Sepsis Management

Ashley Montoya, Angela Nelson, Shivanee Sathia, Taje Usher,

Chelsea Weaks
 Objectives
Learners will be able to...

● Define sepsis
● Identify signs, symptoms, and risk factors of sepsis/septic
shock.
● Identify labs related to sepsis
● Have an understanding of the pathology of sepsis
● Acknowledge early and late management
● Acknowledge nurse’s role in sepsis management
● Acknowledge local hospitals’ sepsis protocols
● Have knowledge about evidenced-based nursing research
● Identify recent protocols
 What is Sepsis?
Sepsis: It is a systemic response to infection; manifested by Microbes:Bacteria (Gram
two or more Systemic Inflammatory Response Syndrome -ve and gram +ve), virus,
(SIRS) criteria (Hinkle & Cheever, 2014). and fungus.

SIRS include:

● Temperature > 100.4 oF or < 96.8 oF

● Hypotension SBP < 90 / Mean Arterial Pressure <65
● Heart rate > 90 beats/min
● Respiratory rate >20 breath/ min or PaCO2 < 32 mm
Hg
● WBC count > 12,000 cells/mm3, < 4000 cells/mm3,
or > 10% immature WBC (bands)
 Severe Sepsis/Septic Shock

Severe Sepsis: The presence of S/S of sepsis associated with:

o Acute organ dysfunction
o Hypotension SBP <90 and/or hypoperfusion
S/S of Severe Sepsis:
o Lactic acidosis >4 mmol/L
o Oliguria
o Altered mental status/LOC
o Thrombocytopenia and coagulation disorder
o Altered liver function
Septic Shock: Shock associated with sepsis characterised by s/s of
severe sepsis plus persistent hypotension and hypoperfusion
despite adequate fluid replacement
 Pathophysiology
About 92% of sepsis cases come from the community and not
hospital. Sepsis can develop from any type of infection such as UTI,
pneumonia, or strep throat. Anytime there is a break in the skin, it can
lead to infection.

Infection invades the body tissue → Systemic immune system

response → Activation of biochemical cytokines and chemical
mediators
● Histamin
● Prostaglandin
 Pathophysiology

● Uncontrolled systemic clotting

● Vasodilation, capillary ● Intravascular dehydration
leakage, initiation of ● Depletion of clotting factors
clotting cascade

● Disseminated
● Decreased perfusion
intravascular
● Uncontrolled bleeding
coagulation (DIC)
● Immune system failure
● Multiple organ failure
● Death
 Critical Labs

● WBC count
○ > 12,000 cells/mm3,
○ < 4000 cells/mm3, or
○ > 10% immature WBC (bands)
● Lactic acid greater than 36 mg/dL
● Creatinine level elevated from baseline
● Platelet count
○ Thrombocytosis, or
○ Thrombocytopenia
● Procalcitonin
The Nurse’s Role
 Prevention
● Nurses can help prevent sepsis by:
○ Following protocols to prevent hospital-acquired infections
○ Recognizing high-risk patients
■ Immunosuppressed
■ Malnourished
■ Suffer from chronic illness
○ Knowing other common risk factors
■ Advanced age
■ Invasive procedures
■ Indwelling medical devices
■ Antibiotic-resistant microorganisms

(Hinkle & Cheever, 2014)

 Early Detection
● Nurses can improve sepsis outcomes through early detection.
● Nurses must be familiar with common signs & symptoms of sepsis.
● Nurses should utilize available tools to help detect sepsis early.
 Tools For Early Detection
Screening EMR-Based Alert
 Early Nursing Management
● Establish vascular access.
● Obtain serum lactate levels.
● Obtain two blood cultures from different sites to identify microorganism
responsible for infection.
● Obtain urine sample for urinalysis and culture.
● Ensure patient receives chest x-ray.
● Identify source of infection and prevent further infection.
● Appropriate administration of IV antibiotics within first hour of
recognition of sepsis.
● Keep HOB elevated and administer supplemental oxygen.
● Assess, monitor, and manage body temperature.
● Place an indwelling catheter.
● Administer fluid replacement therapy using supportive measures
● Monitor and maintain adequate organ system function
 Later Nursing Management
● Hospitalize or discharge patient within 3 hours.
● Continue to communicate with and educate patient and their family.
● Monitor electrolytes and maintain nutritional support.
● Closely monitor respiratory status.
○ Intubation and mechanical ventilation for respiratory distress manifested by severe sepsis
● Monitor patient’s MAP.
○ Administer vasopressors for hypotension that does not respond to initial fluid resuscitation to
maintain a MAP of 65 mm Hg or higher
● Monitor patient’s hemoglobin and platelets.
○ If hemoglobin levels fall below 7 g/dL -> red blood cell (RBC) transfusion is recommended to a target
hemoglobin range of 7-9 g/dL
○ Even in the absence of apparent bleeding, patients with severe sepsis should receive platelet
transfusion if platelet counts fall below 10,000/µL
 Nursing Evidence-Based Practice: The SOFA Protocol
1. The Sepsis-3 task force, convened in 2014, introduced new definitions for sepsis and septic
shock and required that infection be the cause of sepsis.
● Sequential Organ Failure
Assessment (SOFA) evaluates
the severity of organ
dysfunction and morbidity
and estimating mortality
risk. The higher the score,
the greater the risk.
● Evaluates respirations,
coagulation, hepatic,
cardiovascular, and central
nervous system.

Makic, M. B. & Bridges, E. (2018). Managing Sepsis and Septic Shock: Current guidelines and Definitions. The American Journal of Nursing., 118(2), 34-39.
 Nursing Evidence-Based Practice: The qSOFA Protocol
1. qSOFA (quick SOFA) is an abbreviated organ assessment
a. Relies on only blood pressure, respiratory rate, and mentation.

2. The clarification of sepsis-related terms is expected to expedite intervention. If nurses are

“thinking sepsis” when subtle changes occur in patients who may possibly have an infection,
then nurses may help to implement early intervention, resulting in improved patient outcomes.

Makic, M. B. & Bridges, E. (2018). Managing Sepsis and Septic Shock: Current guidelines and Definitions. The American Journal of Nursing., 118(2), 34-39.
 Nursing Evidence-Based Practice: MEWS
1. MEWS, for Modified Early Warning Score, was developed in 2001 to identify hospitalized patients at risk for clinical
deterioration.
2. Includes all criteria examined by qSOFA but also examines heart rate and temperature.
3. Points are assigned based on values for each parameter with scores of 5 or higher being associated with increased risk of
death and ICU admission.
4. The MEWS assessment is valuable for nurses because it helps them detect subtle changes in a patient’s presentation.
5. The MEWS has been shown to decrease the number of code Blues by as much as 50%

Lester, Donna. (2018). A Review of the Revised Sepsis Care Bundles: The rationale behind the new definitions, screening tools, and treatment guidelines. The American Journal of Nursing., 118(8), 40-51.
 Evidence-Based Practice: 1-hour Sepsis Bundle
1. A combination of the old 3-hour and 6-hour protocols
a. Measure lactate level. Remeasure if initial lactate is > 2 mmol/L
b. Obtain blood cultures prior to administration of antibiotics
c. Administer broad spectrum antibiotics
d. Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥ 4
mmol/L.
e. Apply vasopressors if patient is hypotensive during or after fluid resuscitation to
maintain MAP ≥ 65 mmHg.
2. The 1-hour bundle was developed to treat sepsis as a medical emergency with the same degree
of urgency as trauma and stroke.

Lester, Donna. (2018). A Review of the Revised Sepsis Care Bundles: The rationale behind the new definitions, screening tools, and treatment guidelines. The American Journal of Nursing., 118(8), 40-51.
Sepsis in Hampton Roads
Sentara’s Sepsis Bundles
Sentara’s Sepsis Bundles (cont.)
Sentara’s Sepsis Bundles (cont.)
Sentara’s Sepsis Bundles (cont.)
 CHKD’s “Children At High Risk” (CAHR) Alert
Emergency Department Pit Stop Guide
. .

Pit STOP q 30 minutes Pit STOP q 60 minutes Pit STOP q 2 hours

❏ Overhead/CAHR Team Activation
❏ PAT sends CAHR page
Vascular Access ❏ Monitors/assess
Vascular Access
❏ <30 minutes, if unable-notify ❏ Notify Pit Stop Team of any changes
❏ <15 minutes, if unable-notify provider
provider Vascular Access
Vitals
Vitals ❏ As required for other conditions
❏ Full monitors
❏ Full monitors Vitals
❏ Q 15 minutes
❏ Q 60 minutes ❏ As per policy
IVF bolus
IVF bolus IVF bolus
❏ 20cc/kg NS IV Push
❏ 20cc/kg NS IV Push ❏ Refer to MD
Labs
Labs Labs
❏ BCX, BCC, lactate, procalcitonin
❏ Refer to MD ❏ Refer to MD
❏ Dex-Stick
Antibiotics Antibiotics
❏ iStat-8
❏ Refer to MD ❏ Refer to MD
Antibiotics
❏ Ceftriaxone 50mg/kg IV up to 2gm
❏ Vancomycin 15mg/kg IV up to 2 gm
(after ceftriaxone)
Bon Secours - DePaul’s Protocols
 But did you know…
• The 30ml/kg normal saline resuscitation protocol that is used in Depaul’s protocol, was derived
from a study done in 2011 by Rivers et al. on early goal directed therapy
• Since 2011, 3 randomized control trials and 1 meta-analysis repeating the early goal directed
therapy advocated by Rivers et al failed to demonstrate improved outcomes and in fact trended
towards worse outcomes
• Increasing amount of research by Latham et al, Teboul, Monnet, and Marik has demonstrated
that individualized volume resuscitation with use of devices such as NICOM (non-invasive
cardiac output monitor) and early initiation of vasopressors improves outcomes
• Additionally two recently published articles on volume resuscitation (Self et al in 2018 and
Rochwerg et al in 2014) support improved outcomes with resuscitation using lactated ringers vs
normal saline. Lactated ringers decreased mortality, decreased metabolic acidosis, and
hyperkalemia.
Recent Protocols - Vitamin C
 VICTAS Trials
(VItamin C, Thiamine And Steroids in Sepsis)
1. The Vitamin C, Thiamine And Steroids in Sepsis (VICTAS) Study is a double-blind, placebo-controlled, adaptive randomized clinical
trial designed to investigate the efficacy of the combined use of vitamin C, thiamine and corticosteroids versus indistinguishable
placebos for patients with sepsis. The objective of this study is to demonstrate the efficacy of combination therapy using vitamin C,
thiamine and corticosteroids in reducing mortality and improving organ function in critically ill patients with sepsis.
2. Participants randomized to the treatment protocol will receive the VICTAS Intervention, consisting of intravenous vitamin
C, thiamine, and hydrocortisone for four days or until ICU discharge.
3. The VITAS Clinical trials are currently being implemented at 28 major institutions such as Vanderbilt, Emory, Johns Hopkins,
Cleveland Clinic, etc.
Drug: Vitamin C Drug: Thiamine Drug: Hydrocortisone
Intravenous vitamin C (1.5 grams every Intravenous thiamine (100 mg every 6 Intravenous hydrocortisone (50 mg
6 hours) will be administered for 4 days hours) will be administered for 4 days every 6 hours) will be administered for
or until ICU discharge. or until ICU discharge. 4 days or until ICU discharge.

Other Name: Ascorbic acid Other Name: Thiamine hydrochloride Other Name: Hydrocortisone sodium
succinate
Placebo Comparator: Control Protocol
A placebo to match the VICTAS intervention will be administered for four days or until ICU discharge. During the treatment period, if
an indication for steroids exist, the treating physicians are permitted to initiate open-label corticosteroid therapy based on local
practice and international guidelines. If this occurs, the hydrocortisone/placebo will be withheld and subjects will be started on
open-label corticosteroids.
 Nursing Research

• Title: Impact of Nurse-Initiated ED Sepsis Protocol on Compliance with Sepsis Bundles, Time to Initial Antibiotic Administration, and
In Hospital Mortality
• The aims of this study:
1. Evaluate the impact of a nurse-initiated ED sepsis protocol on time to initial antibiotic administration
2. Ascertain compliance with 3-hour Surviving Sepsis Campaign (SSC) targets
3. Identify predictors of in-hospital sepsis mortality.
• Methods:
• Inclusion: Adult patient admitted through ED that were discharged with a diagnosis of severe sepsis or septic shock
• Retrospective chart review of pre- and post- protocol initiation
• ED triage nurses used established screening criteria to identify patients who potentially had sepsis and then initiated serum
lactate and blood culture studies, inserted IV catheters, ordered chest radiographs, and obtained electrocardiograms
• Results:
• Significant improvement in serum lactate measurement (83.9% vs 98.7%, P = .003) and median time to initial antibiotic
administration (135 minutes vs 108 minutes, P = .021)
• No change in mortality at 30 days
• Compliance with medical interventions requiring multiple health care-provider involvement (ie, antibiotic and fluid
administration) remained suboptimal which may explain no change in mortality
 Summary
● Sepsis is the third leading cause of death in the U.S
● Identifying signs and symptoms as well as gettings labs is critical component in
early treatment of sepsis.
● Start antibiotics within 3 hours
● Monitoring lactate levels q4 to ensure levels are normalizing.
● Implementation and knowledge of recent protocols that include Hydrocortisone,
Vitamin C and Thiamine.
 Reflection
❖ The Surviving Sepsis bundle is used throughout all hospitals in the Hampton Roads Area. However, the
Vitamin C cocktail is currently being implemented at Norfolk General being that it was created there
and is part of the VICTAS Trial.
❖ Sentara, CHKD, and Bon Secours have all constructed protocols that adhere closely to the 1-hour
sepsis bundle, with minimal variations.
❖ Although the Vitamin C regimine shows great promise, physicians in other hospitals shy away from
using it merely due to uncertainty.
❖ The VICAS Trails will continue to enroll participants aged 18 years and older who meet the inclusion
and exclusion criteria, with an estimated primary completion date of December 2019 and a projected
study completion date of October 2021.
 Early Management Late Management
S- hivering, fever, or very cold
● Serum lactate

E-
● Monitor
Sepsis: ● 2 blood cultures from
electrolytes
xtreme pain or general discomfort Systemic different sites
● Maintain
● Chest x-ray
response to nutritional

P-
● IV antibiotics within
support
infection hour 1
ale or discolored skin ● Elevate HOB and
● Crystalloids with
albumin
administer

S-
● Intubation and
supplemental oxygen
mechanical
leepy, difficult to wake up, or confused" ● Assess, monitor, and
ventilation
manage body
● Administer

I-
temperature
vasopressors
● Indwelling catheter
“ feel like I might die” ● RBC transfusion
● Fluid replacement
● Platelet
therapy

S- hort of breath
● Maintain adequate
organ system function
●
transfusion
Drotrecogin alfa
(activated) Xiris

Vitamin C, Hydrocortisone, Thiamine

Protocol

2 or more of the SIRS Criteria: ● At the time antibiotics are ordered

● All patients except pregnant women

❏ Temperature > 100.4 or < 96.8 ● Hydrocortisone 50 mg IV q6h for 4 days (or
❏ Heart rate > 90 beats/min until discharge) (no taper)
❏ Respiratory rate >20 breath/ min
● Ascorbic Acid 1500 mg IV q6h for 4 days (16
OR PaCo2 < 32 mm Hg
❏ WBC count > 12,000 cells/mm3, < 4000 doses) or until discharge

cells/mm3, or > 10% immature WBC (bands) ● Thiamine 200 mg IV q12h for 4 days or 100

mg 16huntil discharge
 References
Angus, D. C., Barnato, A. E., Bell, D., Bellomo, R., Chong, C. R., Coats, T. J., Davies, A., …., Young, J. D. (2015). A systematic review and meta- analysis of early goal-directed therapy for septic shock: The

ARISE, ProCESS and ProMISe investigators. Intensive Care Med, 41(9), 1549-1560. doi: 10.1007/s00134-015-3822-1

Bruce, H. R., Maiden, J., Fedullo, P. F., & Kim, S. C. (2015). Impact of nurse-initiated ED sepsis protocol on compliance with sepsis bundles, time to initial antibiotic administration, and in-hospital mortality. Journal of Emergency Nursing,41(2), 130-137.

doi:10.1016/j.jen.2014.12.007

Emory University. (2018). Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS). (Clinicaltrials.gov Identifier NCT03509350). Retrieved https://clinicaltrials.gov/ct2/show/study/NCT03509350?show_desc=Y#locn

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth's textbook of medical-surgical nursing(13th ed.). Wolters Kluwer/Lippincott Williams & Wilkins: Philadelphia.

Latham, H. E., Bengtson, C. D., Satterwhite, L., Stites, M., Subramaniam, D. P., Chen, G. J., & Simpson, S. Q. (2017). Stroke volume guided resuscitation in severe sepsis and septic shock decreases time on

pressors and ICU stay. Journal of Critical Care, 42, 42-46. doi: 10.1016/j.jcrc.2017.06.028

Lester, D. (2018). A review of the revised sepsis care bundles: The rationale behind the new definitions, screening tools, and treatment guidelines. The American Journal of Nursing., 118(8), 40-51.

Makic, M. B. & Bridges, E. (2018). Managing sepsis and septic shock: Current guidelines and definitions. The American Journal of Nursing., 118(2), 34-39.

Marik, P., Khangoora, V., Riviera, R., Hooper, M., & Catravas, J. (2017). Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock. CHEST Journal, 151(6), 1229-1238. doi.:10.1016/j.chest.2016.11.036

Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Peterson, E., & Tomlanovich, M. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med,

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Septic Shock Treatment & Management. (2018, January 22). Retrieved February 20, 2019, from https://emedicine.medscape.com/article/168402-treatment

Tromp, M., Hulscher, M., Bleeker-Rovers, C. P., Peters, L., Berg, D. T., Borm, G. F., . . . Pickkers, P. (2010). The role of nurses in the recognition and treatment of patients with

sepsis in the emergency department: A prospective before-and-after intervention study. International Journal of Nursing Studies, 47(12), 1464-1473. doi:10.1016/j.ijnurstu.2010.04.007

Yu, H., Chi, D., Wang S., & Liu, B. (2016). Effect of early goal-directed therapy on mortality in patients with severe sepsis or septic shock: a meta- analysis of randomised controlled trials. BMJ

Open, 6(3), e008330. doi: 10.1136/bmjopen-2015-008330

Zhong, Z. W., & Zue, J. J. (2010). Early goal-directed therapy collaborative group of Zhejiang Province: The effect of early goal-directed therapy on treatment of critical patients with severe sepsis/septic

shock: A multicenter, prospective, randomized controlled study [in Chinese]. Chinese Critical Care Medicine, 22(6), 6:331-34.
 ODU School of Nursing Honor Code

“I pledge to support the Honor System of Old Dominion University. I will

refrain from any form of academic dishonesty or deception, such as
cheating or plagiarism. I am aware that as a member of the academic
community, it is my responsibility to turn in all suspected violators of
the Honor Code. I will report to a hearing if summoned.”

Signatures:
Ashley Montoya, Angela Nelson, Shivanee Sathia, Taje Usher, Chelsea Weaks
Date: March 1, 2019