September is Sepsis Awareness Month, so to recognize the advances we’ve made in improving patient outcomes, we’re going through the sepsis bundle in this article. 

You can listen to episode 243 of the Straight A Nursing podcast to reinforce your reading. Listen wherever you get your podcast fix or straight from the website here.

Sepsis is a life-threatening medical emergency that is caused by a massively overblown response to infection. Sepsis is usually caused by a bacterial infection, but it can be due to viral infections such as COVID-19. The pathogens most commonly associated with sepsis are E. coli, Staphylococcus aureus, and some strains of Streptococcus. Infections that lead to sepsis can begin anywhere in the body, but most commonly start in the urinary tract, lungs, skin, and GI tract.

Sepsis affects more than 1.7 million adults in the U.S. each year and is a leading cause of death in U.S. hospitals. In fact, according to the Centers for Disease Control and Prevention, one in three patients who die in the hospital have sepsis. Early recognition and treatment are necessary to improve patient outcomes. 

Early goal directed therapy for sepsis was first introduced in 2001, and the Surviving Sepsis campaign was launched in 2002. Since then, guidelines for the management of sepsis have been developed and continually improved upon. These guidelines are often referred to as “the sepsis bundle.”

What are the stages of sepsis?

Sepsis is divided into three stages – sepsis, severe sepsis and septic shock. 

  • Sepsis is present when the body has an overblown response to infection.
  • Severe sepsis is when the response has caused organ damage. The symptoms will depend on which organs are affected. For example, if the lungs are affected, the patient will have an increased respiratory rate and require oxygen to maintain an adequate SpO2. 
  • Septic shock is when the patient remains hypotensive even after the administration of fluids.

What is the sepsis bundle?

A bundle refers to any collection of interventions that, when done as a whole, greatly improve patient outcomes. The sepsis bundle is a collection of tests and treatments that help us identify and treat the infection. The goal is to catch sepsis early and initiate treatment before it causes significant organ damage. In this early stage, improved outcomes are noted when all these interventions are completed within one to three hours from the time sepsis is recognized.

Step 0: The key to treating sepsis is to recognize sepsis! And we do that with a sepsis screening tool that evaluates a variety of factors: 

  • Abnormal vital signs
  • Elevated lactate
  • Confirmed or suspected infection
  • Organ involvement – this includes things like tachypnea, tachycardia, hypotension, hypoxia and decreased LOC

As soon as sepsis is recognized, this is time zero and the clock starts ticking!

Step 1: Obtain cultures. In order to utilize the most appropriate antibiotics, we have to identify the pathogen. Because antibiotics will skew the results, we always want to get cultures BEFORE starting any antibiotics. In most cases we will obtain what is called a “pan culture.” This means we get blood, urine, wound and sputum cultures where applicable. We need to do this quickly because the next step is absolutely crucial.

Step 2: Start broad-spectrum antibiotics. Antibiotics are to be administered as soon as possible after recognizing the signs of sepsis. Most facilities have a goal of antibiotic administration within one hour. Note that you won’t have culture results within one hour, so patients are started on “broad spectrum” antibiotics. Once the culture results tell us the specific pathogen, antibiotic therapy becomes more targeted. Some common broad-spectrum antibiotics utilized in sepsis are piperacillin/tazobactam (Zosyn), ceftriaxone, cefepime and meropenem.

Step 3: Administer fluids. Rapid fluid resuscitation is a vital component of sepsis treatment. The Surviving Sepsis guidelines call for 30ml/kg of crystalloid when the lactate is 4.0 or higher, or if the patient is hypotensive. 

Crystalloids refer to fluids that have small molecules and provide immediate volume to the vascular space. Note that these fluids can shift easily into the interstitial space, especially when the vasculature is permeable, such as in sepsis. So, your patient could end up with pretty significant edema if a lot of fluids are utilized. This is why we use a weight-based fluid goal and monitor patients closely for signs of improvement or deterioration. Examples of crystalloids are 0.9% sodium chloride (“normal saline”) and Lactated Ringers. 

Step 4: Improve blood pressure. If the patient remains hypotensive after the fluids are administered, they are in septic shock and will require additional support in the form of vasopressors. Vasopressors are medications that cause the blood vessels to constrict, which increases blood pressure. The goal with vasopressors is to achieve a mean arterial pressure of 65 mm Hg or higher. The recommended first-line vasopressor to use in sepsis is norepinephrine

What’s the most important element in surviving sepsis?

Aside from early recognition and initiation of the bundle outlined above, the most important thing we can do for our patients with sepsis is identify the source and control the spread of infection. You will hear this called “source control.”

  • Does the patient have a UTI and use an indwelling catheter? Remove the catheter.
  • Does the patient have an abscess or infected wound? The patient will go to surgery for debridement and washout of the wound.
  • Does the patient have an infected gallbladder? The patient will go to surgery for a cholecystectomy and abdominal washout. 
  • Does the patient have a central line infection? Obtain alternate IV access and remove the central line.

Ongoing assessments and interventions:

Hemodynamic monitoring  – In order to ensure the patient receives the appropriate amount of fluids and/or vasopressors you will closely monitor hemodynamics. Hemodynamic monitoring provides valuable information about the body’s ability to provide oxygen to the tissues (“heme” means blood and “dynamics” means flow).  It looks at things like mean arterial pressure, cardiac output, stroke volume and peripheral vascular resistance to guide interventions in sepsis.

Lactate – the lactate level will be remeasured to determine if the treatments have been effective. Generally this is six hours after the sepsis was identified. What you want to see is the lactate decreasing with an overall goal being a lactate less than 2 mmol/L. 

Monitor blood pressure – You will continue to monitor your patient for hypotension. Hypotension may indicate your patient needs additional interventions. Some patients will require two vasopressors or even three, while others will need an inotrope (a medication to make the heart pump more strongly).

Blood glucose management – Blood glucose rises in times of stress, and sepsis is no exception. There is currently strong evidence to maintain a blood glucose level at or below 180 mg/dL.

DVT prophylaxis – Your patient will also have ongoing DVT prophylaxis that will be both mechanical and pharmacologic in nature. Mechanical prevention involves wearing SCDs and pharmacologic prevention will likely be with low-molecular-weight heparin.

Labs – You’ll be collecting lab samples regularly for a patient with sepsis. Some common tests include CBC, CMP (monitor electrolytes, liver and renal function), and arterial blood gas (monitor acid-base imbalance, lactate and level of hypoxemia).

Monitor your patient for organ dysfunction – This will include keeping a close eye on things like neurological status, urine output, oxygenation, cardiac rhythms and capillary refill.

Advanced interventions – Very ill patients will require mechanical ventilation and even continuous renal replacement therapy. Your interventions will always be specific to the patient’s condition and severity of the inflammatory response.

Recognizing Sepsis

The Sepsis Alliance has developed an acronym to help the public understand the signs of sepsis so treatment can begin as soon as possible. The acronym is TIME: 

T: Temperature – The individual has a temperature that is higher or lower than normal

I: Infection – The individual may have signs and symptoms of infection

M: Mental decline – The individual is sleepy, difficult to wake up, or confused

E: Extremely ill – The individual is in severe distress, has shortness of breath or is in significant pain/discomfort

SEPSIS TIME ACRONYM

So there you have it, a quick overview of the initial treatment utilized when a patient screens positive for sepsis. For more critical care topics, click here.

References:

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., … Levy, M. (2021). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine, 49(11), e1063. https://doi.org/10.1097/CCM.0000000000005337

Medline Plus. (n.d.). Comprehensive Metabolic Panel (CMP): MedlinePlus Medical Test. https://medlineplus.gov/lab-tests/comprehensive-metabolic-panel-cmp/

Radigan, K. (n.d.). Improving Sepsis Outcomes: Raising the Bar | 2020-07-14. Relias Media | Online Continuing Medical Education | Relias Media – Continuing Medical Education Publishing. https://www.reliasmedia.com/articles/146567-improving-sepsis-outcomes-raising-the-bar

Ryoo, S. M., & Kim, W. Y. (2018). Clinical applications of lactate testing in patients with sepsis and septic shock. Journal of Emergency and Critical Care Medicine, 2(2), Article 2. https://jeccm.amegroups.com/article/view/4083