-19 pandemic, the expectation was that patients who reached intensive care would need help to breathe, hence the rush to procure enough ventilators.

In the event, however, many needed a lot more than that. A significant percentage had heart problems, required haemodialysis to keep their kidneys working, and developed devastating blood clots and multi-organ failure.

Coronavirus infection is not just a primary lung problem

In fact, the response in these patients looked a lot like sepsis; the immune system’s overreaction to an infection or injury where it attacks the body’s own organs and tissues.

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‘COVID-19 is an infection and it affects all of the organs,’ says Nicki Credland, chair of the British Association of Critical Care Nurses (BACCN).

Nicki Credland: ‘COVID-19 affects
multiple organs, much the same as sepsis’

‘Right at the beginning we thought it was going to be a primary lung problem, that only affected patients’ ability to breathe independently, but we’ve now – through research and watching how patients progress through their COVID diagnosis – realised that it affects lots of different organs, not just the lungs, in much the same way that sepsis does.’

The similarities between the two don’t stop when the patient leaves hospital.

There is a growing recognition that some people with COVID-19 will take a long time to recover, and that the after-effects – such as extreme fatigue – are also common to the two conditions, leading to a need for rehabilitation and long-term support.

Sepsis-like reaction in people with COVID-19

According to UK Sepsis Trust executive director Ron Daniels, the links have significance on a number of levels.

It means that people who have been seriously ill with COVID-19 should be aware they may have a heightened risk of developing sepsis within the next year.

More positively, it means the knowledge of sepsis – and recovery from sepsis – that has been built up over the years can be put to good use in helping people who have survived COVID-19.

‘In academic nursing and medical communities people were sceptical about saying there was a link and they were trying to persuade themselves that COVID-19 was in some way unique,’ says Dr Daniels, who is also a consultant in intensive care in Birmingham.

‘But gradually what’s happened, internationally, is that people have come to accept it. Now when we’re saying it to non-academic front-line staff, they’re just so bloody relieved that finally they can accept that, yes, this is a sepsis response to a virus.

‘In the early days of COVID-19, whether you were a nursing student, a medical student or a consultant, you were scared. You didn’t know what you were dealing with and patients were coming in thick and fast, and you were firefighting, trying to manage.

‘But during that interim period when you had a lot of patients in intensive care, they were all progressing in similar ways, but some suddenly started to die quite quickly of multi-organ failure. It became evident that the mode of death there was sepsis – they were behaving identically to patients with sepsis.’

Differences between care in COVID-19 cases and in sepsis cases

The evidence base for a link between sepsis and COVID-19 is building, Dr Daniels says, pointing out that the Global Sepsis Alliance reported in April that based on the scientific data available, it could ‘more definitely state that COVID-19 did indeed cause sepsis’.

The BACCN’s Ms Credland, who is also a senior lecturer and head of the department for paramedical, perioperative and advanced practice at Hull University, says that there are similarities and differences in nursing people with severe COVID-19 and those with sepsis.

‘The way that patients react to COVID and sepsis is that ultimately they end up in a similar position, in that they end up in multi-organ failure requiring significant intensive care support,’ she says.

‘Their hearts don’t work properly, their lungs don’t work properly, the ability for their blood to clot doesn’t work properly, there’s a neurological impact. There’s a huge raft of different things that COVID creates that we didn’t understand properly when we first saw it back in January, February.’

However, there is an important difference from how sepsis would normally be dealt with, she adds.

‘The main nursing difference with COVID is the fact that it is so highly contagious,’ she says.

’If you’ve got a patient with sepsis, who, say, picked up a skin infection: they were doing some gardening and pricked their finger and that finger became infected and that led to sepsis, the nursing responsibility for that from an intensive care point of view would be to manage that multi-organ failure. The difference with COVID is that you’ll still have to do all that, but wearing personal protective equipment.’

Similarities in recovery and the long-term effects

Larry Matthews: ‘ The problems for
survivors are similar’

UK Sepsis Trust lead support nurse Larry Matthews is heading a small team that provides support – including through a telephone helpline – to people affected by sepsis, including survivors and their families, as well as those who have lost loved ones to the condition.

‘We are getting people calling who have had COVID,’ he says.

‘The problems they experience are similar. The crucial things are extreme fatigue – the post-viral fatigue that COVID patients appear to be getting seems to be remarkably similar to the nature of the fatigue that people get post-sepsis. The cognitive functions that people are experiencing are similar, so problems with short-term memory, difficulty concentrating, and sometimes a problem with fluency, remembering words when speaking.

‘The difference, as might be expected, is that the problem for many COVID-19 survivors is severe breathlessness. Although that can happen post-sepsis, there are a lot more callers post-COVID experiencing those kind of problems. There are also people who are experiencing cardiovascular problems, such as tachycardia – quite a few people seem to be getting this, a bit like POTS (postural orthostatic tachycardia syndrome), having sudden surges in heart rate.’

Knowing what is ‘normal’ for COVID-19 recovery

The difficulty for patients – and for health professionals – is knowing what is ‘normal’ as part of recovery, and when to seek help.

‘It can be tremendously difficult. We’re fortunate here in that so many things that people bring up with us are things that we’re accustomed to giving advice on, like fatigue, anxiety, insomnia, and managing pain,’ Mr Matthews says.

‘The other thing is about validation of how people are. A lot of people, especially those who weren’t admitted to hospital, a month or so ago were being labelled as over-anxious, and that perhaps some of these [symptoms] were health anxiety or imagining things. That can even be across family members and employers. That is so common post-sepsis as well.’

There are many educational resources on recovery available online Picture: iStock

What nurses can do to support patient post-COVID-19

How should nurses equip themselves to support patients and their families post-COVID-19 – and, indeed, post-sepsis?

Educate yourself ‘The first thing is to gain some knowledge and understanding of it,’ says UK Sepsis Trust’s Larry Matthews. ‘There are lots of resources on the internet so I’d advise nurses to educate themselves on post-COVID-19 recovery – what does it look like and what are the common problems.

‘The important thing is that patients, and nurses are aware of sepsis and know what the important signs are, and when to ask the question “could it be sepsis?”. Patients recovering should have that information to hand. It needs to be delivered in a balanced way – you obviously don’t want to scare people.’

See the UK Sepsis Trust’s guide for patients and relatives (pictured right).

Educate your patients ‘The difficulty – and we have the same thing with sepsis – is what do you tell people when they’re about to be discharged home. How much do you tell them about how things might be?’ Mr Matthews says.

‘You obviously don’t want to make them overly anxious, but at the same time they need some information. What we tend to do is explain the possibilities: that recovery is variable – some people might have uncomplicated and speedy recoveries, but for a lot of people, they will be tired, they may feel weak, they may be not thinking as clearly as they normally would do, and this may go on for weeks or perhaps months. ’

Signpost help and support Find out if there are post-COVID-19 clinics within your organisation, Mr Matthews says. ‘You can signpost patients to the UK Sepsis Trust helpline, or give them information about the UK Sepsis Trust – we’re happy to talk to anyone recovering with COVID-19, because the skills and knowledge that we have supporting people with sepsis is so transferable.’

After-effects can be cognitive, physical or psychological

Dr Daniels says there are other similarities between COVID-19 and sepsis, in the long-term recovery process.

‘We’re hearing of the long-haulers with COVID-19 and that’s of no surprise to those of us who have been looking after people with sepsis for years, because it’s exactly the same,’ he says.

’We know that of people who survive sepsis, 40% have one or more of cognitive, physical or psychological after-effects at one year. These people are going to need support, they’re going to need to be listened to, to be connected with people who can empathise, perhaps from their own peer group. They’re going to need signposting to physiotherapy, to counselling, to online self-help resources and so forth. That’s whether they’ve had COVID-19 or sepsis.’

About 20% of people who survive sepsis end up back in hospital within the next 12 months with another infection, Dr Daniels says, so people recovering from COVID-19 should also be told what to look out for in case they too develop a further infection.

‘The patients have been at death’s door, they’ve got all these after-effects, they’ve lost weeks of their lives, they’ve got no clue what’s happened to them,’ he says. ‘Normally we ask families to keep a relatives’ diary to fill in the gaps for their loved ones, but of course no-one’s been able to do that.’

Fatigue is a common after-effect of both sepsis and COVID-19 Picture: iStock

Follow-up care for patients after intensive care

The BACCN’s Ms Credland says COVID-19 has shone a light on what was already known about the impact of being in intensive care.

‘Everyone thinks that after you go home from intensive care that’s it – you are better, job done, if you like,’ she says. ‘What COVID-19 has highlighted is that simply is not the case.’

‘Those of us that work within critical care and within sepsis have highlighted for many years that there is a significant amount of issues in patients who have needed intensive care admission for lots of reasons – sepsis being one of them and COVID-19 now being another – that will need continued follow-up and that will have lots of problems after intensive care, psychological and physical.’

Coping after COVID-19: ‘a long route to full recovery’

John Biddle spent eight weeks in
hospital

When John Biddle went to the Cheltenham Festival on 13 March, all he was planning was a good day at the races.

But less than two weeks later he was on a ventilator in hospital and his wife Chris had been told to prepare for the worst.

Mr Biddle had contracted COVID-19 and its impact was devastating. He had blood clots, a bleed on the brain, kidney problems, heart problems and sepsis.

Within two days of being admitted to Bristol Royal Infirmary, he was transferred to London’s Royal Brompton Hospital, where he was kept alive on an ECMO (extracorporeal membrane oxygenation) machine and dialysis.

‘The nurses in hospital were fantastic, they were brilliant. But the aftercare, now that I’m out, has been a bit lacking’

John Biddle, recovering COVID-19 patient

‘He’d gone on the ECMO on the Monday – they told me he had sepsis and the blood clots as well as COVID, and so it was all stacked against him,’ says Ms Biddle. ‘They said, if things didn’t go right, they were going to switch the machines off, because there wasn’t anything more they could do for him, but he rallied and he did improve.’

Mr Biddle spent eight weeks in hospital, including one week in a rehabilitation unit. But although he was discharged towards the end of May, he is by no means recovered. As well as gangrene on his fingers and one toe, he has extreme fatigue; walking even short distances leaves him breathless.

More help needed with my recovery at home

He was ‘clapped’ out of intensive care, which felt emotional, he says, but understood it was not the end of his journey.

‘I knew it was going to be a long route to full recovery,’ he says. ‘I could only walk about 50 yards before getting out of breath. Each day, I’ve been going a little bit further – I’ve done 8,000 steps on one day.’

Mr Biddle is still recovering months
after his discharge home

‘My hand’s all swollen up with the gangrene and I can’t use a knife and fork properly, so Chris has to cut up my food for me,’ he adds.

The couple feel that there hasn’t been the follow-up from health services that they would have liked.

Mr Biddle has been referred for physiotherapy but that was because of a problem with his pre-existing arthritis and a trapped nerve.

‘The GP has been good,’ he says. ‘And the nurses in hospital were fantastic, they were brilliant. They phoned Chris every day and kept in touch.

‘But the aftercare, now that I’m out, has been a bit lacking. It’s worrying.’


Further information

UK Sepsis Trust

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