Sepsis 2

“Hey Curmudge, it was fun last week doing our folksy introduction to sepsis laced with ten-dollar words, but why so much technical stuff?”

“It’s hard to express the complexity of the human body without a few big words, which, you may have noticed, were all defined in the text. I also felt that any terms as hard to learn as those deserved to be spread around. By the way, I haven’t been holding my breath as you recommended last week. I’ve been reading about how health care handles sepsis. May I share?”

“You may, as long as you haven’t been reading a medicinal biochemistry text.”

“Articles on sepsis often start with its diagnosis. In reality, when a patient arrives in an ED, the ED doc’s first question isn’t, ‘Does this person have sepsis?’ His first mental query must be, ‘What’s wrong with this person?’ Then a lot of things happen almost simultaneously. The doc tries to alleviate the patient’s distress (she wouldn’t be in the ED if she didn’t have distress), performs a history and physical, and begins tests and interventions indicated by the history and physical.”

“Of course, several things can help the doc avoid starting at square one. If someone is accompanying the patient, they can help with the history. If the patient can’t communicate, that person would be essential. Similar information might also come along with the patient if she is sent from a skilled nursing facility. In addition, they should know if the patient has a fever and perhaps an infection and what organ is affected. In that case, the physician would order a blood culture before starting a broad-spectrum antibiotic.”

“In the physical—and possibly in triage—the first indication of sepsis will likely be signs of an infection, hypotension, a systolic BP of less than 90 or mean arterial pressure (MAP) less than 65. This tells the provider that time is of the essence, not only because of the crowded ED waiting room but because the patient’s life may be in the balance. All of the actions below should be taken within one hour of the patient’s arrival at the ED. IV access is established, and a fluid challenge and vasopressors (to raise blood pressure) would be ordered. An arterial line to measure consistent and accurate blood pressure and a central venous catheter to deliver IV fluids and vasopressors to the larger veins of the body should be placed immediately.”

“Now that sepsis is suspected, Curmudge, the next task is to learn how bad it might be. Here’s a useful algorithm:
1. SIRS (Systemic Inflammatory Response Syndrome): Temperature >100.4F (38C) or <96.8F (36C), heart rate >90, respiratory rate >20, WBC >12,000 or <4,000. Patient already found to be hypotensive.
2. Sepsis: SIRS plus source of infection.
3. Severe sepsis: Sepsis plus organ dysfunction.
4. Septic shock: Persistent hypotension and organ dysfunction despite aggressive fluid resuscitation.
If sepsis isn’t found, seek an alternative diagnosis. If sepsis is found, admit the patient to the hospital—the ICU for those with severe sepsis or septic shock—ASAP.”

“Transferring the patient to the ICU and to the care of intensivists and critical care nurses will bring the hospital’s best resources to bear on her condition. In general, these are the kinds of therapies that will be used:
1. Increase perfusion to organs and tissues by increasing blood pressure with fluid resuscitation and through the use of vasopressor medications (examples are norepinephrine and dopamine).
2. Treat the underlying infection through use of antibiotic therapy or surgery.
3. Provide oxygen and treat respiratory distress (if present).”

“Here are some (there are more) specific things to be done at Affinity hospitals (and elsewhere) for the sepsis patient. They should occur within the first six hours, and are called Early Goal-Directed Therapy.
1. Draw labs for blood cultures and obtain specimens from other sources for identification of infection. Serum lactate levels are an indicator of oxygen deficits (Curmudge, I put this in because I knew you’d be interested in the biochemistry).
2. Perfusion: If mean arterial pressure is <65, give sufficient IV fluids to assist in raising blood pressure. Start norepinephrine or dopamine to keep systolic BP >90 and mean arterial pressure >65. When fluid challenge therapy is not effective, implement Critical Care Nursing Considerations.
3. Oxygenation: Keep oxygen saturation >90%. Mechanical ventilation if needed.”

“Julie, putting the patient on a ventilator is certain to impress the patient’s relatives of the seriousness of her situation. The only patients that I’ve seen on a ventilator were at death’s door."

“Remember, Curmudge, that not all sepsis patients come in through the ED. Some are inpatients who have taken a turn for the worse. Nurses in the medical/surgical units are taught to watch for these observable symptoms in their routine rounding on the patients under their care:
1. Chills, shaking, low body temperature, or fever.
2. Rapid breathing (hyperventilation), lightheadedness, rapid heart beat.
3. Decreased urine output (oliguria).
4. Confusion or delirium.
5. Warm skin or skin rash.
These should trigger the nurse’s concern about SIRS. She should immediately initiate quantitative measures, like BP and temperature, and should contact the physician. More specific quantitative indicators of sepsis, used to augment routine bedside assessment, are listed in Affinity’s Cellular Perfusion Assessment Parameters.”

“Next week, Julie, let’s focus on Affinity’s experience with sepsis. We’ll point out how our care of sepsis patients exemplifies standard work, which is essential in implementing a Lean culture.”

“Lean, Curmudge! I was afraid that you’d forgotten about Lean.”

Affinity’s Kaizen Curmudgeon