Sepsis Screening?

[annie.rn]

Hi there,

I would like some opinions about a clinical situation.

At the community hospital I work at, we do a sepsis screening w/ each assessment and anytime the patient's temperature is greater or equal to 100.3. If the patient screens positive then we have to call the doctor and ask if they want to initiate the "sepsis bundle" of orders. These orders consist of fluid bolus, lactate level, blood cultures and initiation of empiric antibiotics. We are also supposed to initiate a rapid response.

So, I had a young patient who had a lap appy after a perforation.

[OneDuckyRN]

I'll do my best from memory. This is for an adult (I work adult Med/Surg).

First level of screening:

Completed q shift and if temp. greater than 100.3 F.

HR >90?

RR>20?

Temp > 100.9 or

WBC > 12,000?

If yes to 2 or more then you proceed to second level of screening:

Does pt. have suspected or known infection?

Is pt. on abx.?

If yes to one or more, proceed to third level of screening:

Answer a system by system check for dysfunction/deterioration.

If any one system is positive for deterioration from baseline then you initiate the Sepsis Protocol:

Call MD to notify him/her of positive sepsis screen along with reasons why pt. met the criteria.

Call a rapid response. (This gets a bit iffy. I don't see why they always need to be notified. I explained a bit more in one of my above posts.)

MD decides whether or not to order sepsis bundle. Bundle includes:

Fluid bolus

BC x 2

Lactate level

Initiation of antibiotics

We have an intervention in our charting system (Meditech) to document all of this.

In my scenario I was concerned about the pt. because he clearly met several of the sepsis criteria and he just looked bad. I've taken care of a lot of post-op perforated appy patients and he got my antenna wiggling.

Our protocol is similar to this with one difference: nurses can order lactate levels independently (per protocol, no cosign required) for 2/4 SIRS criteria met. If the lactate comes back >2, then we notify the physician and get orders for the sepsis bundle. I work on a medical stepdown so a lot of our patients are already on the RRT radar, but I'll give them a call and just let them know if I have someone headed down the sepsis pathway. I won't call a full RRT unless something is changing rapidly though.

[SierraBravo]

I agree with pedsRN, this patient doesn't sound septic, although it's hard to say that positively without actually seeing the patient. Sounds like a pretty normal post-op patient, though. With respect to the sepsis bundle, are you saying that at your institution patients get a fluid bolus before the lactate level comes back?

[jadelpn, LPN, EMT-B]

If a patient wakes up feeling crappy and is unstable, then I would call an RRT and the MD, as a couple sets of eyes are better than one. Not necessarily because of sepsis, just that this kid is not turning a corner.

The copious amounts of drainage would be an red flag to me--and maybe a culture on the drainage? Unfortunately, abx have been started and not an ideal timing on the culture, and not immediate results, however.

Just document WHY the sepsis protocol was not followed--in this instance the MD was the primary and had orders that they wanted to have employed.

Chances are the infection is resistant to the abx ordered. Also, just a thought--do you all use IV Tylenol? May be something to bring up at the next meeting you have regarding policies, with your pharmacist. Especially for the patients who have abdominal issues and temps.

Geez this poor kid! But good on you for being vigilant in his treatment!!

[dudette10, MSN, RN]

The MD would not order the sepsis bundle b/c the pt. had an known infection.

What?!

Based on my limited knowledge of abx treatment, cefepime was appropriate as a first-line agent in those with abdominal infections from the intestines. Vanc is also an appropriate treatment if it appeared that cefepime wasn't working. His fluids were going at an appropriate continuous rate also in the setting of infection. The only parts of the sepsis bundle that were missing is bolus, cultures, and lactate, all of which are relatively harmless to the patient.

I would have been more worried regarding his respiration rate, which is usually the first thing to become abnormal with sepsis. With him, it would obviously be the second thing because he already was febrile. Granted, he just woke up, and his inspiratory effort may have been poor secondary to his abdominal pain. However, you said his SpO2 via pulse oximetry was only 85%. That worries me even more. There is a "shunting theory" in sepsis, which is a compensation to maintain SBP. I found a great abstract that is succinct in describing this.

Microcirculatory perfusion is disturbed in sepsis. Recent research has shown that maintaining systemic blood pressure is associated with inadequate perfusion of the microcirculation in sepsis. Microcirculatory perfusion is regulated by an intricate interplay of many neuroendocrine and paracrine pathways, which makes blood flow though this microvascular network a heterogeneous process. Owing to an increased microcirculatory resistance, a maldistribution of blood flow occurs with a decreased systemic vascular resistance due to shunting phenomena. Therapy in shock is aimed at the optimization of cardiac function, arterial hemoglobin saturation and tissue perfusion. This will mean the correction of hypovolemia and the restoration of an evenly distributed microcirculatory flow and adequate oxygen transport. A practical clinical score for the definition of shock is proposed and a novel technique for bedside visualization of the capillary network is discussed, including its possible implications for the treatment of septic shock patients with vasodilators to open the microcirculation.

Bench-to-bedside review: Sepsis is a disease of the microcirculation

It is possible that the addition of vanc to his abx regimen is what caused improvement in his condition.

And here is the surviving sepsis campaign website. It is very informative and helpful.

Surviving Sepsis Campaign | Surviving Sepsis Campaign

[lovinglife2015]

Is this homework?

[SierraBravo]

What?!

cefepime was appropriate as a first-line agent in those with abdominal infections from the intestines. Vanc is also an appropriate treatment if it appeared that cefepime wasn't working. His fluids were going at an appropriate continuous rate also in the setting of infection. The only parts of the sepsis bundle that were missing is bolus, cultures, and lactate, all of which are relatively harmless to the patient.

I would have been more worried regarding his respiration rate, which is usually the first thing to become abnormal with sepsis. With him, it would obviously be the second thing because he already was febrile. Granted, he just woke up, and his inspiratory effort may have been poor secondary to his abdominal pain. However, you said his SpO2 via pulse oximetry was only 85%. That worries me even more. There is a "shunting theory" in sepsis, which is a compensation to maintain SBP. I found a great abstract that is succinct in describing this.

Actually, for complicated intra-abdominal infections, unless the kid had an allergy to it, metronidazole would usually be ordered along with the cefepime. Vancomycin would have made more sense to add into the treatment regimen if they cultured the drainage and found it to be beta-lactam resistant.

I agree, cultures and a lactate should have been drawn. But a bolus should only be given after you get the lactate results back. What if the kid is

Most importantly, we don't know what the kid's age is. Because that will determine whether or not his given VS were actually normal.

[hppygr8ful, ASN, RN, EMT-I]

On our unit we do really well with implementing the early sepsis screens and everyone is good about calling the MD's when a pt. screens positive. However, it seems like the MD's aren't on board with following through with the orders. If the patient is already on abx., the MDs rarely want to initiate the protocol. A patient can still become septic if they are on abx. already, correct? I don't see why it's any skin off their noses.

I think that's why they are now telling us to call a rapid response for positive screens. We have standing rapid response orders that the RR nurses can initiate. They let the doctor know what was ordered after the fact. It just seems a little backward to me. We don't have a dedicated RR team so I'd rather not pull the ICU nurse away from his/her patients in order to get labs ordered that the MD could just order in the first place.

I think the floor nurses should be allowed to order blood cultures and lactate levels as a protocol order for positive sepsis screens. The doctors, of course, would have to order the fluids and abx.

I found a power point presentation online from UCLA medical center and that is how they do it. How do they do it where you work? Where everyone else works?

.

Part of the problem is that Doctor and hospitals are not getting compensated by Insurance companies, Medicare or Medicaid are not getting paid for what 3 party payers deem unnecessary tests. If the tests come back negative 3rd party reviewers can deny payment. So doctors who want to get paid are more cautious about ordering tests. I actually had a Dr. Tell me this.

hppy

[MunoRN, RN]

It's important to remember that sepsis screening tools do not determine what patients are septic, they only tell us what patients might warrant a closer look. The tricky thing about sepsis is that the early signs of sepsis that can be looked at through routinely available information (vitals, routine labs, etc) are frequently no different than what we would expect to see in any hospitalized patient, most of whom never go into septic shock. As a result, these screening tools produce a large number of false positives. As a RR nurse I have no problem evaluating these patients even though for every 20 patients I look at there might only be one who is actually septic or going septic, that's still better than missing that one patient.

Primarily what you're looking for are signs of poor perfusion which includes urine output, HR, etc but BP is the primary indicator without more specific sepsis labs being available. With a lap appy post rupture, you're going to expect an inflammatory process to occur and what you've described so far could fall within the boundaries of that expected process (and even more to post-op atelectasis).

There once was a time when we'd do blood cultures x2 right of the bat, maybe even repeat BC with each temp spike, although we've moved away from that. Keep in mind that drawing a set of blood cultures typically involves taking 30-40 mls of blood from the patient so it's hardly benign, particularly if it's a patient at risk for poor perfusion. Usually what we'll do now is draw a lactate, typically two spaced apart to look for a trajectory since it can be elevated in a post-op patient unrelated to sepsis.

[dudette10, MSN, RN]

Actually, for complicated intra-abdominal infections, unless the kid had an allergy to it, metronidazole would usually be ordered along with the cefepime. Vancomycin would have made more sense to add into the treatment regimen if they cultured the drainage and found it to be beta-lactam resistant.

I agree, cultures and a lactate should have been drawn. But a bolus should only be given after you get the lactate results back. What if the kid is

Most importantly, we don't know what the kid's age is. Because that will determine whether or not his given VS were actually normal.

Thanks for the info on the abx.

Although the OP said this is a "young patient," she refers to him as "this guy" later down, and she said there was a 40 yo lap appy patient on her unit last year. I don't think the event occurred on a pediatric patient.

[annie.rn]

You call an RRT with every SIRS alert? Or do you just have to notify them so the patient is on their radar? We have a dedicated RRT nurse, and they keep track of everyone on the SIRS watch list.

We are supposed to but in practice it doesn't happen. We don't have a dedicated RRT.

[annie.rn]

Our protocol is similar to this with one difference: nurses can order lactate levels independently (per protocol, no cosign required) for 2/4 SIRS criteria met. If the lactate comes back >2, then we notify the physician and get orders for the sepsis bundle. I work on a medical stepdown so a lot of our patients are already on the RRT radar, but I'll give them a call and just let them know if I have someone headed down the sepsis pathway. I won't call a full RRT unless something is changing rapidly though.

This would be awesome! It would set my mind at ease.

[annie.rn]

I agree with pedsRN, this patient doesn't sound septic, although it's hard to say that positively without actually seeing the patient. Sounds like a pretty normal post-op patient, though. With respect to the sepsis bundle, are you saying that at your institution patients get a fluid bolus before the lactate level comes back?

I believe so as bolus, lactate, BC and abx. are the four orders included in the sepsis bundle. However, the MD can choose not to do any or all of the orders.

The pt. was a 23 yo., healthy guy. I've taken care of a good number of post-op perforated appy pts. but this guy seemed different. His incision looked "hot" and the drainage was so much more copious than what I've experienced w/ similar pts. in the past. The sat. of 85 on room air made me worry b/c I'd really been pushing the I.S., deep breathing and ambulation since he'd been febrile during day shift. On 2L NC I could only get him up to 91-92%. RR 22/24. That is unusual for a young, non-smoking male with no prior health history. He should've able to compensate pretty well, I would think. I felt like it was an ominous sign of possibly the beginning of a crash if no intervention.