QUICK Sepsis and Septic Shock

LESSON
Description/Etiology
Sepsis is a potentially fatal host response to infection that occurs in association with
systemic inflammatory response syndrome (SIRS). SIRS is a severe inflammatory reaction
that is diagnosed when two or more of the following criteria are present: temperature
> 100.4 F/38 C or < 96.8 F/36 C; heart rate > 90/min; respiratory rate > 20/min or
PaCO2< 32 mm Hg; and WBC count > 12,000/mm3, < 4,000 mm3, or the presence of >
10% immature forms. SIRS can occur with or without an infection, but sepsis can only be
diagnosed when SIRS occurs in a person with a suspected or confirmed infection. Severe
sepsis (i.e., sepsis with multiple-organ dysfunction) can lead to septic shock (i.e., severe
sepsis with persistent hypotension despite adequate fluid resuscitation) and death.
The bloodstream, the skin, and the respiratory, gastrointestinal, and genitourinary tracts are
common sites of infection associated with sepsis. Most infections associated with sepsis
are bacterial in origin. Gram-positive bacteria that cause sepsis include Staphylococci,
Enterococci, and Streptococci. Gram-negative bacteria that may cause sepsis include
Escherichia coli, Pseudomonas spp., Klebsiella spp., Proteus spp., and Pseudomonas
spp. Infections associated with sepsis can also be fungal, viral, rickettsial, or parasitic in
origin. Although the pathophysiology of the continuum from infection to sepsis to septic
shock is not completely understood, it is thought to involve an imbalance between pro-
and anti-inflammatory mediators that result in tissue damage. Subsequent activation of
inflammatory and coagulation pathways occurs and contributes to maldistribution of blood
flow and significant immunosuppression. Clinical signs and symptoms of sepsis vary
depending on the cause of infection and can mimic other conditions, which can make sepsis
ICD-9 difficult to diagnose. Laboratory and diagnostic tests are performed to assess for other
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causes and to determine the cause of infection.
Treatment involves fluid resuscitation, intensive antimicrobial therapy aimed at the
Authors suspected source of infection, vasopressors to increase mean arterial pressure (MAP),
Eliza Schub, RN, BSN transfusion of blood products for bleeding complications, and intensive patient monitoring.
Cinahl Information Systems, Glendale, CA Improved survival for patients who have been diagnosed with septic shock has been
Tanja Schub, BS demonstrated when early goal-directed therapy (e.g., maintaining adequate urine output,
Cinahl Information Systems, Glendale, CA
MAP at 65 mm Hg, and central venous pressure [CVP] at 812 mm Hg) is provided.
Collaboration of amultidisciplinary team of clinician specialists in infectious disease, critical
Reviewers
Darlene Strayer, RN, MBA
care, and/or surgery may be necessary. In severe cases, dialysis and/or surgery (e.g., surgical
Cinahl Information Systems, Glendale, CA resection of an infectious site or to resolve renal disease) may be indicated. Prognosis
Teresa-Lynn Spears, RN, BSN, PHN, AE- depends on the pathogenic cause, site, and severity; the promptness and effectiveness of
C treatment; the hosts immune response; and whether or not organ dysfunction or septic
shock has occurred.
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA Facts and Figures
More than 18 million cases of severe sepsis occur each year, resulting in 1,400 deaths
Editor worldwide. In the United States, sepsis affects 0.3% individuals in the general population.
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
Severe sepsis accounts for 2% of hospital admissions, with ~ 50% of these patients requiring
treatment in the intensive care unit (ICU); in fact, severe sepsis accounts for 10% of all ICU
admissions. An estimated 750,000 new cases of severe sepsis occur in hospitalized patients
March 18, 2016
in the U.S. annually. The incidence of severe sepsis and septic shock is increasing in the

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U.S., likely due to the growing number of older adults and high-risk patients in the general population, the increasing use of
invasive procedures in healthcare settings, the growing number of antibiotic resistant microorganisms, and the increased use of
chemotherapy and immunosuppressant drugs. The incidence of sepsis increases with age. About 60% of cases of severe sepsis
develop in patients who are older than 65 years of age. The incidence of severe sepsis in hospitalized patients is 0.2:1,000 in
children and 26.2:1,000 in adults who are > 85 years of age. Even with aggressive treatment, mortality rates for patients with
severe sepsis and/or septic shock are 2050%.Sepsis may account for more than one-third of in-hospital deaths in the U.S. The
incidence and mortality in septic shock is higher in men than in women. Annual hospital costs for treatment of sepsis in the
U.S. are estimated at $14 billion.

Risk Factors
Risk factors for sepsis and death from septic shock include genetic factors, catheterization, presence of an intravascular
or prosthetic device, certain surgeries, urinary tract infection, appendicitis, diverticulitis, Crohns disease, cholecystitis,
renal disease, prostatitis, meningitis, and complicated obstetric delivery. Children, older adults, and individuals who are
immunocompromised are at increased risk for both sepsis and progression to septic shock. Additional risk factors for
progression to septic shock include prolonged time between onset of manifestations and initiation of treatment for sepsis,
misdiagnosis of infection, microbial drug resistance and persistent infection, including supra- and nosocomial infections,and
use of ineffective antibiotics (e.g., when microbial is not susceptible to the antibiotic).

Signs and Symptoms/Clinical Presentation

Sepsis: Fever or hypothermia, hyperventilation, tachycardia, chills, shaking, warm skin, skin rashes, lethargy, confusion,
coma, hyperglycemia, muscle weakness, bleeding diathesis (i.e., predisposition to bleeding/hemorrhage), increased
cardiac output, and signs and symptoms that reflect the primary site of infection (e.g., diarrhea, abdominal pain, and
abdominal distention in cases of gastrointestinal infection; severe headache, neck stiffness, and cervical/submandibular
lymphadenopathy in cases of head and neck infection)
Severe sepsis/septic shock: Liver dysfunction (e.g., jaundice), hypotension, cool skin, pancreatitis, renal failure,
decreased cardiac output, adrenal dysfunction, acute respiratory distress syndrome, multiple-organ dysfunction syndrome,
encephalopathy, neuropathy, and disseminated intravascular coagulation (DIC)

Assessment
Physical Findings of Particular Interest
In adults with septic shock, systolic blood pressure (BP) can be < 90 mm Hg or reduced 40 mm Hg from baseline; MAP
can be < 70. Systolic BP in children may be < 2 standard deviations below normal for age
Laboratory Tests That May Be Ordered
Blood cultures may be positive for bacteria, and Gram stain can identify the type of bacteria; daily testing may be indicated
CBC may reveal or WBCs, a low platelet count, and/or anemia
BUN, serum creatinine, myoglobin, osmolality, bilirubin, and lactate may be ; serum albumin may be ; and liver
enzymes may be
UA may show urine creatinine and urine culture may be positive for bacteria
Coagulation studies may show prolonged PT, prolonged PTT, and fibrinogen, which may indicate DIC
ABGs may show lactic acidosis, blood oxygen levels, or respiratory alkalosis
Cytologic analysis of cerebrospinal fluid (CSF) may indicate meningitis
Other Diagnostic Tests/Studies
Chest X-ray may be ordered to assess for pneumonia, if suspected
Ultrasound, CT scan, or MRI may be ordered to identify the site of infection

Treatment Goals
Promote Goal-Directed Therapy and Return to Normal Physiologic Function
Frequently monitor vital signs, oxygen levels, cardiac output, neurologic status, skin color, laboratory/other diagnostic test
results, urine output, glucose level, and level of consciousness (LOC)
Maintain patent airway and provide supplemental oxygen as ordered; maintain mechanical ventilation or intubation if
ordered
Infuse prescribed intravenous fluids (e.g., normal saline, Ringers lactate solution) or colloids (e.g., albumin) to maintain
electrolytes and restore circulating fluids
 Transfuse prescribed blood products (e.g., whole blood, plasma products or packed red blood cells), and monitor closely
for an adverse transfusion reaction
Administer prescribed medications, as ordered; monitor treatment efficacy and for adverse effects
Administer antimicrobials as ordered to treat infection
- The type of medication used will depend on the type of bacteria or other organism and the site of infection; combination
therapy may be ordered
- Broad-spectrum intravenous (IV) antibiotics should be initiated as quickly as possible (ideally within the first hour) in
patients who present with sepsis-likesigns and symptoms, even before diagnosis of sepsis is confirmed and/or the source
of infection is identified
Administer vasopressors (e.g., DOPamine, norepinephrine, vasopressin) and/or inotropics (e.g., DOBUTamine) if ordered
to treat hypotension
Administer corticosteroids (e.g., hydrocortisone) if ordered to reduce systemic inflammation
Administer sodium bicarbonate if ordered to treat acidosis
Administer prophylactic medications if ordered to prevent complications, including
- heparin to prevent deep vein thrombosis (DVT)
- H2 receptor antagonists to prevent stress ulcers
Administer recombinant activated protein C if ordered to treat coagulopathy, if present
If applicable, remove the source of infection (e.g., catheter); assist with drainage of abscess or debridement at a site of
infection if ordered
Use aseptic techniques for patient care according to facility protocol and maintain skin integrity
Monitor for complications, including organ failure, DIC, respiratory distress, and DVT
Promote adequate bed rest and provide enteral nutritional support, as ordered
Follow facility pre- and posttreatment protocols if patient becomes a candidate for dialysis or surgery; reinforce pre-
and posttreatment education and verify completion of facility informed consent documents. Closely monitor for
treatment-related complications
Assess patient anxiety level and for knowledge deficits regarding sepsis and septic shock; provide emotional support and
educate about sepsis/septic shock pathophysiology, potential complications, treatment risks and benefits, and individualized
prognosis

Food for Thought

Although corticosteroids are commonly used in the treatment of patients with septic shock, researchers in a study of 6,663
patients treated for septic shock in 28 ICUs in three countries reported that administration of low-dosecorticosteroids within
48 hours of diagnosis of septic shock was not associated with a decreased 30-day mortality rate overall. However, the
investigators did find that early administration of low-dose corticosteroids reduced the 30-day mortality rate by 19% in the
patients with the highest severity of illness (Funk et al., 2014)
The Surviving Sepsis Campaign guidelines recommend corticosteroid use only in patients with refractory shock with
hemodynamic instability despite adequate fluid resuscitation and vasopressor use
Prompt recognition of sepsis and septic shock is crucial to the provision of potentially life-saving interventions. Nurses are
the healthcare providers that typically spend the most time with patients and are, therefore, well positioned to identify signs
and symptoms of these conditions. Investigators who conducted a study involving 242 acute and critical care pediatric nurses
found that the participants could easily recognize septic shock, but were less adept at recognizing patients with earlier stages
of sepsis (Jeffery et al., 2014)

Red Flags
Closely monitor for tachycardia when using vasopressor or inotropic therapy (i.e., pharmacologic agent use to change the
force/strength and speed of a muscle contraction [e.g., heart])
Severe sepsis is the most common cause of death in noncoronary critical care units

What Do I Need to Tell the Patient/Patients Family?

Provide discharge instructions and verify the patients understanding of the prescribed medication regimen, including
potential adverse effects
Educate about the importance of continued medical surveillance and seeking immediate medical attention for new or
worsening signs and symptoms
References
1. Cawcutt, K. A., & Peters, S. G. (2014). Severe sepsis and septic shock: Clinical overview and update on management. Mayo Clinic Proceedings, 89(11), 1572-1578.
doi:10.1016/j.mayocp.2014.07.009
2. Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., ... Vincent, J. L. (2013). Surviving sepsis campaign: International guidelines for management of
severe sepsis and septic shock: 2012. Critical Care Medicine, 41(2), 580-637. doi:10.1097/CCM.0b013e31827e83af
3. Funk, D., Doucette, S., Pisipati, A., Dodek, P., Marshall, J. C., & Kumar, A. (2014). Low-dose corticosteroid treatment in septic shock: A propensity-matching study. Critical
Care Medicine, 42(11), 2333-2341. doi:10.1097/CCM.0000000000000518
4. Jeffery, A. D., Mutsch, K. S., & Knapp, L. (2014). Knowledge and recognition of SIRS and sepsis among pediatric nurses. Pediatric Nursing, 40(6), 271-278.
5. Kalil, A., & Bailey, K. L. (2015, April 17). Septic shock. Medscape. Retrieved March 1, 2016, from http://emedicine.medscape.com/article/168402-overview
6. Liu, V., Escobar, G. J., Greene, J. D., Soule, J., Whippy, A., Angus, D. C., & Iwanshyna, T. J. (2014). Hospital deaths in patients with sepsis in 2 independent cohorts. JAMA:
Journal of the American Medical Association, 213(1), 90-92. doi:10.1001/jama.2014.5804
7. Makic, M. B.F. (2014). Shock and multiple organ dysfunction syndrome. In J. L. Hinkle & K. H. Cheever (Eds.), Brunner & Suddarths textbook of medical-surgical nursing (13th
ed., Vol. 1, pp. 301-309). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
8. Opal, S. M. (2014). Sepsis. In F. F. Ferri (Ed.), 2014 Ferris clinical advisor: 5 books in 1 (pp. 1005-1006). Philadelphia, PA: Elsevier Mosby.