Sepsis: Question clarifying disease process

[pedi_nurse]

Hey guys! When I was a new nurse I worked peds pulm and lost a patient to pertussis the shift following mine. This kid had either had a genetic disorder or was an ex-premie (I don't recall now) with a trach and gt and some developmental delay, but was otherwise pretty active kid. The morning he passed away, his vitals were fine as far as I remember, but his early morning WBC came back extremely elevated. I put a call into the doc and got the team there pretty quickly to assess him. When I left at shift change, they were working on securing a bed for him in the PICU. When I returned to work that night, I was informed he had passed away in the PICU after his parents decided not to do ECMO.

At the time, I was told the kid suffered from a cytokine storm. No mention of the word sepsis. My question is, can you have a cytokine storm without actually being septic? Or was this patient septic? I'm a school nurse now, but have been going through some refresher courses and learned about the issue of sepsis causing damage/death being due to the immune response (aka cytokine release). I'm sure I was taught this in school, but have long associate sepsis in my mind as a BSI. Does anyone have some insight they can offer me? Feeling a bit dumb for not having learned this more thoroughly before now.

[Wuzzie]

I found this information and thought it explained it pretty well.

"When the immune system is fighting pathogens, cytokines signal immune cells such as T-cells and macrophages to travel to the site of infection. In addition, cytokines activate those cells, stimulating them to produce more cytokines. Normally, this feedback loop is kept in check by the body. However, in some instances, the reaction becomes uncontrolled, and too many immune cells are activated in a single place. The precise reason for this is not entirely understood but may be caused by an exaggerated response when the immune system encounters a new and highly pathogenic invader. Cytokine storms have potential to do significant damage to body tissues and organs. If a cytokine storm occurs in the lungs, for example, fluids and immune cells such as macrophages may accumulate and eventually block off the airways, potentially resulting in death.

The cytokine storm (hypercytokinemia) is the systemic expression of a healthy and vigorous immune system resulting in the release of more than 150 known inflammatory mediators (cytokines, oxygen free radicals, and coagulation factors). Both pro-inflammatory cytokines (such as Tumor necrosis factor-alpha, Interleukin-1, and Interleukin-6) and anti-inflammatory cytokines (such as interleukin 10 and interleukin 1 receptor antagonist) are elevated in the serum of patients experiencing a cytokine storm."

http://www.sinobiological.com/Cytokine-Storm-Cytokine-Storms-a-5800.html

[pedi_nurse]

Thanks! Yeah, after it happened, I did read up on cytokine storms. I guess what I'm wondering is what the difference is between that and sepsis.

[PeakRN]

You can have a cytokine storm without sepsis, although typically as a response to certain biologics.

Certainly in light of active infection this seems unlikely, but not impossible especially in a medically complex patient.

I would also consider that diagnosis can be shifted by the development in medicine. We know that the increase is sepsis diagnosis is very much linked to us labeling it instead of saying that the patients cause of death was meningitis, UTI, PNA, and so on. It isn't that the infectious etiology wasn't recognized but that as the aggressive management of systemic infections developed we used the term sepsis more.

[pedi_nurse]

On 1/23/2019 at 9:53 PM, PeakRN said:

You can have a cytokine storm without sepsis, although typically as a response to certain biologics.

Certainly in light of active infection this seems unlikely, but not impossible especially in a medically complex patient.

I would also consider that diagnosis can be shifted by the development in medicine. We know that the increase is sepsis diagnosis is very much linked to us labeling it instead of saying that the patients cause of death was meningitis, UTI, PNA, and so on. It isn't that the infectious etiology wasn't recognized but that as the aggressive management of systemic infections developed we used the term sepsis more.

Thanks for the response. This makes a lot of sense.