Sepsis

[dudette10, MSN, RN]

The other day, I got a call from the nursing home where my loved one resides. The nurse told me that she was congested, the doc was called, and a z-pack was ordered. I asked the vital signs: elevated temp, elevated respiration rate, and satting 92% on 2L NC. I asked for the doc’s number and called him.

He threw the nurse under the bus. “Oh, she didn’t tell me the vital signs!” He repeated it x 3 throughout our conversation, and I asked for her to be sent to the hospital.

When we got to the hospital, her work of breathing was noticeable to even my non-medical husband. Within a couple hours, we watched her get worse—she went from “congested” to severe sepsis right before our eyes—and she was transferred to ICU.

After confirming her DNR/DNI status and our wish to give her a chance with only fluid resuscitation and antibiotics and possible NIV, if necessary, she made a very nice turnaround within 24 hours. She received a short stint on BiPAP overnight. The day dawned to her satting well on 2L NC, work of breathing nearly nil, and almost back to her baseline mental status.

According to Kaplan (2014), definitions for Systemic Inflammatory Response Syndrome (SIRS), sepsis, severe sepsis, septic shock, and Multiple Organ Dysfunction Syndrome (MODS) were developed. SIRS has the same initial s/s of sepsis, but is nonspecific and unrelated to infection.

The first symptoms are an acutely elevated respiratory rate, fever, tachycardia > 90 BPM, and abnormal WBCs (Kaplan, 2014). Two of the four need to be present to diagnose SIRS. In the presence of a suspected or known source of infection, sepsis can be diagnosed, as an infectious source is the key difference between SIRS and sepsis. Of course, a nurse or doctor has to look at the whole picture of the person. For example, tachycardia with elevated RR could be cardiac in origin, and, in that case, the patient fits the criteria of SIRS; however, many acute care protocols use the above s/s as a sepsis screening tool.

Once sepsis has been diagnosed, severe sepsis and septic shock are additive diagnoses as more s/s begin to occur. That’s why sepsis survival is improved with quick action. “The goal is to treat sepsis during its mild stage, before it becomes more dangerous” (Mayo Clinic, 2014).

In non-hospital settings, it is extremely important for nurses to be knowledgeable of SIRS and sepsis signs and symptoms in order to advocate appropriately for patients. Due to the lack of medical resources and the expectation that nurses are the eyes and ears of distant doctors, a complete picture of the patient should be communicated, including all vital signs, nursing interventions done, and evaluation of those interventions.

The Surviving Sepsis Campaign website is a good place to start. While geared toward acute care facilities, much information can be gleaned from the website for use in other care environments. Please see http://www.survivingsepsis.org/Pages/default.aspx.

References

Mayo Clinic. (2014). Sepsis symptoms. Retrieved from http://www.mayoclinic.org/diseases-conditions/sepsis/basics/symptoms/con-20031900

Kaplan, L. J. (2014). Systemic inflammatory response syndrome. Retrieved from http://emedicine.medscape.com/article/168943-overview#showall

[Here.I.Stand, BSN, RN]

I'm glad she's ok!! You're absolutely right--

In non-hospital settings, it is extremely important for nurses to be knowledgeable of SIRS and sepsis signs and symptoms in order to advocate appropriately for patients. Due to the lack of medical resources and the expectation that nurses are the eyes and ears of distant doctors, a complete picture of the patient should be communicated, including all vital signs, nursing interventions done, and evaluation of those interventions.

[dudette10, MSN, RN]

It's also important to note that the continuum from sepsis to severe sepsis can happen very quickly. In the absence of fever, the respiratory rate with possible sources of infection will be the first indicator. (Can't provide a reference for that but our sepsis protocol inservices emphasized that.) My loved one was congested with an elevated RR. The spike in temp came next. Pneumonia is one of the most common diagnoses that can progress to sepsis. Her increased oxygen demands are what concerned me the most.

Fever often comes later in the process, as it takes time for the body to increase temp. I have had two memorable rapid responses in acute care where the patient had a diagnosed infection on admission, and the elevated RR and oxygen demands acutely presented. Temp was normal at the beginning of the rapid response, but by the end, it shot up to over 101. Fever presentation can happen quickly, but it is not, statistically speaking, the first indicator. Respiratory rate is.

However, I caution taking single pieces and reacting to them, especially for new grads. It's a bigger clinical picture that drives actions. A COPDer with pneumonia can be stepped down from ICU with an elevated RR and higher oxygen demands than at home and also mild tachycardia, but is the patient clinically improving? At that point, when they already have abx on board, the snapshot picture is incomplete.

[BrandonLPN, LPN]

Why on earth would a nurse call the doctor and not tell him the vital signs? What a waste of time.

[dudette10, MSN, RN]

I don't know, but he didn't ask, either.

[Been there,done that, ASN, RN]

You are spot on with the assessment, rationale and quoted protocols.

However in the real world .. protocols are NEVER carried out according to the book.

Each scenario is dependent on the players.

My father died from sepsis, because.. those involved did not follow the allmighty protocol.

[Susie2310]

dudette10, I'm very glad to hear that your family member is recovering from severe sepsis.

I just wanted to mention that the Medscape article does mention that SIRS can be caused by severe infection, along with other causes.

[dudette10, MSN, RN]

dudette10, I'm very glad to hear that your family member is recovering from severe sepsis.

Thank you, Susie. However, the day I wrote it was Monday morning, and it looked like she would beat it. Unfortunately, the antibiotics were little good, as she continued to have a fever, so they entertained viral and did a nasopharyngeal swab. She has Influenza A. Monday afternoon, her O2 requirements started increasing again. Today, full-blown ARDS, and we made her comfort care.

[Susie2310]

dudette10, I am so very sorry.

My family member squeaked through severe sepsis/SIRS. I am so sorry for what you are all going through. I wish I could say something more helpful.

[dudette10, MSN, RN]

The fact that she has flu A brings me to another point (reference below). Make sure your loved ones at risk for flu get the shot as early as possible in the season so that they are protected as quickly as possible. I failed to do that. The NH called me only three weeks ago for flu shot consent, which was about five weeks after this season's vaccine was released.

What You Should Know for the 2014-2015 Influenza Season | Seasonal Influenza (Flu) | CDC

[dudette10, MSN, RN]

dudette10, I am so very sorry.

My family member squeaked through severe sepsis/SIRS. I am so sorry for what you are all going through. I wish I could say something more helpful.

Your sympathy is much appreciated.

[Susie2310]

Your sympathy is much appreciated.

Please take care.