nursing essay on sepsis

High School
You don't have any recent items yet.
You don't have any modules yet.
You don't have any books yet.
You don't have any Studylists yet.
Information

Sepsis Essay Complete copy

Managing care for the adult patient (mod003302), anglia ruskin university, students also viewed.

Episode of care Gibb's model
Literature Critical Appraisal Framework 2020
Credibility Interview
Balfour v balfour-Merrit v merrit
The cardiovascular system- week 1 A&P
MEMO - dr. okunola - Legal opinion

Related Studylists

Preview text, recognising and, responding to an acutely-, ill patient with sepsis, word count: 3000.

Table of Contents

Introduction............................................................................................................................
Analysing the ABCDE assessment..................................................................................

Pathophysiology of Sepsis................................................................................................

Management of sepsis.........................................................................................................

Psychosocial impact of sepsis.........................................................................................
Conclusion............................................................................................................................
References............................................................................................................................

addition, I will use the Situation Background Assessment Recommendation (SBAR) tool to identify who I will escalate Julia to, recommended by NICE (2020).

Firstly, I will introduce myself to Julia as recommended by Granger (2013). I will gain informed consent from Julia prior to conducting the analysis (Royal college of Nursing (RCN), 2017). I will also maintain dignity and respect throughout the analysis (NMC, 2020). I will explain to Julia that I will be analysing her assessment.

Airway (A) Julia’s is talking in full sentences, indicating the airway is patent (Resus council, 2017).

Breathing (B) According to BTS (2020), the normal range is 12 to 20 breath per minute. However Julia’s has a respiratory rate of 28 breath per minute, indicating she is tachypneic, therefore scoring 3 on the NEWS2 chart. In addition, the normal arterial oxygen saturation is 94% to 98% for a patient without a known COPD or risk factors for hypercapnic respiratory failure (BTS, 2020). Julia has an oxygen Saturation of 91%, suggesting she is hypoxic, and therefore scoring 3 on the NEWS chart. Julia’s chest is clear, indicating there are no signs of pulmonary oedema.

Circulation (C) According to the British Heart Foundation (BHF) (2019), the normal range is 60 to 100 beats per minute. Julia’s heart rate is 112 beat per minute, indicating she is tachycardic, scoring 2 on the NEWS2 chart. The BHF (2019) states that the normal blood pressure range is 100/60 mmHg to 140/90 mmHg. Julia has a blood pressure reading of 89/45. This suggests she is hypotensive, therefore scoring 3 on the NEWS2 chart. The normal human body temperature range is 36 to 37°C (BHF, 2019). Julia has a high temperature of 39°C, indicating Julia is pyrexic, scoring 2 on the NEWS2 chart. The normal value of the Capillary refill time (CRT) is less than 2 seconds (Dutton & Finch, 2018). Julia’s CRT value is 2 seconds, which indicates slightly poor peripheral perfusion. The normal urine output ranges between 0/kg/hr to 1/kg/hr (Tait et al., 2016). Julia had a decreased urine output from 30 mls/hr to 10 mls/hr in the last three hours with weight of 75kgs, indicating signs of

oliguria. A normal blood lactate level is 0-1 mmol/L (Dutton & Finch, 2018). Julia has a lactate level of 6 mmols/L, indicating there is inadequate delivery of oxygen and tissue hypoxia.

Disability (D) As Julia is a type 2 diabetic patient the normal blood glucose pre-prandial is between 4 to 7 mmol/L and under 8 mmol/L when tested 90 minutes post-prandial, according to Diabetes UK (2019). Julia’s blood glucose is slightly elevated to 9. mmols/L. The elevation indicates Julia may potentially be experiencing potentially mild hyperglycaemia. Julia is alert and orientated, indicating good perfusion to the brain, therefore scoring 0 on the NEWS2 chart.

Exposure (E) The red hot shiny swollen skin in the left hand extending from the finger to the axilla, suggests an increase of blood flow in the affected area and confirms the localised infection cellulitis.

After conducting the analysis, I have identified the red flags of sepsis based of the parameters and the total NEWS2 aggregated score of 13. As indicated by the NEWS2 chart, Julia is at a high clinical risk, Julia needs to be in a high dependency unit requiring emergency attention. Therefore, using the SBAR I will escalate her to the critical care outreach.

The tissue injury on Julia left index finger enabled cellulitis to get past the skin and mucous membrane barrier. Cellulitis is a common bacterial infection that involves the skin, specifically the dermis and subcutaneous fat (Raff & Kroshinsky, 2016). which triggered a widespread host response. The host response comprises of the activation of innate immune cells (white blood cells (WBCs), particularly neutrophils and monocytes), coagulation system (plasma proteins which result in blood clotting), complement system (plasma proteins which aid in fighting infections), and endothelial cells (inner lining of the blood vessels) (Ashelford et al., 2019).

angiotensin-1. Angiotensin-1 is converted in the lungs by angiotensin converting enzyme into angiotensin-2 (a potent vasoconstrictor) (Totora & Derrickson, 2015). Angiotensin-2 increases vascular resistance, increasing blood pressure to normal (Atlas, 2007). Angiotensin-2 also stimulates the secretion of aldosterone causing sodium and water retention into vessels, increasing blood volume, and subsequently increases blood pressure. In addition, the retention of fluid and electrolytes in the kidney, which decreases urinary excretion (Hunt, 2019), decreasing her urine output from 30 mls/hr to 10 mls/hr in the last three hours, causing Julia to become oliguric. Angiotensin-2 also triggers sympathetic stimulations to release epinephrine and norepinephrine hormones (Totora & Derrickson, 2015). This increases contractility and heart rate to112 bpm in Julia to compensate the fall in cardiac output. Angiotensin-2 also stimulates the SNS to release antidiuretic hormones to aid in water retention increasing blood volume, causing vasoconstrictions (Hunt, 2019).

Systemic effects such as fever, occur due to the inflammatory mediators (Groeneveld et al., 2012), causing Julia to become hyperpyrexic at 39°C. In addition, stress hormones such as glucagon, raises glucose levels and insulin resistance as a defense mechanism for fighting infections (Ballantyne, 2019), which may have caused the slight elevation in Julia’s blood glucose to 9 mmols /L.

There are various guidelines that recommend a range of treatment and management interventions, of which I will use to stop Julia from deterioration. NICE (2020) guideline suggests the Sepsis Six pathway whereas the RCUK (2020) recommends the ABCDE approach. Both methods have resulted in the improvement of patient outcomes (Thim, et al., 2012 and Ashelford et al., 2019). It is essential to carry out the intervention within an hour (Dutton and Finch, 2018).

Airways (A) Julia’s airway is patent, however I will monitor her to ensure she maintains ventilation (RNUK, 2020).

Breathing (B)

I will assist into an upright position, by laying her flat with the legs raised. administer high-flow oxygen 15 litres using a non-rebreathe mask and an oxygen reservoir bag (NICE, 2020). The oxygen supply will be combined with compressed air and humidification as oxygen can result in Julia experiencing dry nose, mouth and throat (O'Driscoll, et al., 2019). Doing this is aimed to reduce hypoperfusion and increase blood pressure (Ashelford et al., 2019).

Circulation (C)

I will take blood tests for blood gases (particularly glucose and lactate), other biochemical, coagulation and haematological routine checks, and samples for microbiological investigations to confirm cellulitis or identify another pathogen (RNUK, 2020). If possible, I will aim to request a blood culture before infusion of intravenous fluid (NICE, 2020). I will insert two wide bore intravenous cannulae into and administer a bolus of 500ml of warmed crystalloid solution (for example, Hartmann’s solution) to restore tissue perfusion, for under 15 minutes as Julia is hypotensive (RNUK, 2020). Fluid replacement increases fluid retention restoring blood pressure (Ashelford et al., 2019). I will regularly reassess Julia’s heart rate and blood pressure, with the aim of her blood pressure returning to normal (RNUK, 2020). I will monitor Julia to see whether she improves after the fluid intake. If there is no improvement, I will administer a second dose of fluid replacement. I will use SBAR to seek assistance if she fails to respond to the repeated boluses of fluid. I will also administer a broad-spectrum antibiotic intravenously dependent on local resistance patterns (Ashelford et al., 2019), which should be given within an hour after sepsis diagnosis (NICE, 2013). I will also keep an eye on her serial lactate measurement for potential further deterioration (e. septic shock) (Dutton and Finch, 2018). In addition, monitoring lactate measurement aids in showing the effectiveness of oxygen therapy and fluids (Ashelford et al., 2019). I will insert catheter in order to monitor Julia’s hourly urine output using the fluid balance chart. This also aids in to monitoring cardiac output, which also aids in monitoring Julia’s response to treatment (Ashelford et al., 2019).

her needs and wishes, respect for dignity and attempts in delivering holistic care. (RCN, 2017).

By maintaining the 6C’s (NMC, 2015), I will communicate effectively by informing Julia of the multidisciplinary team participating in her care and any events that will take place such as ward transfers and treatment. I will also provide compassionate care by showing personal interest (NMC, 2015), through reassurance of the team doing their best for her recovery. I will be conscious of potential stressors such as anxiety which may as a result of being diagnosed with sepsis. I will provide Julia with opportunities to speak about potential anxieties she may be experiencing through asking certain questions, which also aids in developing a trusting relationship with her (Dutton and Finch, 2018).

As part of the discharge planning, I will refer her to diabetic nurse who will review her medications and educate her with lifestyle advice, to include monitoring and maintain a normal level blood glucose (Dutton and Finch, 2018). I will refer Julia to the pain management team, which they will review her pain medication with the doctor as pain might affect sleep at night and might have an impact on her healing process. I will refer Julia to a physiotherapist and occupational therapist team, which they will support Julia to get her independence by giving her hand movement exercise, which will help her gain hand mobility before discharging her and obtaining equipment as she might need assistance at home to help with her living after discharge (NICE, 2018). I will also refer her to the GP as a follow up check-up to monitor her co-morbidities. I will request that the GP should measure her blood pressure regularly and also alert her GP in circumstances where her blood pressure reading is not accurate (NICE, 2018), and review her current medication for her history of hypertension.

I will discuss attaining consent for the involvement of family, friends or social services support as part of the integrated-care strategy, as there no indication of her family on admission (Dutton and Finch, 2018). Should she consent to social services, they will look in her financial, practical and social issues, of which they will put together a package of care for her. This will enable her to be in contact with a team of support workers and professionals to regularly do a home visit to help her with her daily

actives (e. cooking. Shopping and cleaning until she recovers) (Dutton and Finch, 2018).

The case scenario highlights the importance for recognising and responding to acutely-ill patients with sepsis Early diagnosis is vital for the instigation of treatment as soon as possible to ensure best outcomes as delay in treatment can lead to death. It also highlights the importance the various pathways ABCDE, SBAR tool and the NEWS2 early warning score tool, as triggers for diagnosis of sepsis, leading to early recognition and treatment Using the NEWS2, designated by the NHS has improved the identification of patients with possible sepsis, hence no need for an additional step in the pathway to admission for. Furthermore, the case study also highlights the importance of improving the outcome of the patient using the sepsis six pathway and Resus Council guideline, as both stipulates the importance of early treatment and monitoring approaches. In addition, a holistic approach is vital for providing support for an acutely-ill patient by taking into consideration the physical, emotional, social economic and spiritual needs. Furthermore, using an integrated- care approach with family, friends and social service achieves improvement in patients’ health and well-being. Finally, following ethical and legal principles demonstrates the competence of a nurse as well as meeting the NMC standard of care for patients.

Nursing and Midwifery Council, 2015. The Code: Professional Standards Of Practice And Behaviour For Nurses, Midwives And Nursing Associates. [online] Nmc. Available at: <nmc/standards/code/> [Accessed 21 April 2020].

National Institute for Health and Care Excellence, 2013. Overview | Intravenous Fluid Therapy In Adults In Hospital | Guidance | NICE . [online] Nice. Available at: <nice/Guidance/CG174> [Accessed 23 April 2020].

National Institute for Health and Care Excellence, 2020. The Technology | National Early Warning Score Systems That Alert To Deteriorating Adult Patients In Hospital | Advice | NICE . [online] Nice. Available at: <nice/advice/mib205/chapter/The-technology> [Accessed 21 April 2020].

O'Driscoll, B., Howard, L., Earis, J. and Mak, V., 2019. BTS Guideline For Oxygen Use In Adults In Healthcare And Emergency Settings , British Thoracic Society, [e- journal] 71(1). Available through: ARU Library website <library.aru> [Accessed 14 April 2020].

Payne, L., 2011. Nursing Student's Guide To Clinical Success . 1st ed. Sudbury: Jones and Bartlett Publishers

Raff, A. B., & Kroshinsky, D. (2016). Cellulitis: A Review. JAMA , 316 (3), 325–337. doi/10.1001/jama.

Resuscitation Council, 2019. ABCDE Approach . [online] Resus. Available at: <resus/resuscitation-guidelines/abcde-approach/> [Accessed 22 April 2020].

Royal College of Nursing, 2017. Principles Of Consent | Royal College Of Nursing . [online] The Royal College of Nursing. Available at: <rcn/professional-development/publications/PUB-006047> [Accessed 20 April 2020].

Rojo del Moral, O., Mena-Arceo, R., García-García, A. and Ñamendys-Silva, S., 2018. Organ Function Assessment, Prevention, and Outcomes in Critically Ill Patients with Sepsis. American Journal of Respiratory and Critical Care Medicine, [e- journal] 198(11). Available through: ARU Library website <library.aru> [Accessed 30 March 2020].

Royal College of Physician, 2017. [online] Rcplondon. Available at: <rcplondon/file/8636/download?token=eTi9LiBh> [Accessed 26 April 2020].

Rubin, I., Merrick, J., Greydanus, D. and Patel, D., 2016. Health Care For People With Intellectual And Developmental Disabilities Across The Lifespan. 3rd ed. Switzeland: Springer, p.

Tait, D., James, J., Williams, C. and Barton, D., 2016. Acute And Critical Care In Adult Nursing . 2nd ed. London: Sage

Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine , [e-journal] 5 , 117–121. Available through: ARU Library website <library.aru> [Accessed 24 April 2020].

Totora, J & Derrickson, B, 2015. Introduction to the human body. 10 th ed. Massachusetts: John Wiley and Sons, Inc.

Zhang, J.-M., & An, J. (2007). Cytokines, inflammation, and pain. International Anesthesiology Clinics , [e-journal] 45 (2), 27–37. Available through: ARU Library website <library.aru> [Accessed 14 April 2020].

Multiple Choice

Module : Managing Care for the Adult Patient (MOD003302)

University : anglia ruskin university.

More from: Sophie study list by Sophie Ohaeri 8 8 documents Go to Studylist

Sepsis and Septic Shock

Sepsis and septic shock stand as life-threatening conditions that demand swift and vigilant action from healthcare providers, with nurses playing a pivotal role in their management. As frontline caregivers , nurses are essential in recognizing early signs of sepsis, initiating prompt interventions, and providing comprehensive care to improve patient outcomes .

This article aims to highlight the critical importance of nursing in battling sepsis and septic shock, shedding light on the pathophysiology, risk factors, clinical presentations, and evidence-based interventions. By fostering a comprehensive understanding of these conditions, nurses can proactively contribute to saving lives and minimizing the burden of sepsis on patients and healthcare systems.

What is sepsis and septic shock , pathophysiology, epidemiology, clinical manifestations, complications, assessment and diagnostic findings, medical management, nursing assessment, planning & goals, nursing interventions, discharge and home care guidelines, documentation guidelines.

One of the most common types of circulatory shock and the incidences of this disease continue to rise despite the technology.

Sepsis is a systemic response to infection . It is manifested by two or more of the SIRS (Systemic Inflammatory Response Syndrome) criteria as a consequence of documented or presumed infection.
Septic shock is associated with sepsis. It is characterized by symptoms of sepsis plus hypotension and hypoperfusion despite adequate fluid volume replacement.

The pathophysiology of sepsis involves an evolving process. The following shows the process of how sepsis works its way inside of our body.

Microorganisms invade the body tissues and in turn, patients exhibit an immune response.
The immune response provokes the activation of biochemical cytokines and mediators associated with an inflammatory response.
Increased capillary permeability and vasodilation interrupt the body’s ability to provide adequate perfusion, oxygen , and nutrients to the tissues and cells.
Proinflammatory and anti-inflammatory cytokines released during the inflammatory response and activates the coagulation system that forms clots whether or not there is bleeding .
The imbalance of the inflammatory response and the clotting and fibrinolysis cascades are critical elements of the physiologic progression of sepsis in affected patients.

Sepsis has affected a lot of people in the United States and around the world as well. The rise in the numbers of those affected with sepsis is alarming and should be given utmost attention.

Annually, an estimated 750, 000 people in the United States are affected by sepsis.
By 2010, the rate may increase up to 1 million cases every year.
Elderly patients are at most risk for developing sepsis because of decreased physiologic reserves and an aging immune system.
Gram-positive bacteria accounts for 50% of cases of septic shock.
It is also estimated that 20% to 30% with severe sepsis may never identify the site of infection.

There are several factors that can put the patient at risk for septic shock, and these include:

Patients with immunosuppression have greater chances of acquiring septic shock because they have decreased immune system, making it easier for microorganisms to invade the body tissues.
Extremes of age. Elderly people and infants are more prone to septic shock because of their weak immune system .
Malnourishment . Malnourishment can lower the body’s defenses, making it susceptible to the invasion of pathogens.
Chronic illness. Patients with a longstanding illness are put at risk for sepsis because the body’s immune system is already weakened by the existing pathogens.
Invasive procedures. Invasive procedures can introduce microorganisms inside the body that could lead to sepsis.

The signs and symptoms that are associated with septic shock and sepsis include the following:

Since the ability of the body to provide oxygen and nutrients is interrupted, the heart compensates by pumping faster.
Hypotension occurs because of vasodilation .
To compensate for the decreased oxygen concentration, the patient tends to breathe faster, and also to eliminate more carbon dioxide from the body.
The inflammatory response is activated because of the invasion of pathogens.
Decreased urine output. The body conserves water to avoid undergoing dehydration because of the inflammatory process.
Changes in mentation . As the body slowly becomes acidotic, the patient’s mental status also deteriorates.
Elevated lactate level. The lactate level is elevated because there is maldistribution of blood .

Before sepsis could invade a patient’s body, it is better to prevent its occurrence here are some ways to prevent sepsis and septic shock.

Strict infection control practices. To prevent the invasion of microorganisms inside the body, infection must be put at bay through effective aseptic techniques and interventions.
Prevent central line infections . Hospitals must implement efficient programs to prevent central line infections, which is the most dangerous route that can be involved in sepsis.
Early debriding of wounds. Wounds should be debrided early so that necrotic tissue would be removed.
Equipment cleanliness. Equipment used for the patient, especially the ones involved in invasive procedures, must be properly cleaned and maintained to avoid harboring harmful microorganisms that can enter the body.

Complications could happen in a patient with sepsis if it is not properly treated or not treated at all.

Severe sepsis. Sepsis could progress to severe sepsis with symptoms of organ dysfunction, hypotension or hypoperfusion, lactic acidosis, oliguria, altered level of consciousness, coagulation disorders, and altered hepatic functions.
Multiple organ dysfunction syndrome . This refers to the presence of altered function of one or more organs in an acutely ill patient requiring intervention and support of organs to achieve physiologic functioning required for homeostasis .

Early assessment and diagnosis of the infection must be established to avoid its progression.

Blood culture. To identify the microorganism responsible for the disease, a blood culture must be performed.
Liver function test. This should be performed to detect any alteration in the function of the liver.
Blood studies. Hematologic test must also be performed to check on the perfusion of the blood.

The current treatment of septic shock and sepsis include identification and elimination of the cause of infection.

Fluid replacement therapy . The therapy is done to correct the tissue hypoperfusion, so aggressive fluid resuscitation must be implemented.
Nutritional therapy . Aggressive nutritional supplementation is critical in the management of septic shock because malnutrition further impairs the patient’s resistance to infection.

Nursing Management

Nurses must keep in mind that the risks of sepsis and the high mortality rate associated with sepsis, severe sepsis, and septic shock.

Assessment is one of the nurse ’s primary responsibilities, and this must be done precisely and diligently.

Signs and symptoms . Assess if the patient has positive blood culture, currently receiving antibiotics , had an examination or chest x-ray , or has a suspected infected wound.
Signs of acute organ dysfunction . Assess for presence of hypotension, tachypnea , tachycardia, decreased urine output, clotting disorder, and hepatic abnormalities.

Sepsis can affect a lot of body systems and even cause their failure, so diagnosis is an important part of the process to establish the presence of sepsis.

Risk for deficient fluid volume related to massive vasodilation.
Risk for decreased cardiac output related to decreased preload .
Impaired gas exchange related to interference with oxygen delivery.
Risk for shock related to infection.

Healthcare team members should be prepared with a care plan for the patient for a more systematic and detailed achievement of the goals.

Patient will display hemodynamic stability.
Patient will verbalize understanding of the disease process.
Patient will achieve timely wound healing .

Nursing interventions pertaining to sepsis should be done timely and appropriately to maximize its effectivity.

Infection control . All invasive procedures must be carried out with aseptic technique after careful hand hygiene .
Collaboration . The nurse must collaborate with the other members of the healthcare team to identify the site and source of sepsis and specific organisms involved.
Management of fever . The nurse must monitor the patient closely for shivering.
Pharmacologic therapy . The nurse should administer prescribed IV fluids and medications including antibiotic agents and vasoactive medications.
Monitor blood levels . The nurse must monitor antibiotic toxicity, BUN, creatinine , WBC, hemoglobin , hematocrit, platelet levels, and coagulation studies.
Assess physiologic status . The nurse should assess the patient’s hemodynamic status, fluid intake and output , and nutritional status .

After implementation of the interventions, the nurse must evaluate their effectiveness.

Patient displayed hemodynamic stability.
Patient verbalized understanding of the disease process.
Patient achieved timely wound healing .

Even after discharge, the patient must still be taught how to establish home and community care regimen.

Prevent shock episodes . The nurse should instruct the patient and the family strategies to prevent shock episodes through identifying the factors implicated in the initial episodes.
Instructions on assessment . The patient and the family should be taught about assessments needed to identify the complications that may occur after discharge.
Treatment modalities . The nurse must teach the patient and the family about treatment modalities such as emergency administration of medications, IV therapy , parenteral or enteral nutrition , skin care , exercise, and ambulation .

Proper documentation must be established both for legal protection and data organization.

Document individual risk factors.
Document assessment findings.
Document results of the laboratory tests and diagnostic studies.
Document plan of care and teaching plan.
Document client’s responses to treatment, teaching, and actions performed.
Document modifications in the plan of care.

Posts related to Sepsis and Septic Shock:

Risk for Infection

1 thought on “Sepsis and Septic Shock”

I’m not sure if you are aware, but under “Medical Management: Pharmacologic Therapy” Drotrecogin alfa by Eli Lily & Company (pharm company) was taken off the market on Oct of 2011. Good luck with all your endeavors and keep up the good work!

Sepsis assessment and management in critically Ill adults: A systematic review

Contributed equally to this work with: Mohammad Rababa, Dania Bani Hamad, Audai A. Hayajneh

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Adult Health Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Mohammad Rababa,
Dania Bani Hamad,
Audai A. Hayajneh

Published: July 1, 2022
https://doi.org/10.1371/journal.pone.0270711
Reader Comments

Early assessment and management of patients with sepsis can significantly reduce its high mortality rates and improve patient outcomes and quality of life.

The purposes of this review are to: (1) explore nurses’ knowledge, attitude, practice, and perceived barriers and facilitators related to early recognition and management of sepsis, (2) explore different interventions directed at nurses to improve sepsis management.

A systematic review method according to the PRISMA guidelines was used. An electronic search was conducted in March 2021 on several databases using combinations of keywords. Two researchers independently selected and screened the articles according to the eligibility criteria.

Nurses reported an adequate of knowledge in certain areas of sepsis assessment and management in critically ill adult patients. Also, nurses’ attitudes toward sepsis assessment and management were positive in general, but they reported some misconceptions regarding antibiotic use for patients with sepsis, and that sepsis was inevitable for critically ill adult patients. Furthermore, nurses reported they either were not well-prepared or confident enough to effectively recognize and promptly manage sepsis. Also, there are different kinds of nurses’ perceived barriers and facilitators related to sepsis assessment and management: nurse, patient, physician, and system-related. There are different interventions directed at nurses to help in improving nurses’ knowledge, attitudes, and practice of sepsis assessment and management. These interventions include education sessions, simulation, decision support or screening tools for sepsis, and evidence-based treatment protocols/guidelines.

Our findings could help hospital managers in developing continuous education and staff development training programs on assessing and managing sepsis in critical care patients.

Nurses have poor to good knowledge, practices, and attitudes toward sepsis as well as report many barriers related to sepsis management in adult critically ill patients. Despite all education interventions, no study has collectively targeted critical care nurses’ knowledge, attitudes, and practice of sepsis management.

Citation: Rababa M, Bani Hamad D, Hayajneh AA (2022) Sepsis assessment and management in critically Ill adults: A systematic review. PLoS ONE 17(7): e0270711. https://doi.org/10.1371/journal.pone.0270711

Editor: Paavani Atluri, Bay Area Hospital, North Bend Medical Center, UNITED STATES

Received: December 1, 2021; Accepted: June 14, 2022; Published: July 1, 2022

Copyright: © 2022 Rababa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the article and its files.

Funding: This study was funded by The deanship of research at Jordan University of Science and Technology (grant number 20200668).

Competing interests: The authors have declared that no competing interests exist.

Introduction

Sepsis is a global health problem that increases morbidity and mortality rates worldwide and which is one of the most common complications documented in intensive care units (ICUs) [ 1 ]. About 48.9 million cases of sepsis and 11 million sepsis-related deaths were documented in 2017 worldwide [ 2 ]. Sepsis is an emergency condition leading to several life-threatening complications, such as septic shock and multiple organ dysfunction and failure [ 3 ]. Sepsis has negative physiological, psychological, and economic consequences. Untreated sepsis can lead to septic shock; multiple organ failure, such as acute renal failure [ 4 ]; respiratory distress syndrome [ 5 ]; cardiac arrhythmia (e.g. Atrial Fibrillation) [ 6 ]; and disseminated intravascular coagulation (DIC) [ 7 ]. Also, sepsis is associated with anxiety, depression, and post-traumatic stress disorder [ 8 ]. As for the financial burden of sepsis on the healthcare system, the cost of healthcare services and supplies for ICU critical care patients with sepsis is high [ 1 ]. In 2017, the estimated annual cost of sepsis in the United States (US) was over $24 billion [ 2 ].

Previous studies have shown that among nurses, misunderstanding and misinterpretation of the early clinical manifestations of sepsis, poor knowledge, attitudes, and practices related to sepsis, and inadequate training might lead to delayed assessment and management of sepsis [ 9 – 11 ]. Moreover, the limited numbers of specific and sensitive assessment tools and standard protocols for the early identification and assessment of sepsis in critical care patients leads to delayed management, therefore increasing sepsis-related mortality rates [ 10 ].

Critical care nurses, as frontline providers of patient care, play a vital role in the decision-making process for the early identification and prompt management of sepsis [ 11 ]. Therefore, improving nurses’ knowledge, attitudes, and practices related to the early identification and management of sepsis is associated with improved patient outcomes [ 12 , 13 ]. To date, there remains a wide gap between the findings of previous research and sepsis-related clinical practice in critical care units (CCUs). Furthermore, there is no evidence in the nursing literature regarding nurses’ knowledge, attitudes, and practices related to the early identification and management of sepsis in adult critical care patients and the association of these factors with patient health outcomes. Therefore, summarizing and synthesizing the existing research on sepsis assessment and management among adult critical care patients is needed to guide future directions of sepsis-related clinical practice and research. Accordingly, this review aims to identify nurses’ knowledge, and attitudes, practices related to the early identification and management of sepsis in adult critical care patients.

Materials and methods

The present review used a systematic review design guided by structured questions constructed after reviewing the nursing literature relevant to sepsis assessment and management in adult critical care patients. The authors (MR, DB, AH) carefully reviewed and evaluated the selected articles and synthesized and analyzed their findings to reach a consensus. This review was guided by the following questions: (a) what are nurses’ knowledge, attitudes, and practices related to sepsis assessment and management in adult critical care patients?, (b) what are the perceived facilitators of and barriers to the early identification and effective management of sepsis in adult critical care units?, and (c) what are the interventions directed at improving nurses’ sepsis assessment and management?

Eligibility criteria

The review questions were developed according to the PICOS (Participants, Interventions, Comparisons, Outcome, and Study Design) framework, as displayed in Table 1 .

PPT PowerPoint slide
PNG larger image
TIFF original image

https://doi.org/10.1371/journal.pone.0270711.t001

Inclusion criteria.

The articles were retrieved and assessed independently by two researchers (MR, DB) according to the following inclusion criteria: (1) being written in English, (2) having an abstract and reference list, (3) having been published during the past 10 years, (4) focusing on critical care nurses as a target population, (5) examining knowledge, attitudes, and practices related to the assessment and management of sepsis, and (6) having been conducted in adult critical care units.

Exclusion criteria.

Studies were excluded if they were (1) written in languages other than English, and (2) conducted in pediatric critical care units or non-ICU. Dissertations, reports, reviews, editorials, and brief communications were also excluded.

Search strategy.

An electronic search of the databases CINAHL, MEDLINE/PubMed, EBSCO, Embase, Cochrane, Scopus, Web of Science, and Google Scholar was conducted using combinations of the following keywords: critical care, intensive care, critically ill, critical illness, knowledge, awareness, perception, understanding, attitudes, opinion, beliefs, thoughts, views, practice, skills, strategies, approaches, barriers, obstacles, challenges, difficulties, issues, problems, limitations, facilitators, motivators, enablers, sepsis, septic, septic shock, and septicemia. The search terms used in this review were described in S1 File . The search was initially conducted in March 2021, and a search re-run was conducted in April 2022. The search was conducted in the selected databases from inception to 4/2022. The initial search, using the keywords independently, resulted in 1579 articles, and after using the keyword combinations, this number was reduced to 241 articles. Then, after applying the inclusion and exclusion criteria, the number of articles was reduced to 92. A manual search of the reference lists of the 92 articles was carried out to identify any relevant publications not identified through the search. The researcher (MR) used the function “cited by” on Google Scholar to explore these publications in more depth. The researchers (MR, DB) then screened the identified citations of these publications, applying the eligibility criteria. In case of discrepancies, the researchers (MR, DB) discussed their conflicting points of view until a consensus was reached. Then, after careful reading of the article abstracts, 61 irrelevant articles were excluded, and a total of 31 articles were included in this review. Fig 1 below shows the Preferred Reporting Items for Meta-Analysis (PRISMA) checklist and flow chart used as a method of screening and selecting the eligible studies.

https://doi.org/10.1371/journal.pone.0270711.g001

Data extraction

The following data were extracted from each of the selected studies: (1) the general features of the article, including the authors and publication year; (2) the characteristics of the study setting (e.g., single vs. multisite); (3) the sociodemographic and clinical characteristics of the target population, including mean age, and medical diagnosis (e.g., sepsis, septic shock, and SIRS); (4) the name of the sepsis protocol used, if any; (5) the characteristics of the study methodology (e.g., sample size and measurements); (7) the main significant findings of the study; and (8) the study strengths and limitations. All extracted data were summarized in an evidence-based table ( Table 2 ). Data extraction was performed by two researchers (MR, DB). An expert third researcher (AH) was consulted to reach a consensus between the two researchers throughout the process of data extraction.

https://doi.org/10.1371/journal.pone.0270711.t002

Ethical considerations

There was no need to obtain ethical approval to conduct this systematic review since no human subjects were involved.

Quality assessment and data synthesis

A quality assessment of the selected studies was performed independently by two researchers based on the guidelines of Melnyk and Fineout-Overholt [ 14 ]. Disagreements between the two researchers (MR, DB) were identified and resolved through a detailed discussion held during a face-to-face meeting. For complicated cases, the researchers (MR, DB) requested a second opinion from a third researcher (AH). According to the guidelines of Melnyk and Fineout-Overholt [ 14 ], twelve of the studies were at level 3 in terms of quality, four studies at level 5, and nine studies at level 6.

A qualitative synthesis was performed to synthesize the findings of the reviewed studies. The following steps were applied throughout the process of data synthesis:

The data in the selected studies were assessed, evaluated, contrasted, compared, and summarized in a table ( Table 2 ). This data included the design, purpose, sample, main findings, strengths/limitations, and level of evidence for each of the studies.
The similarities and differences between the main findings of the selected studies were highlighted.
The strengths and limitations of the reviewed studies were discussed.

Description of the selected studies

Most of the reviewed studies were conducted in Western countries [ 9 , 11 , 12 ], with only one study conducted in Eastern countries [ 1 ], and two in Middle-Eastern countries [ 15 , 16 ]. The detailed geographical distribution of the studies and other characteristics are described in Table 2 .

Nurses’ knowledge, attitudes, and practices

Nine of the selected studies assessed nurses’ knowledge and attitudes related to sepsis assessment and management in critically ill adult patients [ 1 , 9 , 12 , 15 , 17 – 21 ] ( Table 3 ) . Nucera et al. [ 18 ] found that ICU nurses had poor attitudes towards blood culture collection techniques and timing and poor levels of knowledge related to the early identification, diagnosis, and management of sepsis. For example, the majority of nurses reported that there is no need to sterilize the tops of culture bottles, and there is no specific time for specimen collection [ 18 ]. However, the participating nurses reported good levels of knowledge related to blood culture procedures and the risk factors for sepsis. Similarly, R. J. Roberts et al. [ 19 ] found the participating nurses to have good knowledge of septic shock and good attitudes toward the initiation of antibiotics for critically ill adult patients with sepsis. Only two studies assessed nurses’ practices related to sepsis assessment and management [ 15 , 19 ]. For example, in the study of R. J. Roberts et al. [ 19 ], 40% of the nurse participants reported that they were aware of the importance of initiating antibiotics and IV fluid within one hour of septic shock recognition [ 20 ]. Also, Yousefi et al. [ 15 ] found the participating nurses to have good practices related to sepsis assessment and management.

https://doi.org/10.1371/journal.pone.0270711.t003

Barriers to and facilitators of sepsis assessment and management

The reviewed studies identified three types of barriers to the early identification and management of sepsis, namely patient-, nurse-, and system-related barriers ( Table 4 ). Meanwhile, only nurse- and system-related facilitators were reported in the reviewed studies. The most-reported barriers and facilitators were system-related. The reported barriers included (a) the lack of written sepsis treatment protocols or guidelines adopted as hospital policy [ 22 , 23 ]; (b) the complexity and atypical presentation of the early symptoms of sepsis [ 19 ]; (c) nurses’ poor level of education and clinical experience [ 1 , 12 ]; (d) the lack of sepsis educational programs or training workshops for nurses [ 22 , 23 ]; (e) the high comorbid burden among patients with sepsis, which complicates the critical thinking process of sepsis management [ 19 ]; (f) nurses’ deficits in knowledge related to sepsis treatment protocols and guidelines [ 22 – 24 ]; (g) the lack of mentorship programs in which junior nurses’ actions/activities are strictly supervised by experienced nurses [ 17 , 23 ]; (h) heavy workloads or high patient-nurse ratios [ 22 ]; (i) the shortage of well-trained and experienced physicians, particularly in EDs [ 19 , 22 , 23 ]; (j) the lack of awareness related to antibiotic use for patients with sepsis [ 19 , 22 ]; (k) the lack of IV access and unavailability of ICU beds [ 25 ]; (l) the non-use of drug combinations for the treatment of sepsis [ 22 , 26 , 27 ], and (m) poor teamwork and communication skills among healthcare professionals [ 22 , 26 ]. Only three facilitators of sepsis assessment and management were identified in the reviewed studies. These facilitators were (1) nurses’ improved confidence in caring for patients with sepsis, (2) increased consistency in sepsis treatment, and (3) positive enforcement of successful stories of sepsis management [ 22 , 27 ].

https://doi.org/10.1371/journal.pone.0270711.t004

Measurement tools of sepsis-related knowledge, attitudes, and practices

One of the reviewed studies used a Knowledge, Attitudes, and Practice (KAP) questionnaire developed according to the Surviving Sepsis Campaign (SSC) guidelines [ 15 ] to measure nurses’ knowledge, attitudes, and practices related to sepsis assessment and management. Meanwhile, eight studies [ 1 , 9 , 12 , 17 – 21 ] used self-developed questionnaires based on the literature and SSC guidelines and validated by expert panels. Details of these measurement tools and their psychometric properties are summarized in Table 5 .

https://doi.org/10.1371/journal.pone.0270711.t005

Interventions directed at improving nurses’ sepsis assessment and management

Educational programs..

Only four of the selected studies examined the impact of educational programs on nurses’ knowledge, attitudes, and practices related to sepsis management and found significant improvements in nurses’ posttest scores ( Table 6 ) [ 11 , 15 , 28 , 29 ]. For example, Drahnak’s study [ 28 ] implemented an educational program developed by the authors and integrated with patients’ health electronic records (HER) and found significant improvements in nurses’ post-test nursing knowledge scores. Another educational program developed by the authors was implemented to improve ICU nurses’ knowledge, attitudes, and practices related to sepsis and found a significant improvement in posttest scores among the intervention group [ 15 ]. Another study was designed to examine the effectiveness of the Taming Sepsis Educational Program® (TSEP™) in improving nurses’ knowledge of sepsis [ 11 ]. A 15-minute structured educational session was developed to decrease the mean time needed to order a sepsis order set for critically ill patients through improving ER nurses’ knowledge about SSC guidelines and found that the mean time was reduced by 33 minutes among the intervention group [ 29 ].

https://doi.org/10.1371/journal.pone.0270711.t006

Simulation.

Only two studies examined the effect of using simulation in improving the early recognition and prompt treatment of sepsis by critical care nurses ( Table 6 ) [ 30 , 31 ]. Vanderzwan et al. [ 30 ] assessed the effect of a medium-fidelity simulation incorporated into a multimodel nursing pedagogy on nurses’ knowledge of sepsis and showed significant improvements in six of the nine questionnaire items. While Giuliano et al. examined the difference in mean times required for sepsis recognition and treatment initiation between nurses exposed to two different monitor displays in response to simulated case scenarios of sepsis and showed a significant reduction in the mean times required for sepsis recognition and treatment initiation by those nurses who were exposed to enhanced bedside monitor (EBM) display [ 31 ].

Decision support tools.

Four of the selected studies examined the effectiveness of decision support tools, adapted based on the SSC guidelines and the “sepsis alert protocol”, on the early identification and management of sepsis and confirmed the effectiveness of these tools ( Table 7 ) [ 32 – 35 ]. The decision support tools used in three of the studies guided the nurses throughout their decision-making processes to reach effective assessment, high quality and timely management of sepsis, and, in turn, optimal patient outcomes [ 32 , 33 , 35 ]. However, no significant differences in the time of blood culture collection and antibiotic administration were reported between the intervention and control groups in the study of Delawder et al. [ 34 ].

https://doi.org/10.1371/journal.pone.0270711.t007

Sepsis protocols.

Eight of the selected studies examined the effectiveness of sepsis protocols [ 24 , 36 – 38 ] and sepsis screening tools [ 16 , 39 – 41 ] for the early assessment and management of sepsis ( Table 7 ). All of these articles revealed that the implementation of sepsis screening tools or protocols based on the SSC guidelines leads to the early identification and timely management of sepsis, as well as the improvement in nurses’ compliance to the SSC guidelines for the detection and management of sepsis. For example, in one study, patients who received Early Goal-Directed Therapy (EGDT) had a lower mortality rate as compared to patients who received usual care [ 16 ]. The sepsis screening tools and guidelines were also tested to examine their impact on some patient outcomes, and variabilities were identified. For example, the use of the Modified Early Warning Score (MEW-S) tool revealed no significant improvement in patient mortality rate [ 41 ]. In contrast, mortality rates were decreased by using the Nurse Driven Sepsis Protocol (NDS) [ 40 ], Quality Improvement (QI) initiative [ 38 ], and a computerized protocol [ 37 ]. In addition, nurses in the computerized protocol group had better compliance with the SSC guidelines than did nurses in the paper-based group [ 37 ]. One of the selected studies compared between a paper-based sepsis protocol and a computer-based protocol and found that antibiotic administration, blood cultures, and lactate level checks were conducted more often and sooner by nurses in the computerized protocol group [ 37 ]. Two of the selected studies used the EGDT as a screening tool for sepsis and found no significant differences in times of diagnosis, blood culture collection, or lactate measurements between the control and intervention groups [ 16 , 24 ]. However, significant differences were found in the time of antibiotic administration in the study of Oliver et al. [ 24 ]. Although El-khuri et al. [ 16 ] revealed no significant differences in the time of antibiotic administration, the mortality rate among patients in the intervention group declined significantly.

Most of the reviewed studies focused on assessing critical care nurses’ knowledge, attitudes, and practices related to sepsis assessment and management, revealing poor levels of knowledge, moderate attitude levels, and good practices. Also, this review revealed that the three most common barriers to effective sepsis assessment and management were nursing staff shortages, delayed initiation of antibiotics, and poor teamwork skills. Meanwhile, the three most common facilitators of sepsis assessment and management were the presence of standard sepsis management protocols, professional training and staff development, and positive enforcement of successful stories of sepsis treatment. Moreover, this review reported on a wide variety of interventions directed at improving sepsis management among nurses, including educational sessions, simulations, screening or decision support tools, and intervention protocols. The impacts of these interventions on patient outcomes were also explored.

The findings of our review are consistent with the findings of previous studies which have explored critical care nurses’ knowledge related to sepsis assessment and management [ 42 ]. Also, recent studies conducted in different clinical settings support the findings of our review regarding nurses’ knowledge of sepsis. For example, a recent study conducted in a medical-surgical unit revealed that nurses had good knowledge of early sepsis identification in non-ICU adult patients [ 43 ]. The variations in nurses’ levels of knowledge related to sepsis assessment were attributed to variations in educational level and work environment (i.e., ICU vs. non-ICU).

The evidence indicates that the successful treatment of critically ill patients with suspected or actual sepsis requires early identification or assessment [ 44 , 45 ]. Early assessment is a critical step for the initiation of antibiotics for patients with sepsis, leading to improved patient outcomes and a decline in mortality rates [ 44 ]. The current review also revealed the significant role of educational programs in improving nurses’ knowledge, attitudes, and practices related to the early recognition and management of sepsis. These findings are in line with the findings of another study, which tested the impact of e-learning educational modules on pediatric nurses’ retention of knowledge about sepsis [ 45 ]. The study revealed that the educational modules improved the nurses’ knowledge acquisition and retention and clinical performance related to sepsis management [ 45 ]. The findings of our review related to sepsis screening and decision support tools are in congruence with the findings of a previous clinical trial which assessed the impact of a prompt telephone call from a microbiologist upon a positive blood culture test on sepsis management [ 46 ]. The study revealed that this screening tool contributed to the prompt diagnosis of sepsis and antibiotic administration, improved patient outcomes, and reduced healthcare costs [ 46 ]. The findings of our review related to the effectiveness of educational programs in improving the assessment and management of sepsis were consistent with the findings of a recent quasi-experimental study. The study found that incorporating sepsis-related case scenarios in ongoing educational and professional training programs improved nurses’ self-efficacy and led to a prompt and accurate assessment of sepsis [ 47 ]. One of the interventions explored in this review was a simulation that facilitated decision-making related to sepsis management. The simulation was found to be effective in mimicking the real stories of patients with sepsis and proved to be a safe learning environment for inexperienced nurses before encountering real patients, increasing nurses’ competency, self-confidence, and critical thinking skills [ 48 ]. Also, a recent study showed that the combination of different interventions aimed at targeting sepsis assessment and management, including educational programs and simulation, may lead to optimal nurse and patient outcomes [ 49 ].

Limitations

The present review has several limitations. There is limited variability in the findings of the reviewed studies in terms of the main variable, sepsis. Moreover, the review excluded studies written in languages other than English and conducted among populations other than critical care nurses. However, there may be studies written in other languages which may have significant findings not considered in this review. Further, only eight databases were used to search for articles related to the topic of interest, which may have limited the number of retrieved studies. Finally, due to the heterogeneity between the selected studies, a meta-analysis was not performed.

Relevance to clinical practice

Our findings could help hospital managers in developing continuous education and staff development training programs on assessing and managing sepsis for critical care patients. Establishing continuous education, workshops, professional developmental lectures focusing on sepsis assessment and management for critical care nurses, as well as training courses on how to use evidence-based sepsis protocol and decision support and screening tools for sepsis, especially for critical care patients are highly recommended. Also, our findings could be used to development of an evidence-based standard sepsis management protocol tailored to the unmet healthcare need of patients with sepsis.

To date, nurses remain to have poor to good knowledge of and attitudes towards sepsis and report many barriers related to the early recognition and management of sepsis in adult critically ill patients. The most-reported barriers were system-related, pertaining to the implementation of evidence-based sepsis treatment protocols or guidelines. Our review indicated that despite all educational interventions, no study has collectively targeted nurses’ knowledge, attitudes, and practices related to the assessment and treatment of sepsis using a multicomponent interactive teaching method. Such a method would aim to guide nurses’ decision-making and critical thinking step by step until a prompt and effective treatment of sepsis is delivered. Also, despite all available protocols and guidelines, no study has used a multicomponent intervention to improve health outcomes in adult critically ill patients. Future research should focus on sepsis-related nurse and patient outcomes using a multilevel approach, which may include the provision of ongoing education and professional training for nurses and the implementation of a multidisciplinary sepsis treatment protocol.

Supporting information

S1 checklist. prisma 2020 checklist..

https://doi.org/10.1371/journal.pone.0270711.s001

S1 File. Search strategies.

https://doi.org/10.1371/journal.pone.0270711.s002

Acknowledgments

The authors want to thank the Liberian of Jordan University of Science and Technology for his help in conducting this review.

View Article
PubMed/NCBI
Google Scholar
14. Melnyk BM, Fineout-Overholt E, editors. Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins; 2011.

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings
Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Early Recognition and Initial Management of Sepsis in Adult Patients

Jessie King , MD, PhD, Lead, Carol E Chenoweth , MD, Peter C England , MD, Andrew Heiler , MBA, RN, Michael T Kenes , PharmD, FCCM, BCPS, BCCCP, Krishnan Raghavendran , MD, Winnie Wood , MSN, RN, CNS, and Shiwei Zhou , MD. Clinical Guidelines Oversight: Megan Mack , MD, Dave Wesorick , MD, and April Proudlock , BBA, RN.

Affiliations

Patient Population: Sepsis is medical emergency, associated with high morbidity and mortality, and early recognition and standardized treatment of sepsis saves lives 1 . This guideline is intended for adult patients.

We recommend following the Surviving Sepsis Campaign’s International Guidelines for the Management of Sepsis and Septic Shock (2021) 2 , on which this guideline is based. We also endorse the SEP-1 treatment bundle ( Figure 1 ) as standard of care for the initial management of a patient with sepsis.

Initial Recognition and Treatment of Sepsis. * Draw one set of blood cultures from each lumen of any central venous catheter, and at least one set from a peripheral site ** For hemodynamically unstable/critically ill patients, administration of broad (more...)

Definitions: Sepsis is a syndrome characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. 1 SEP3 clinically defined sepsis as acute organ dysfunction (e.g., ≥2 new SOFA points), plus evidence of infection 2 . However for billing, documentation, and treatment purposes, the older definitions of sepsis are still used.

Sepsis: two Systemic Inflammatory Response syndrome (SIRS) criteria plus evidence of infection.

Severe sepsis: Sepsis with evidence of organ dysfunction.

Septic shock: Sepsis with persistent hypotension, despite fluid resuscitation.

Recognition of sepsis

Severe sepsis and septic shock are medical emergencies, and we recommend that sepsis improvement programs be established for all hospital units/services at Michigan Medicine with the goal of standardizing and improving early recognition, resuscitation, and treatment. (I-C)
Currently, screening tools and alerts have been put in place to help identify patients developing sepsis. We recommend that clinicians review the data in the sepsis navigator when the alert is received to determine whether the patient should be treated for sepsis. (I-E)

Initial Approach to the Sepsis Patient: The SEP-1 Bundle

Figure 1 shows a recommended approach to early recognition and initial therapy for sepsis

Antibiotics

Figure 2 summarizes the approach to empiric antibiotic recommendations for sepsis patients.
Sepsis patients with nosocomial infections, organ dysfunction, signs of hypoperfusion or shock (including elevated lactate) presumed to be the result of infection, and/or immunosuppression should be treated with the immediate initiation of broad-spectrum antibiotics, while stable sepsis patients can undergo a rapid clinical evaluation to identify the source of sepsis before initiating empiric antibiotics. (I-C)
Antimicrobial Stewardship disease state treatment guidelines should be utilized to select empiric antimicrobial therapy and to ensure appropriate dosing ( Table 1 ). (I-E)
MRSA nasal swabs, when negative, can eliminate the need for MRSA coverage in sepsis patients. (I-E)
For adults with possible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials immediately, ideally within 1 h of recognition. (I-C)
For adults with possible sepsis without shock, we suggest a time-limited course of rapid investigation, and if concern for infection persists, the administration of antimicrobials within 3 h from the time when sepsis was first recognized. (I-C)
For adults with a low likelihood of infection and without shock, we suggest deferring antimicrobials while continuing to closely monitor the patient. (II-E)

Empiric Antibiotic Recommendations. * Nosocomial infection is defined as infection onset after 48 hours of hospitalization, hospitalization or extended care facility stay within the last 90 days, or isolation of a nosocomial pathogen within the previous (more...)

Resuscitation-Fluids ( Figure 1 )

○ We suggest that 30 mL/kg (adjusted body weight for BMI > 30) of intravenous (IV) crystalloid fluid be given within the first 3 hours of resuscitation (I-E)
○ We also suggest consideration of fluid resuscitation in patients with mild lactate elevation (2-4) and/or signs/symptoms of volume-depletion (I-C).
○ We recommend using balanced crystalloids (lactated ringers) over normal saline for sepsis resuscitation (I-B)
○ We suggest considering albumin in patients who received large volume of crystalloids and have a low serum albumin over using crystalloids alone as discussed in the text (below) (II-C)
○ History of heart failure and liver failure are not contraindications to fluid resuscitation. For patients at risk for poor tolerance of fluids (e.g., reduced cardiac function, aortic stenosis, end-stage renal disease), however, we suggest frequent reassessment of intravascular volume status, with total volume of fluid-resuscitation based on response to therapy (II-E)

Resuscitation - Reassessment ( Figure 1 )

After the initial fluid bolus, reassessment should include physical examination and repeat lactate level. Mean arterial pressure (MAP) should be used to determine the need for vasopressors, if not already started (see below), and additional fluids. (I-E)
Useful physical examination maneuvers include the passive leg raise with subsequent assessment of perfusion ( Figure 3 ), or assessment of capillary refill. (II-E)
In the ICU, other hemodynamic parameters may be followed as well.

Passive Leg Raise. A passive leg raise maneuver compares hemodynamic data when the patient is semi-recumbent to that when the legs are raised, as in the figure. Initial hemodynamic measurements should be taken while the patient is the semi-recumbent position. (more...)

Resuscitation - Vasopressors and Steroids ( Figure 1 )

For adults with septic shock, we recommend using norepinephrine as the first-line agent over other vasopressors (Starting dose: 0.05-0.15 mcg/kg/min, titrated to effect). (I-B)
For adults with septic shock on norepinephrine with inadequate MAP levels, we suggest adding vasopressin at a rate of 0.03 units/min instead of escalating the dose of norepinephrine. In our practice, vasopressin is usually started when the dose of norepinephrine is in the range of 0.25-0.5 mcg/kg/min. (II-E)
For adults with septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we suggest adding epinephrine. (II-E)
When using vasopressors peripherally we recommend they be delivered via a high-quality IV (18+g; in forearm or upper arm; ultrasound-confirmed; and with a nursing check per PIV policy to ensure proper functioning of the IV). The appropriateness of peripheral administration should be reassessed at least daily, transition to central administration in patients with high or escalating vasopressor dosing. (II-C)
For adults with septic shock with a persistent norepinephrine requirement (e.g., ≥4 hours of NE at any dosage), we suggest using stress-dose steroids (i.e. IV hydrocortisone 50mg q6hr +/- oral fludrocortisone 50 mcg q24hr). (II-C)
For adults with septic shock, we recommend using invasive monitoring of arterial blood pressure via radial arterial catheter over non-invasive monitoring, as soon as practical (II-E). If radial artery access is not feasible, then non-invasive monitoring vs alternative arterial access can be determined on a case-by-case basis.

Source Control

When an anatomical area is identified as responsible for sepsis/septic shock, intervention to achieve source control increases the patient’s likelihood of survival. (I-C)
Procedures for source control should be done as early as feasible, within 6-12 hours of admission, or as soon as possible after resuscitation. Some patients may not achieve hemodynamic stability without adequate source control. (I-C)
Patients should be monitored for adequacy of source control after procedures/interventions are made, with the expectation of clinical improvement within 48 hours of definitive treatment. (II-E)
For patients where intervention cannot be performed or such interventions do not provide complete source control, Infectious Disease should be consulted for assistance in management. (I-E)

De-resuscitation

A positive fluid balance after resuscitation for sepsis is associated with worsened clinical outcomes. Extraneous or superfluous fluid administration (i.e., maintenance fluids or intravenous medications/carriers when enteral administration is acceptable) should be avoided. Achievement of a negative volume status (using diuresis or dialysis), once stable, should be achieved and guided by the utilization of physiologic parameters. (I-E)

De-escalation of Antibiotics

For adults with an initial diagnosis of sepsis or septic shock and adequate source control, where optimal duration of therapy is unclear, we suggest using clinical evaluation to decide when to discontinue antimicrobials.
Serial procalcitonin measurements can help support the discontinuation of empiric antibiotics, as outlined in this Procalcitonin Guideline (I-E)

Post-Discharge

Survivors of life-threatening illnesses, such as sepsis and septic shock should be screened for the physical, mental, and cognitive dysfunction that characterizes post-intensive care syndrome and referred to specialists, as appropriate. (II-C)
After a sepsis hospitalization, patients should follow up with an appropriate healthcare provider, depending on discharge circumstance (e.g., PCP, physical medicine and rehabilitation, or another appropriate specialist), and receive post-hospital care to promote recovery (e.g., physical therapy, occupational therapy, etc.), as appropriate. (I-E)

Sepsis in Vulnerable Populations - Congestive Heart Failure

Fluid resuscitation should not be withheld due to a history of heart failure. However, patients at risk for poor tolerance of fluid (e.g., reduced LVEF or severe diastolic dysfunction) should have frequent reassessment of clinical status and intravascular volume during the course of fluid resuscitation, with ultimate volume guided by clinical response.

Sepsis in Vulnerable Populations - Neutropenia

Neutropenic patients should be closely monitored for signs/symptoms of infection as they are particularly vulnerable to the development of sepsis and septic shock. (I-E)
The hematological malignancy population has an increased risk of antibiotic resistance, and therefore antibiotic choice should be guided by the Neutropenic Fever Guidelines . Anti-pseudomonal antibiotics are recommended. (I-C)
Source control in the neutropenic population is no different than in non-neutropenic patient in theory, though the least invasive method should be used, due to challenges with wound healing and concomitant thrombocytopenia. (I-E)
Stimulation of neutrophil production with any of the various colony stimulating factor formulations is not recommended due to the risk of immune reconstitution syndrome which can threaten clinical stability (II-E)

Sepsis in Vulnerable Populations - Cirrhosis

There should be a high level of suspicion for infection/sepsis in cirrhotic patients admitted to the hospital.
It is reasonable to consider albumin administration in addition to balanced crystalloids in patients who meet criteria for fluid resuscitation and require vasopressors (e.g. ≤3.2) (II-C)
Severe liver disease can be considered an immunocompromised or hemodynamically at-risk state, and therefore represent a vulnerable population with regards to the development of sepsis or septic shock.

Table 1 Overview of the Initial Evaluation and Empiric Antibiotics for the Septic Patient #

View in own window

This is not an exhaustive list of sources of sepsis. Rather, it intends to remind the user of common sources, and to demonstrate a general approach to the sepsis patient.

For patients with nosocomial infection, evidence of hypoperfusion or shock, or immunosuppression, an anti-pseudomonal antibiotic +/- MRSA coverage (e.g., cefepime/zosyn +/- vancomycin) should be started immediately. Stable sepsis patients should undergo a rapid evaluation to determine the likely source of infection to guide antibiotic selection (See Figure 2 ). Hemodynamically unstable patients, thought to be decompensating from unknown or resistant gram-negative bacterial infections, likely warrant double coverage of gram-negative organisms to ensure susceptibility of at least one antibiotic to presumed organism (i.e., addition of an aminoglycoside).

Table 2 Vasoactive Agents

Overgaard CB. Circulation 2008;118:1047-56.

Table 3 Resuscitative Fluids

Myburgh JA, Mythen MG. N Engl J Med 2016; 369:1243-51.

Strength of Recommendation Classification

I = Generally should be performed; II = May be reasonable to perform; III = Generally should not be performed

Level of Evidence Classification

A = systematic reviews of randomized controlled trials with or without meta-analysis; B = randomized controlled trials; C = systematic review of non-randomized controlled trials or observational studies, non-randomized controlled trials, group observation studies (cohort, cross-sectional, case-control); D = individual observation studies (case study/case series); E = expert opinion regarding benefits and harm

Clinical Background and Rationale for Recommendations

Recommendations

Sepsis and septic shock are medical emergencies, and we recommend that sepsis improvement programs be established for all hospital units/services at Michigan Medicine with the goal of standardized early recognition, resuscitation and treatment.
Current screening tools and alerts have been put in place to help identify those patients developing sepsis. We recommend that you review the data in the sepsis navigator when the alert is received in order to determine whether your patient should be treated for sepsis.

Severe sepsis and septic shock are medical emergencies and delays in treatment lead to increased morbidity and mortality. 3 – 5 Sepsis improvement programs highlight awareness of the disease and lead to improved recognition through education. The Electronic Health Record (EHR) can be utilized to help with screening and alerting providers about potential sepsis cases. However, these systems have traditionally performed sub-optimally 6 , 7 and thus provider education and recognition is crucial to improved sepsis recognition and care.

Sepsis care should be standardized across the hospital since many studies have demonstrated improved clinical outcomes with bundled sepsis treatment. 8 – 10 A large retrospective study evaluated compliance with a 2013 statewide mandate for bundled sepsis care in New York. 5 This analysis showed that bundled, protocolized sepsis care was associated with improved clinical outcomes. A similar but larger study involving 1,012,410 patients among 506 hospitals located in five states demonstrated improved sepsis outcomes, including mortality, with protocolized sepsis care. 11

Quick sequential organ failure assessment, or qSOFA, is a set of three variables developed in 2016 to predict mortality in patients with known or suspected sepsis. 2 The three variables include a Glasgow Coma Score < 15, a respiratory rate ≥ 22 breaths/minute, and a systolic blood pressure ≤ 100 mmHg. If a patient has two or more variables present at a given time, then the patient is qSOFA positive. Studies have shown that qSOFA is a better predictor of mortality in patients with suspected or known sepsis when compared to other screening tools such as SIRS, NEWS or MEWS. However, the goal of a screening tool is high sensitivity, so that clinicians can identify patients with the disease process of interest, not prediction of mortality. 12

Here at Michigan Medicine, we are actively screening our patients for sepsis on presentation to the ED and on the inpatient floors. When patients screen positive with a concern for sepsis or who meet criteria for severe sepsis, a BPA and page are pushed to the First Contact. We recommend that the First Contact review the data in the Sepsis Navigator to understand why the BPA fired and to evaluate whether sepsis treatment should be initiated in the patient. Consideration of patient symptoms, laboratory values, and underlying risk of infection in determination of whether the patient should be treated for sepsis.

For adults suspected of having sepsis, we recommend measuring blood lactate
For adults with severe sepsis or septic shock, we suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate
When infection is suspected, at least 2 sets of blood cultures should be drawn (aerobic & anaerobic).
Blood cultures should be drawn from 2 separate peripheral sites in most patients. However, if the patient has an indwelling central catheter that is suspected to be infected, cultures should be performed through each lumen of the catheter, in addition to the peripheral site.
The “SEP-1 Bundle” is an all-or-none treatment bundle for severe sepsis/septic shock that was instituted as a quality metric by the Center for Medicare and Medicaid Services (CMS) in the interest of standardizing sepsis care. According to the bundle, there are tasks to be completed within 3 hours and 6 hours of suspicion/recognition of sepsis in order to “pass” the metric. These specifically are:3 Hour Bundle: measure lactate, draw blood cultures, start appropriate antimicrobial therapy, give fluid resuscitation (30 mL/kg) for hypotension or lactate >4, start pressors if hypotension is profound during or persistent after the fluid resuscitation
6 Hour Bundle: Repeat lactate if initial lactate >2, Repeat volume status and tissue perfusion assessment after fluid resuscitation, titrate pressors to goal MAP>65mmHg

Lactate levels are important in the identification 13 – 15 , risk stratification 16 – 18 and resuscitation 19 – 22 of patients with sepsis, and an elevated lactate may be a sign of occult shock. 16 , 18

Lactate has been studied as a method to identify patients with sepsis. In comparison to other lab markers, including white blood cell count, neutrophil count, and procalcitonin , lactate has been shown to be a better predictor of severe sepsis and septic shock. 13 – 15

All patients with suspected or confirmed sepsis should have a lactate checked upon time of recognition. 16 Lactate levels are important in the risk stratification 5 , 6 and resuscitation 7 of patients with sepsis, and elevated lactate may be a sign of occult shock. 23 Elevated lactate levels have been associated with increased mortality for both intermediate lactate elevations (≥ 2) and high lactates (≥ 4). 16 , 17 Thus, elevated lactate levels are concerning in patients with sepsis and should suggest to providers the need for fluid resuscitation, hemodynamic support, and additional resources such as rapid response intervention or a higher level of care.

Lactate should be rechecked to evaluate the effectiveness of resuscitation if the initial lactate is greater than or equal to 2. 24 Lactate clearance can be confounded by patient comorbidities, especially cirrhosis, or use of beta-agonists (i.e., albuterol or epinephrine) and should be interpreted within a broad clinical context and not as a single marker of resuscitation. 25 Other markers of resuscitation such as central venous oxygen saturation 26 and capillary perfusion 27 have been shown to be non-inferior to lactate reduction and may aid in evaluation of resuscitation, along with lactate reduction (see Resuscitation & Reassessment).

Blood cultures

A blood culture “set” includes 2 bottles, 1 aerobic and 1 anaerobic. A blood culture “site” refers to the location from which the culture is drawn. When infection is suspected, at least 2 sets of blood cultures should be drawn (aerobic & anaerobic). Blood cultures should be drawn from 2 separate peripheral sites in most patients. However, if the patient has an indwelling central catheter that is suspected to be infected, cultures should be performed through each lumen of the catheter, in addition to the peripheral site.

As antibiotic administration significantly decreases the sensitivity of blood cultures, blood cultures should be obtained prior to the initiation of antibiotics, unless the patient is unstable or critically ill, in which case antimicrobials should be initiated immediately, regardless of whether blood cultures have been obtained. 28 How long to wait for cultures to be drawn in the setting of severe sepsis is at this discretion of the clinician, but it seems reasonable to start antibiotics if cultures are unable to be obtained within 45 minutes.

Sepsis patients with nosocomial infections, organ dysfunction, signs of hypoperfusion or shock, or immunosuppression should be treated with the immediate initiation of broad spectrum antibiotics, while stable sepsis patients can undergo a rapid clinical evaluation to identify the source of sepsis before initiating empiric antibiotics
Antimicrobial Stewardship disease state treatment guidelines should be utilized to select empiric antimicrobial therapy and to ensure correct doses are administered to patients ( Table 1 )
MRSA nasal swabs, when negative, are associated with a high negative predictive value (NPV) (i.e., >90%) of colonization or infection with MRSA, and can help eliminate the need for or reduce the duration of MRSA coverage in sepsis patients.
For adults with possible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials immediately, ideally within 1 h of recognition.
For adults with possible sepsis without shock, we suggest a time-limited course of rapid investigation, and if concern for infection persists, the administration of antimicrobials within 3 h from the time when sepsis was first recognized.
For adults with a low likelihood of infection and without shock, we suggest deferring antimicrobials while continuing to closely monitor the patient.

Antimicrobial therapy should be selected to include coverage for likely organisms at the presumed site of infection. Local data ( https://www.med.umich.edu/asp/ ) should be utilized to tailor antimicrobial therapy. This includes local antibiograms ( https://labportal.med.umich.edu/portal/apps/antibiogram/ ) and treatment guidelines according to disease state, which are held and maintained on the Antimicrobial Stewardship website ( https://www.med.umich.edu/asp/adult.html ). Patients with a reported Beta-lactam allergy should be considered for referral to the Beta-lactam Evaluation Team during their hospitalization ( https://www.med.umich.edu/asp/pdf/adult_guidelines/Beta-lactam-Evaluation-and-Empiric.pdf ).

Antimicrobial therapy should be prioritized for septic patients with presumed infection. Antibiotics should be targeted to cover presumed organisms based upon likely organisms at the presumed source of infection and tailored based upon local prevalence of, and risk factors for, resistance among those organisms. While risk factors for resistant organisms vary depending on geographic location of included study patients, specific type of infection, and number of variables collected, general risk factors include patients with a higher severity of illness, those with previous broad-spectrum antimicrobial exposure, those with exposure to high-risk healthcare settings (i.e. prolonged hospitalization, long-term care facilities, dialysis centers, etc.), immunosuppression, and previous recent resistant organisms. 29 – 31 Double-coverage of gram-negative organisms, while exposing patients to additional antimicrobial agents and their adverse effects, is often used to maximize the chances that a suspected or proven bacteria is susceptible to one of the two antimicrobials until microbiologic susceptibilities result. The benefit of double-coverage likely is maximized in patients with highest risk of resistant organisms or in areas with a high local prevalence of resistant organisms. In patients at a high risk of immediate morbidity and mortality from their infection (i.e., septic shock with escalating vasopressor requirement), the benefit of double coverage likely outweighs the immediate risks, in contrast to patients at low risk of morbidity and mortality from infection, where judicious waiting for culture results to tailor antibiotics will not lead to additional harm. 32 De-escalation strategies should be tailored based upon a patient’s clinical status, as well as laboratory or stewardship resources available to rapidly detect or rule-out bacterial organisms.

Antimicrobial delivery should be optimized to ensure rapid achievement of therapeutic targets and concentrations at the presumed site of infection. Strategies to optimize the pharmacokinetic-pharmacodynamic parameters should be utilized when able and include extended (or continuous)-infusion beta-lactams, and extended-interval aminoglycosides. 33

MRSA accounts for a small percentage of culture positive infections in critically ill patients (i.e., 5%), yet a majority of critically ill septic patients receive anti-MRSA antibiotics. 34 Individual risk factors for MRSA include recent IV antibiotics, history of recurrent skin infections or chronic wounds, presence of invasive devices, hemodialysis, recent hospital admission, severity of illness, and most importantly, prior history of MRSA infection or colonization. Failure to cover for MRSA in a patient with a true MRSA infection may be harmful, but unnecessary coverage for MRSA in a patient without MRSA may also be harmful. 35 MRSA nasal swab testing is often used to avoid initiation of MRSA-targeted antibiotics, as it has a high negative predictive value for not only respiratory infections (96.5%), but also other systemic infections as well. 36 Prior MRSA nasal swabs within the previous 60 days have also performed well when examining the durability of a previous negative result. 37 Importantly, a positive MRSA nasal swab does not indicate an active MRSA infection or necessitate the use of anti-MRSA antibiotics. Rather, a positive swab indicates that the patient is colonized with MRSA, and that this organism should be covered if a S. aureus infection is presumed.

Timing of Antibiotics

Early administration of effective antimicrobials has been shown to reduce mortality in patients with sepsis or septic shock in observational or retrospective studies. 4 , 5 , 23 , 38 However, the importance of early antimicrobial treatment, must be tempered against the adverse effects of indiscriminate overuse of antibiotics, such as allergic or hypersensitivity reactions, renal dysfunction, Clostridioides difficile infections and antimicrobial resistance. 39

In multiple large-scale studies of sepsis, the association of early antimicrobial administration and reduced mortality are strongest for patients with septic shock, and therefore support use of early administration of antimicrobials for patients with septic shock, in whom the risk of delayed, inadequate, or avoidance of treatment is the highest.. 5 , 40 , 41

In the above studies, the association of timing of antimicrobials in patients with sepsis without shock and mortality, is less consistent. Therefore, in patients with sepsis without shock, rapid assessment of the patient for infectious or non-infectious source for sepsis within 3 hours is recommended. The decision whether antimicrobials should be deferred or administered may be based on findings in the rapid assessment.

When the decision to initiate antimicrobial agents is made, significant effort should be placed on ensuring rapid administration to the patient. This includes leveraging institutional strategies such as optimization of automated dispensing cabinets for medication availability closest to patient, ordering as “STAT” compared with “routine”, and prioritizing administration once medication is at the patient’s bedside.

Resuscitation

○ We suggest that 30 mL/kg (adjusted body weight for BMI >30) of intravenous (IV) crystalloid fluid should be given within the first 3 h of resuscitation
○ We suggest using balanced crystalloids (lactated ringers) instead of normal saline for resuscitation
○ Consider albumin in patients who received large volume of crystalloids over using crystalloids alone as discussed in the text (below)
○ Pulmonary edema, heart failure, or cirrhosis is not a contra-indication to fluid resuscitation.

Septic shock is classically designated as a distributive shock characterized by a profound immune response and release of vasodilatory substances resulting in inappropriate vascular dilation and tissue hypoperfusion. However, the over-reactive inflammatory response is commonly secondary to a separate disease process that frequently results in some period of poor volume intake, increased insensible loss (e.g. increased minute ventilation, hyperthermic losses secondary to fever) and potential GI losses, all contributing to intravascular depletion and hypovolemia. Lastly, the inflammatory response has been associated with myocardial dysfunction and decreased cardiac output. These separate but potentially additive causes for hypoperfusion makes septic shock difficult to protocolize. However, given the likelihood for intravascular depletion and hypovolemia it is suggested that initial volume resuscitation be attempted if evidence of tissue hypoperfusion.

The overarching goal of fluid therapy is to improve oxygen delivery to the tissue (DO2) by increasing stroke volume (SV) and cardiac output (CO). The goal of fluid resuscitation (or an endpoint for fluid therapy) is not to increase the mean arterial pressure (MAP). 42 A patient is deemed “fluid responsive” when SV increases by 10-15% after a fluid challenge (i.e., 250-500 mL); such patients should receive judicious fluids until the appropriate increase in SV/CO subsides. Administration of fluids to patients deemed not fluid responsive only serves to overload the patient with unnecessary fluid which subsequently impairs organ function.

Fluid resuscitation has shown benefit in experimental studies by improving microvascular prefusion, 43 (p) improving cardiac output and oxygen delivery, 44 , 45 and improved organ function. 46 However, the data around impact of initial fluid administration on clinical outcomes is less robust. 30 mL/kg was utilized in the landmark paper, Early Goal Directed Therapy 47 (EGDT), in which significant mortality benefit was demonstrated by protocolized sepsis care. The PROMISE, 48 PROCESS 49 and ARISE 50 trials evaluated bundled sepsis care and did not focus on the timing and amount of fluid given and thus provide no specific insight into the benefit of early or large volume fluid resuscitation. The previously mentioned large clinical trials that were published post-EGDT showed no significant difference in “usual care” compared to protocolized EGDT, but the volumes administered in each of these trials did approach the similar 30 mL/kg given in EGDT. More recently the Classic trial 51 and Clovers trial 52 attempted to evaluate restrictive versus fluid resuscitation in septic patients. Unfortunately these papers do not provide additional guidance on initial fluid resuscitation as both studies do not account for fluid resuscitation received prior to randomization which was often 2-3 liters. It is thus unclear based on these large clinical trials whether fluid administration alone has benefit for patients with tissue hypoperfusion.

There is observational data 53 , 54 that demonstrate clinical outcome benefits to bundled sepsis care and are frequently referenced in the discussion of early large volume fluid resuscitation, however none of these studies focuses specifically on early fluid administration alone.

There are current concerns in the medical community that over-administration of intravascular fluids to hospitalized patients is associated with worse clinical outcomes. 55 , 56 However, these studies focus on large volume administration over longer durations of time and do not apply to the initial 30mL/kg fluid resuscitation. Ongoing volume administration, which is discussed below, is more likely an area with greater risk of harm to a patient. Thus, we continue to suggest the administration of 30 ml/kg of fluid resuscitation be administered in the first 3 hours of sepsis onset, especially given the potential for hypovolemia in our septic patients. Further research evaluating specific volume targets and time of administration is needed.

Given clinical concerns for over-resuscitation in our morbidly obese population, it is reasonable for the initial volume of resuscitation to be based on ideal or adjusted body weight, instead of actual weight. Literature 57 currently is sparse on this subject.

The choice of fluids for resuscitation are typically separated into crystalloids and colloids. Crystalloids have the advantage of being more readily available and lower in cost when compared to colloids. Colloids have the theoretical benefit of increasing oncotic pressure intravascularly and thus preventing extravasation of the fluid into the extravascular space.

There have been several large trials that have attempted to address which resuscitative fluid, colloid (albumin) or crystalloid, is superior in critically ill patients. These studies show no clear benefit of one over the other in mortality at 28 days. 58 – 60 Thus, given the cost difference and lack of clear benefit, we recommend crystalloids as first-line fluid for resuscitation in septic patients.

Several studies have shown benefit to balanced solutions (e.g. lactated ringers, Plasma-Lyte, or normosol) over normal saline, including reduction in major adverse kidney events within 30 days (MAKE-30), 61 and reduced in-hospital mortality in patients with sepsis. 62 Finally a meta-analysis 63 of nearly 35,000 patients was recently published in the New England Journal that provides a signal for mortality reduction with the use of balanced crystalloids. The clinical impact or separation of effect is likely more pronounced in patients who require large volume resuscitation compared those with more conservative fluid needs. Regardless, choice of fluid therapy should be individualized for each patient. Balanced fluids likely produce less elevations in serum chloride levels, whereas 0.9% NaCl is likely advantageous for those at risk of cerebral edema or dysnatremia. Lacking robust, definitive evidence, and apart from a strong indication to choose one agent over another, we suggest administration of balanced crystalloids for patients with sepsis over 0.9% NaCl. Albumin may have a role in sepsis management, but not as a first line resuscitative fluid as discussed above. In patients who have received large volumes of crystalloids, the addition of albumin may have clinical benefit. The ALBIOS 59 study, in which patients received approximately 3000 to 4000 mL of fluid over the seven day study period, demonstrated that patients receiving albumin, in addition to crystalloid, had a statistically higher mean arterial pressure and lower net fluid balance. A more recent retrospective analysis by Gomez et al. 64 compared patients who received normal saline with 5% albumin versus normal saline alone in patients that received > 60 ml/kg of fluid resuscitation in 24 hours. This study demonstrated a lower adjusted hospital 30-day mortality in patients that received albumin. Additionally, those in the albumin arm had a lower incidence of renal injury. Thus, albumin may provide some benefit when providing large volume resuscitation. Further analysis of what constitutes large volume and timing of albumin administration is necessary for a stronger recommendation to be made.

Given the limited availability of the blood product albumin, and its associated cost, efforts have been taken to produce synthetic colloids (i.e., hydroxyethyl starches, gelatins, dextrans). Unfortunately, multiple studies have shown the harm of using synthetic colloids in a variety of clinical settings for resuscitation in comparison to crystalloids. 65 – 69 These are resuscitation fluids which contain large molecules aimed at increasing intravascular oncotic pressure with the physiologic goal of keeping resuscitative fluid from extravasating into extravascular tissue. However, these studies all found that patients receiving synthetic colloids have higher rates of AKI and need for renal replacement therapy, and failed to find a mortality benefit in favor of colloids.

Pre-existing conditions that make patients more vulnerable to fluid overload (heart failure, cirrhosis, ESRD, etc) are generally not a contraindication to initial fluid resuscitation (30 mL/kg) and reduced volumes do not lead to lower rates of intubation, or increased ventilator-free days as demonstrated in one retrospective propensity-score matched analysis. 70 There is a mortality benefit to initial volume resuscitation in these patients, 71 , 72 however, and if lower volumes are being considered, appropriate documentation of their current volume status and contraindication to fluid is recommended.

Ongoing management after Initial Resuscitation: Reassessment and Support

After the initial fluid bolus, reassessment should include physical examination and repeat lactate level, to determine the need for vasopressors, if not already started (see below) and additional fluids.
Useful physical examination maneuvers include the passive leg raise (see Figure 3 ), and assessment of capillary refill for the determination of whether additional fluid resuscitation may be beneficial.
There is neither a mortality benefit nor harm in choosing additional fluids or vasopressors for patients with ongoing hypotension after initial fluid resuscitation.

Since the original Goal Directed Therapy article was published, 47 there have been numerous studies trying to elucidate the best method by which to assess a patient’s volume status in the setting of sepsis. Many methods, including Swan-Ganz catheter, 73 measurement of central venous pressure (CVP), 74 and mixed venous oxygenation 75 are invasive and are correlated with mortality outcomes, but have not been definitively shown to improve survival. Newer non-invasive technologies for measuring cardiac output have been developed, however these require additional training and are not widely available outside of the intensive care units.

After the initial 30 mL/kg bolus, we recommend reassessment of the clinical status of the patient. Lactate should be rechecked to evaluate the effectiveness of resuscitation if the initial lactate is greater than or equal to 2. 24 If there is recurrent or refractory hypotension, we recommend performing a physical examination that includes whether the patient remains responsive to additional fluid resuscitation which may be accomplished through an additional small volume bolus (250-500 mL given rapidly, over 10 minutes), or by performing a passive leg raise (see Figure 3 ), and then followed by objective measures of SV/CO (non-invasive cardiac output systems, ECHO, esophageal doppler, etc.). When measurement of CO or SV is not possible, a >15% increase in pulse pressure could indicate that the patient is fluid responsive utilizing a passive leg-raise test for 60–90 seconds.

Other markers of resuscitation such as central venous oxygen saturation 26 and capillary perfusion 27 have been shown to be non-inferior to lactate reduction and may aid in evaluation of resuscitation. Physical exam findings such as skin mottling, and poor capillary refill indicate ongoing poor perfusion.

There is recent evidence that after initial fluid resuscitation, there is no difference in outcomes when additional fluids are given or vasopressors are initiated. 76

Vasopressors and Steroids

For adults with septic shock, we recommend using norepinephrine as the first-line agent over other vasopressors
For adults with septic shock on escalating rates of norepinephrine, we suggest adding vasopressin at a rate of 0.03 units/min
For adults with septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we suggest adding epinephrine.
For adults with septic shock, we suggest starting vasopressors peripherally to restore MAP rather than delaying initiation until central venous access is secured.
For adults with septic shock requiring norepinephrine for a minimum for 4-6 hours at doses of ≥ 0.25 μg/kg/min, we suggest using stress dose steroids (i.e. IV hydrocortisone 50mg q6hr plus oral fludrocortisone 50 mcg q24hr).
For adults with septic shock, we recommend using invasive monitoring of arterial blood pressure over non-invasive monitoring, as soon as practical and if resources are available. If radial artery access is not feasible, then non-invasive monitoring vs alternative arterial access can be determined on a case-by-case basis.

Norepinephrine is recommended as a first-line agent in the treatment of septic shock and we suggest against dopamine use. Both observational studies 77 – 79 and a multicenter RCT 80 suggested norepinephrine to be superior to dopamine in terms of 28 day mortality, likely driven by an increase in arrhythmias due to dopamine. This finding was confirmed in a subsequent meta-analysis in 2012. 81

Studies have evaluated additional agents including vasopressin, epinephrine, and phenylephrine in comparison to norepinephrine as a first-line vasopressor in septic shock. There was no significant difference between vasopressin and norepinephrine 82 , 83 in terms of 28-day mortality, and when vasopressin is used in conjunction with norepinephrine there may be a survival benefit over high dose norepinephrine monotherapy. 82 Additionally, in meta-analysis, 84 vasopressin was found to cause less tachyarrhythmias than norepinephrine. A RCT 85 comparing norepinephrine and dobutamine to epinephrine alone in the treatment of septic shock found no difference in 28-day mortality between groups or in the incidence of side effects. These results were subsequently confirmed in a large prospective observational study. 86

We suggest starting peripheral vasopressors to achieve MAP goals instead of delaying initiation until central access may be achieved. However, central access should be obtained if ongoing vasopressor support is needed. Traditionally, vasopressor administration mandated immediate placement of a central venous catheter in either the internal jugular, femoral or subclavian veins (to avoid tissue injury, should extravasation occur). However, this frequently led to delays in vasopressor administration which placed patients at risk for ongoing hypotension and continued organ injury. A number of case reports and case series 65 – 67 , 87 – 89 had documented the risk of complications from peripherally administered vasopressors, however the majority of these studies were very old. More recently, an observational study 68 , two systematic reviews 69 , 90 and one meta-analysis 91 have demonstrated low incidence of serious adverse injury secondary to vasopressor administration through a peripheral IV. The incidence of extravasation seems to be greater when IVs are placed distal to the antecubital fossa. Thus, we suggest starting peripheral vasopressors to achieve MAP goals instead of delaying initiation until central access may be achieved. However, central access should be obtained if ongoing vasopressor support is needed.

For adults with septic shock requiring norepinephrine for at least 4 hours at doses of ≥ 0.25 μg/kg/min, we suggest using stress dose steroids (i.e. IV hydrocortisone 50mg q6hr plus/minus oral fludrocortisone 50 mcg q24hr).

All of the major trials on stress dose steroids in septic shock have consistently shown faster resolution of shock with the administration of steroids, with several demonstrating a mortality benefit. Sepsis is defined by a dysregulated host response to infection involving unregulated inflammation, organ dysfunction and hemodynamic instability. In addition, there is evidence that the hypothalamic-pituitary-adrenal (HPA) axis becomes dysregulated in sepsis. 92 Steroids have thus been an attractive treatment option to counteract the widespread inflammatory cascade and re-store the dysregulated HPA access.

In the early 2000’s two large RCTs 90 , 91 demonstrated a faster resolution of shock (i.e. shorter duration of vasopressor therapy). One study 90 which enrolled sicker patients (63% 28-day mortality in placebo group) demonstrated a mortality benefit from steroid therapy.

Two more recent trials 92 , 93 have since been published which have reinforced the administering of stress dose steroids in patients with septic shock. Both of these trials demonstrated a shorter time to shock reversal with steroids, and again a reduction in mortality for the trial 93 that enrolled sicker patients.

For adults with sepsis with hypotension, non-invasive blood pressure cuff measurements can be inaccurate compared to invasive monitoring 11 – 15 , particularly in patients with elevated BMI. Arterial catheters for arterial blood pressure measurement allow continuous, real-time measurements so that therapeutic decisions can be made with accurate and immediate information. While there are associated risks to invasive arterial monitoring 16 , these are small and using ultrasound guidance may increase placement success rates and decrease complication rates. 17 , 18

Resuscitation Targets

Recommendation.

For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mmHg over higher MAP targets

Septic shock is characterized by inappropriate arterial vasodilation secondary to an exaggerated inflammatory response in the patient. This inappropriate arterial vasodilation causes a reduction in the MAP and can lead to decreased organ perfusion if MAP falls below the autoregulatory zone of each organ. Decreased organ perfusion leads to ischemia and organ failure if not corrected. Fluid administration aims to improve cardiac output and maintain MAP but for many patients with septic shock volume administration will not be sufficient and vasopressor support will be required to raise MAP and organ perfusion pressure.

The goal MAP recommended by surviving sepsis guidelines 24 is equal to or greater than 65. This MAP goal was first based on small clinical studies 94 , 95 in which biomarkers (lactate, creatinine), cardiac index and urine output were observed following changes in NE infusions in patients with septic shock. These studies showed no significant benefit in lactate reduction, creatinine or urine output when MAP was raised from 65 to 85 with vasopressors.

In 2014 the SEPSISPAM 96 study was published which compared 28-day mortality between MAP goals of 65 to 70 mmHg against those with a goal of 80-85 mmHg. The study found no significant difference in 28-day mortality and patients with the higher MAP target experienced longer duration on vasopressors and an increased rate of atrial fibrillation. Interestingly, upon subgroup analysis, patients with chronic hypertension demonstrated less adverse renal outcomes when randomized to a higher MAP target. Two large retrospective studies 97 , 98 published following SEPSISPAM demonstrated significant increases in hospital mortality and the incidence of AKI when MAP was < 65 in patients with septic shock.

Additionally an individual patient-data meta-analysis 99 performed on previous studies, of which SEPSISPAM was the majority of the patient data included, showed a non-significant trend for increased mortality in patients > 65 when higher MAP targets were chosen. This led to the more recent 65 trial 100 which was a RCT comparing permissive hypotension (MAP 60-65 mmHg) to usual MAP goals in patients older than 65 years of age requiring vasopressor support in the ICU for vasodilatory shock. The study found no significant difference between groups in terms of 90-day mortality, AKI or vasopressor duration. The mean difference in blood pressure between groups was approximately six, thus it is not surprising that no significant difference was found.

Thus, given the current available data, an initial MAP goal of ≥ 65 mmHg for patients in septic shock seems the best initial goal for all patients with septic shock. The SEPSISPAM and 65 trial remind us that individualized care is important and that adjusting the MAP goal based on individual patient data may be reasonable.

Ongoing Management

Source control.

When an anatomical area is identified as responsible for sepsis/septic shock, intervention to achieve source control increases the patient’s likelihood of survival.
Procedures for source control should be done as early as feasible, within 6-12 hours of admission, or as soon as possible after resuscitation. Some patients may not achieve hemodynamic stability without adequate source control.
Patients should be monitored for adequacy of source control after procedures/interventions are made, with the expectation of clinical improvement within 48 hours of definitive treatment.
For patients where intervention cannot be performed or such interventions do not provide complete source control, Infectious Disease should be consulted for assistance in management.

Definition: Source control is defined as the identification and possible removal of the anatomical area responsible for sepsis and septic shock. Excluding areas that are not responsible for the initiation of sepsis is additionally an important element of source control. Source control is identified as a key element of the surviving sepsis guidelines established and now widely implemented across the globe. 24

Clinical Decision making in source control: Adequate source control is associated with increased survival . 101 , 102 There are a multitude of factors that determine the clinical approach to performance of a procedure in patients with sepsis. 103 The timing of the procedure is often dependent on the presence of hemodynamic stability. In patients with profound septic shock and vasoplegia, source control procedures should be undertaken as soon as the patient is resuscitated. While there is limited data to suggest the appropriate timing of the performance of procedures for source control, it is our recommendation based on a multitude of smaller studies that it be performed within 6-12 hours from admission. 104 , 105 It is also clear from clinical observations that some patients may not achieve hemodynamic stability despite maximal resuscitative efforts without adequate source control. 106

Treatment alternatives: Source control in a critically ill patient could include many different treatment paradigms.

Drainage of closed space infection including abscess-either surgically or with interventional procedures performed with radiologic assistance. Some examples include drainage of infected cholecystitis or pyelonephritis.
Surgical removal of infected organs or medical devices. For example, appendicitis, perforated sigmoid diverticulitis, infected necrotic pancreas in patients with pancreatic necrosis, and ischemic bowel.
Repair of a perforation. For example, perforated ulcers of the stomach, duodenum and small bowel.
Surgical exclusion of continued source of infections such as diversion of fecal stream. For example, performance of a diverting ileotomy or colostomy in patients with perforated diverticulitis and cancers.
Surgical debridement for necrotizing soft tissue infections

The selection of the type of procedure depends on multiple factors. A risk-benefit analysis dictates the timing and the location of performance of the procedure. In general, the least invasive procedure is the first line of therapy. Additional factors include clinical expertise, availability of interventions and other logistic institutional factors, patient preference and the nature of clinical status. 107 The nature of intra-operative procedures depends on hemodynamic and respiratory stability, presence of severe metabolic acidosis, and hypothermia with diffuse coagulopathy. In some patients, anatomic resection of the infected area is not possible. A diversion or drainage of the infected bed is the suggested alternative. Additionally, a surgical procedure such as a laparotomy may be warranted to exclude specific causes of septic shock where further radiologic studies may not be possible. Most procedures are either performed in the operating room or in interventional radiology suites. However, in patients with extreme hemodynamic instability and respiratory distress despite maximal ventilatory support, performance of a bedside procedure in the ICU, is recommended.

Concept of damage control: Evidence of damage control or performance of an abbreviated operation was first initiated in trauma patients with severe non-compressible hemorrhage in the chest or abdomen. Over the last several decades mortality benefits have been observed and now extended to diverse types of traumatic insults. 108 , 109 These principles have been adapted for patients with septic shock where source control has been undertaken. The basic principles of the initial procedure involve arresting areas of hemorrhage or contamination with luminal bowel contents in the operating room. Such maneuvers in emergency general surgery include resection or stapling of small and large bowel. The next steps involve resuscitation in the ICU where facets of coagulopathy, lactic acidosis and hypothermia are addressed through resuscitative measures and goal directed therapy. The final steps include return to the operating room where definitive surgical procedures along with closure of the abdomen is achieved, once the patient is appropriately resuscitated. The definitive procedure may be performed at any time but typically between 48-72 hours after resuscitation in the ICU. There are a number of observational and retrospective case studies evaluating damage control laparotomy versus conventional single stage surgery. A recent meta-analysis of 5 non-randomized and 16 observational studies suggested no difference in crude mortality rates between a damage control versus conventional single stage surgical intervention. 110 However, the standardized mortality ratio displayed clear benefit for damage control surgery. In presence of severe septic shock, metabolic acidosis and coagulopathy, we strongly suggest taking a damage control approach to surgery and resuscitation.

Adequacy of source control : There is little evidence in literature that suggest how to conclude whether source control has been successful or further interventions are needed. For patients where the operative source control has been definitively performed (examples sigmoid colectomy and appendectomy) it is expected that patients will respond with clinical improvement within 48 hours of the intervention. If the patient does not respond to what was thought to be a definitive procedure, further imaging or surgery may be warranted. However, for clinical scenarios where definitive source control is not surgically attainable (for example, uncontrolled enteric fistula with ongoing leak into the abdomen that has been subjected to multiple laparotomies), a combination of non-surgical and long term antibiotics may be necessary. Removal of potentially infected lines and tubes should be performed after initial resuscitation as part of an overall source control plan 19 . For intravascular lines, these should be removed when alternative intravascular access has been established. There may be circumstances in which it is not practical to remove an intravascular line, and the patient should be treated through the line for an extended period of time. We recommend Infectious Disease consultation in this circumstance.

De-Resuscitation

A positive fluid balance after resuscitation for sepsis is associated with worsened clinical outcomes. Achievement of a negative volume status (using diuresis or dialysis), once stable, should be achieved and guided by the utilization of physiologic parameters.

Patients who recover from septic shock often have a positive fluid balance. 111 , 112 After initial resuscitation and stabilization, de-escalation of fluid management and optimization of volume status is required. The goals of de-escalation include restoration of organ function by attaining negative fluid balanced (i.e. progressing toward net even for the hospitalization) through goal-directed fluid removal. This is achieved through use of diuretics or renal replacement therapy and the limitation of fluid intake, including medication carriers and diluents.

While data continues to emerge, it is clear that prolonged positive fluid balance is associated with worsened organ function and clinical outcomes, and that de-resuscitation (i.e. achieving a negative fluid balance after stabilization) is associated with improved clinical outcomes. 113 , 114 Fluid balance therefore is a practice-dependent and modifiable risk factor for clinical outcomes, including mortality. Patients should be assessed frequently and early after initial stabilization utilizing physiologic data (i.e. pre-admission volume status, dynamic and static hemodynamic parameters, assessment of organ function, etc.) when available to guide aggressive volume removal. 115

While early antimicrobial treatment is important for improving mortality in patients with septic shock, limiting the continued overuse of broad spectrum antimicrobials is also important to decrease potential for development of antimicrobial resistant microorganisms. 116 Once a microbial pathogen and susceptibilities had been identified, or a non-infectious cause for acute illness is identified, stopping unnecessary antimicrobials and/or narrowing the spectrum of antimicrobials to target only the identified organisms is recommended. Michigan Medicine Antimicrobial Stewardship guidelines provide appropriate target based treatment guidelines: University of Michigan Health System (umich.edu) If infection has been ruled out, discontinuing all antimicrobials is recommended. De-escalation is generally safe, may decrease cost associated with unnecessary antibiotic use, and can decrease selection pressure for antimicrobial resistance, C.difficile infection and antibiotic adverse events. A recent meta-analysis reviewed 13 studies and found improved short-term mortality and decreased hospital length of stay in patients who had antimicrobial de-escalation. 117

An anterior nares screen for methicillin-resistant Staphylococcus aureus (MRSA) can be a useful tool for discontinuation of anti-MRSA antibiotics, such as vancomycin. 36 A negative MRSA nasal screen may be used to guide the safe discontinuation of anti-MRSA antimicrobials.

For adults with an initial diagnosis of sepsis or septic shock and adequate source control, where optimal duration of therapy is unclear, we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone, as outlined in this Procalcitonin Guideline

Resolution of sepsis physiology may lag behind control of the infection, and procalcitonin can aid in the de-escalation and discontinuation of antimicrobials in a safe and timely manner. Measurement of serum procalcitonin may assist with de-escalation of antimicrobials during treatment of sepsis. A meta-analysis of 14 RCTs assessing the use of procalcitonin compared to controls to guide antimicrobial therapy duration in patients with sepsis suggested improved mortality in those patients managed with use of procalcitonin. In these studies there was no difference in lCU or hospital length of stay. Antibiotic exposure was consistently lower in patients managed using procalcitonin, with minimal adverse effects. 24 Based on benefit, with minimal undesirable effects, procalcitonin is suggested for use, along with clinical evaluation, to guide duration of antimicrobial treatment in patients with sepsis or septic shock and adequate source control.

Post-discharge

Survivors of life-threatening illnesses, such as sepsis and septic shock should be screened for the physical, mental, and cognitive dysfunction that characterizes post-intensive care syndrome and referred to specialists, as appropriate.
After a sepsis hospitalization, patients should follow up with an appropriate physician, depending on discharge circumstance (e.g., PCP, physical medicine and rehabilitation, or another appropriate specialist), and receive the usual post-hospital care (e.g., physical therapy, occupational therapy, etc.), as appropriate.

Post-intensive care syndrome (PICS), or post-hospital syndrome, is a collection of problems that patients can experience after surviving a life-threatening illness, like sepsis or septic shock. 118 , 119 The three domains include alterations in physical function, mental health, and cognitive impairment. More than half of all survivors of critical illness and sepsis will suffer from at least one of these problems. 120 , 121

These problems can be identified through normal patient (or caregiver)-healthcare provider interactions, asking specific questions, or formal testing in each of the three domains. Patients with pre-existing health problems in a specific domain are more likely to develop problems in that area post-hospitalization. 122 Patients with more severe illness are also more likely to develop PICS.

Treatment involves identification of specific symptoms, providing therapy, as able, and referral to specialized providers (i.e. physical therapy, psychiatric services, occupational therapy, etc.). 123 Even with identification and treatment, PICS symptoms are often present at six to twelve months post-hospitalization. For example, in one randomized controlled study, cognitive impairment at 12 months post discharge was seen in 34% and 24% of patients, comparable to moderate traumatic brain injury and mild Alzheimer’s disease, respectively. 124

PICS not only affects patients, but also their caregivers. It is important to counsel caregivers and suggest referral to their own healthcare providers for support. 125 Structure for follow up for sepsis patients after discharge is evolving, and we recommend discussing follow up options with your Care Management team.

Sepsis in Vulnerable Populations

Certain groups of patients are more vulnerable to sepsis and more likely to die from sepsis. These include patients with history of heart failure, cirrhosis, or neutropenia. Patients with heart failure and cirrhosis are less likely to get standard-of-care treatment, especially with regards to fluid resuscitation in the setting of hypotension or elevated lactate. Patients with neutropenia are vulnerable to opportunistic infections as well as community acquired ones, and are profoundly immunosuppressed, limited in their ability to fight these infections at all. Early, and broad spectrum, antibiotics are critical to their survival. Specific considerations for these patient populations are addressed below.

Heart Failure

History of heart failure is not a contraindication to fluid resuscitation. For patients at risk for poor tolerance of fluids (e.g., reduced cardiac function, aortic stenosis, etc), we suggest frequent reassessment of intravascular volume status, with total volume of fluid-resuscitation based on response to therapy

Sepsis accounts for almost 25% of the deaths in patients with chronic heart failure 20 , 21 and patients with CHF have higher mortality rates than patients without CHF who are admitted for sepsis. 22 , 23

While chronic heart failure is not an exception to the SEP1 Bundle mandate by CMS, septic heart failure patients are less likely to receive adequate fluid resuscitation than non-heart failure patients 72 The 3 hour bundle has been shown to reduce mortality in heart failure patients 24 . A large prospective observational study demonstrated that the subgroup of patients with heart failure had reduced mortality when compliant with the 3 hour bundle 24 , and this included the 30 mL/kg fluid bolus, when applicable.

Studies around treatment of sepsis in patients with decompensated heart failure are lacking.

Neutropenia

Neutropenic patients should be closely monitored for signs/symptoms of infection as they are particularly vulnerable to the development of sepsis and septic shock.
The hematological malignancy population has an increased risk of antibiotic resistance, and therefore antibiotic choice should be guided by the Neutropenic Fever Guidelines . Anti-pseudomonal antibiotics are recommended.
Source control in the neutropenic population is no different than in non-neutropenic patient, though the least invasive method should be used, due to challenges with wound healing.
Stimulation of neutrophil production with any of the various colony stimulating factor formulations is not recommended due to the risk of immune reconstitution syndrome which can threaten clinical stability

Immunocompromised states are associated with lower sepsis survival, with neutropenia conveying a particularly high risk of mortality in critically ill sepsis patients. 25 Neutropenia is most frequently associated with malignancy and/or chemotherapy and these patients frequently have additional risk factors such as recent surgeries, central venous catheters, and pre-treatment with antibiotics. National guidelines around management of sepsis in neutropenic cancer patients were published in 2018. 26 These guidelines suggest we follow standard of care (SEP1 bundle) for the initial treatment of sepsis in the neutropenic population. At Michigan Medicine, hematological malignancy patients have increased risk of antibiotic resistance and therefore antibiotic choice should be adjusted per the Neutropenic Fever Guidelines , with anti-pseudomonal antibiotics recommended. There may be a role for antifungal treatment in the setting of prolonged neutropenia for patients not on fungal prophylaxis, given their increased susceptibility to invasive fungal infections.

Source control in the setting of neutropenia or pancytopenia should be no different than in non-neutropenic patients, though it is recommended that the least invasive procedure is used. Surgical interventions, however, should not be delayed due to pancytopenia, but rather blood products should be transfused to the surgeon’s specifications to mitigate associated risk. 26 There is no evidence that granulocyte transfusion is beneficial.

Routine use of G-CSF or GM-CSF is not recommended in patients with neutropenic sepsis, as rapid neutropenia recovery carries a risk of respiratory deterioration due to ARDS. 27 , 28

It is reasonable to consider albumin administration in addition to balanced crystalloids in patients who meet criteria for fluid resuscitation and have a low serum albumin (e.g. ≤3.2) (II-C)

Patients with cirrhosis and septic shock experience higher mortality than those without cirrhosis. 29 This may be due, in part, to altered hemodynamics at baseline in cirrhosis patients, as it is known they have increased renal and neurological organ dysfunction in the setting of sepsis. Unfortunately, there have not been many studies looking at the best practices in management of sepsis in this vulnerable population. Cirrhosis does not exclude patients from standard treatment bundles (SEP1), however there has been debate amongst physicians as to the best fluid for resuscitation in this unique population. A recent single-center randomized controlled trial of albumin infusion (250 mL of 5% solution) versus 30 mL/kg of normal saline demonstrated improved blood pressure (MAP > 65) and lactate clearance at 3 hours as well as improved mortality at 6 days with albumin resuscitation as compared to normal saline. 30 However, the average MELD-Na score in both groups was over 33, and 30-day and 60-day mortality rates were not reported. Although albumin can be used for volume expansion in patients with cirrhosis, the evidence supporting this approach is limited. Therefore, in cirrhosis patients with sepsis, we recommend initial fluid resuscitation with 30 mL/kg of crystalloids, as recommended for patients without cirrhosis. It may be reasonable to add albumin in some circumstances as well.

Literature, Guidelines, and Performance Measures

Strategy for Literature Search

Within the Medline (Ovid) database, the following search strategy was used.

Sepsis/or septicemia or septic or blood poison* or bloodstream infection* or pyaemia* or bacterernia*or endotoxemia* or fungemia* or candidemia*
Not exp neonatal sepsis
exp animals/not humans/not exp adolescents/or exp child/or exp infant/not adult

The Main search retrieved 13,772 references. When the search hedges for Guidelines, Clinical Trials, and Cohort Studies were added, the base results are as follow:

Sepsis Main -Guidelines, total results were 765
Sepsis Main -Clinical Trials, total results were 3863
Sepsis Main -Cohort Studies, total results were 9144

Within the Cochrane Database of Systematic Reviews, 55 reviews were found using the strategy in the search strategies document.

The search was conducted in components each keyed to a specific causal link in a formal problem structure (available upon request). The search was supplemented with very recent clinical trials known to expert members of the panel. Negative trials were specifically sought. The search was a single cycle.

Level of evidence supporting a diagnostic method or an intervention:

A= systematic reviews of randomized controlled trials
B= randomized controlled trials
C=systematic review of non-randomized controlled trials or observational studies, non-randomized controlled trials, group observation studies (e.g., cohort, cross-sectional, case control)
D= individual observation studies (case or case series)
E =opinion of expert panel.
Related National Guidelines

The UMH Clinical Guideline on Sepsis is generally consistent with other guidelines published nationally and internationally, including:

The Centers for Medicare & Medicaid Services collect and publish metrics around SEP1 performance for the 3 hour and 6 hour bundles.

Related National Performance Measures

The Centers for Medicare & Medicaid Services sepsis performance measure bundle (SEP-1).

The development of this guideline was funded by the University of Michigan Health System (UMH).

Guideline Development Team and Disclosures

The multidisciplinary guideline development team consisted of:

The medical team: Jessie King, MD, PhD, Carol E Chenoweth, MD, Peter C England, MD, Andrew Heiler, MBA, RN, Michael T Kenes, PharmD, BCPS, BCCCP, Krishnan Raghavendran, MD, Winnie Wood, MSN, RN, CNS, Shiwei Zhou, MD. Reviewers: Pratima Sharma, MBBS, Hallie Prescott, Tammy Garcia, Carly Redstone.
Guideline development oversight: Megan R. Mack, MD, David H. Wesorick, MD, April Proudlock, BBA, RN, Ellen Patrick, MA
Literature search services were provided by informationists at the Taubman Health Sciences Library, University of Michigan Medical School.

The UMH endorses the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed. Contributions of team members with relevant financial relationships are reviewed by team members without relevant financial relationships to assure the information is presented without bias.

None of team members or consultants have relevant personal financial relationships.

Review and Endorsement

Drafts of this guideline were reviewed in clinical conferences and by distribution for comment within departments and divisions of the University of Michigan Health System to which the content is most relevant: Emergency Medicine, Family Medicine, General Medicine, Infectious Disease, Gastroenterology, and Radiology. Medication recommendations were reviewed by the Pharmacy and Therapeutics Committee. The Executive Committee for Clinical Affairs of the University of Michigan Hospitals and Health Centers endorsed the final version.

These guidelines should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific clinical procedure or treatment must be made by the physician in light of the circumstances presented by the patient.

Data Availability

These links to Internal UMHS Guidelines contain proprietary information so are only accessible to appropriate Michigan Medicine staff. For more information, contact the authors or publisher.

Supplementary material can be found at http://www.uofmhealth.org/provider/clinical-care-guidelines

Internal UMHS Guidelines contain proprietary information so are only accessible to appropriate Michigan Medicine staff. For more information, contact the authors or publisher.

Created: November 2023.

Except where otherwise noted, this work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-sa/4.0/

Cite this Page King J, Chenoweth CE, England PC, et al. Early Recognition and Initial Management of Sepsis in Adult Patients [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2023.
PDF version of this title (731K)

In this Page

Other titles in this collection.

Michigan Medicine Clinical Care Guidelines

Related information

NLM Catalog Related NLM Catalog Entries
PMC PubMed Central citations
PubMed Links to PubMed

Recent Activity

Early Recognition and Initial Management of Sepsis in Adult Patients Early Recognition and Initial Management of Sepsis in Adult Patients

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

IMAGES

The Pathophysiology and Treatment of Sepsis Essay [896 words]
Sepsis: Emergency Condition in Prehospital Setting
(DOC) Care for a Patient with Sepsis, Septic Shock, and Multi-System
Sepsis and Homeostasis
Sepsis: Blood and Fluid Resuscitation
Sepsis and Homeostasis

VIDEO

Sepsis Song
Nurses Role in Managing Sepsis
Sepsis Guideline for Nursing care
Guide to Sepsis for Nursing Students
10 Lines Essay On Nurse In English / Essay On Nurse / 10 Lines On Nurse /International Nurses Day
Role of nursing care in sepsis care

COMMENTS

Sepsis Essay Complete copy
Sepsis Essay Complete copy. Module Managing Care for the Adult Patient (MOD003302) University Anglia Ruskin University. Academic year: 2021/2022. Uploaded by: ... Nursing Student's Guide To Clinical Success. 1st ed. Sudbury: Jones and Bartlett Publishers. Raff, A. B., & Kroshinsky, D. (2016). Cellulitis: A Review.
Causes and Treatments of Sepsis
Sepsis is a major cause of morbidity and mortality in hospitals today. It has been defined as 'the body's response to an infection when organisms invade the body' (Baudouin 2008). ... Essays; Nursing; Causes and Treatments of Sepsis. Paper Type: Free Essay: Subject: Nursing: Wordcount: 2233 words: Published: 5th Jan 2018: Reference this ...
IDENTIFYING AND ASSESSING PATIENT'S SEPSIS BY NURSES IN AN ...
nursing students about identifying sepsis. The research was conducted as a literature review with both meta-synthesis and metaanalysis- . Strict inclusion and exclusion criteria were constructed to secure the quality of the data. The data was collected from different databases such as EBSCO, Sage Premier, Ovid, Science Direct and ...
Recognition and management of sepsis: the nurse's role
Caring for a patient with suspected sepsis is a challenging nursing role. Early recognition and appropriate management of a patient with sepsis saves lives. Nurses play a fundamental role in detecting changes in physiological observations that could indicate the onset of sepsis. Additionally, an awareness of the pathophysiology of sepsis allows ...
An evidence-based approach to a patient with sepsis
This essay will focus on the evidence-based approach to a patient with sepsis. Sepsis is defined as a systemic inflammatory response to infection (Polat et al., 2017). The importance of an evidence-based approach in nursing practice cannot be overstated.
Sepsis and Septic Shock: Nursing Care Management Study Guide
This article aims to highlight the critical importance of nursing in battling sepsis and septic shock, shedding light on the pathophysiology, risk factors, clinical presentations, and evidence-based interventions. By fostering a comprehensive understanding of these conditions, nurses can proactively contribute to saving lives and minimizing the ...
Sepsis Infection Causes and Effects
The aim of this essay is to raise awareness of sepsis, so that nurses will have a greater understanding of this condition and feel more confident in the identification and treatment. The definition of sepsis is the presence of Systemic Inflammatory Response Syndrome (SIRS) criteria in the patients with a new infection.
Sepsis assessment and management in critically Ill adults: A ...
Introduction. Sepsis is a global health problem that increases morbidity and mortality rates worldwide and which is one of the most common complications documented in intensive care units (ICUs) [].About 48.9 million cases of sepsis and 11 million sepsis-related deaths were documented in 2017 worldwide [].Sepsis is an emergency condition leading to several life-threatening complications, such ...
Early Recognition and Initial Management of Sepsis in Adult Patients
Definitions: Sepsis is a syndrome characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. 1 SEP3 clinically defined sepsis as acute organ dysfunction (e.g., ≥2 new SOFA points), plus evidence of infection 2.However for billing, documentation, and treatment purposes, the older definitions of sepsis are still used.
Current sepsis research: What nurses need to know : Nursing2020 ...
Figure. Sepsis is a major cause of mortality in the US, with a reported one out of three inpatient hospital deaths due to sepsis. 1 Despite recently published definitions and guidelines that provide a framework for the care of patients with sepsis, there is no strong consensus among healthcare providers and in the literature on all aspects of recognition and management of this deadly disease ...