New sepsis guidelines urge you to revamp care: Delays can cost lives
Aggressive interventions are needed for first 4 hours in ED
It was easy for ED nurses to recognize signs of septic shock in a 23-year-old woman who had just given birth at St. Clare Hospital in Lakewood, WA: She could barely speak, was hypotensive, hypothermic, and had a grayish coloring.
"I can remember thinking that I had never seen anyone that color that was still alive," says Victoria Leavitt, RN, regional nurse educator for emergency services for Franciscan Health System, a three-hospital system in the Puget Sound area.
The woman soon became obtunded and anuric, with extremely low mean arterial pressures despite vasopressors, fluid, and broad-spectrum antibiotics. "It was heartbreaking, as her husband and parents had come to celebrate the birth of their first grandson, and now their daughter was staring death in the face," says Leavitt. "They asked if there was anything that we could do — and we had nothing."
The woman developed coagulopathies and multiple organ failure, and despite emergent surgery, died the next day.
You probably have experienced the same powerless feeling watching septic patients deteriorate rapidly. However, just-published guidelines for severe sepsis and septic shock give you powerful lifesaving tools, says Maurene A. Harvey, RN, MPH, CCRN, FCCM, past president of the Des Plaines, IL-based Society of Critical Care Medicine and member of the Surviving Sepsis Campaign’s steering committee, which organized the consensus conference that led to the development of the guidelines.1
The guidelines call for aggressive intervention during the first four hours in the ED, says Harvey, pointing to research showing dramatically reduced mortality rates. "The mortality rate for sepsis patients can be decreased from 30-60% to 20-40%, so that means one out of three more lives are saved by what we do in the ED," she says.2
There are 750,000 annual U.S. cases of sepsis, and about a third of these patients come through the ED, reports Harvey. Sepsis kills 200,000 people annually, and cases have skyrocketed 329% in the past 20 years, due to increased numbers of elderly and immunocompromised patients and widespread use of antibiotics, according to the Atlanta-based Centers for Disease Control and Prevention.
Would the new sepsis guidelines and aggressive interventions in the ED have saved the life of the above patient? "I don’t know," admits Leavitt. "But I do know that I would have liked to have had the opportunity to try those treatments. They are making a difference for many patients and decreasing the mortality rates of this truly terrible syndrome."
Don’t waste any time
A pneumonia patient comes to your ED with fever, lethargy, and low urine output, but with a normal blood pressure, and is diagnosed as septic. Does this patient wait several hours for an intensive care unit (ICU) bed before monitoring of lactates and hemodynamics starts and fluid resuscitation begins? Delays in these interventions have cost many sepsis patients their lives, emphasizes Harvey.
"In EDs, there is often inadequate recognition of cryptic shock," she says. "ED nurses have not been trained to be aggressive with these patients and often are not equipped to do hemodynamic monitoring."
Patients therefore often are not fully resuscitated until they get to the ICU, which could be hours later, says Harvey. "Early resuscitation is much more effective," she says.
Rapid, goal-directed treatment for sepsis will require a different mindset for ED nurses, stresses Leavitt. "This very much parallels the shift in thinking that occurred with the advent of thrombolytics for stroke," she says.
Since there is potential to save many lives, don’t delay implementing the new guidelines in your ED, urges Harvey. "So many guidelines are written and never make it to the bedside or take years," she says. "It is very hard to take all of the recommendations and turn it into a plan."
To speed implementation, the Boston-based Institute for Healthcare Improvement worked with the Surviving Sepsis Campaign to create "bundles" listing the most important interventions. (To obtain complete guidelines and sepsis bundles, see the sources at the end of this article.)
"Print this out, put in a clipboard in the ED, and it tells you what to do in the first four hours," recommends Harvey. "Download this tool and bring it to the attention of your managers and directors, because people are dying that don’t need to die."
To dramatically improve care of patients with sepsis, follow these recommendations from the guidelines:
• Draw cultures before giving antibiotics.
According to the guidelines, you should draw at least two blood cultures, including one percutaneously and one drawn through each vascular access device, unless the device was inserted recently, says Steven D. Glow, RN, MSN, FNP, nursing faculty at Pablo, MT-based Salish Kootenai College.
"Also, make the presumptive diagnosis without waiting for the culture," advises Harvey.
• Start intravenous antibiotics within one hour.
"Think about how long it usually takes to get stat antibiotics — in some EDs, it could be three hours," says Harvey. "So it not only takes your working quickly to get these things done, but also collaboration with your lab and pharmacy."
• Give immediate fluid resuscitation for septic patients with shock.
Antibiotics still should be given within an hour, but fluid resuscitation must come first, notes Harvey. "Volume is the answer — they need liters and liters, often," she says.
If blood pressure doesn’t respond or lactate levels still are elevated, obtain a central venous pressure and give fluids to get the level up to 8-12, and then give vasopressors if there is a mean arterial pressure below 65, says Harvey.
Fluid resuscitation may consist of natural or artificial colloids or crystalloids, according to the guidelines. "There is no evidence-based support for one type of fluid over another," says Glow.
Remember that this syndrome destroys the microvasculature, which causes severe coagulopathies, says Leavitt. "The ED nurse should be vigilant in the ongoing assessment of intravascular fluid status as well as early signs of intravascular coagulopathy such as petechia and purpura," she says.
• Consider use of vasopressors.
Vasopressors preferred by the guidelines are norepinephrine or dopamine, but low-dose dopamine should not be used for renal protection as part of the treatment of severe sepsis, says Glow. "Ionotropic therapy with dobutamine may be helpful when combined with vasopressors to increase cardiac output," he adds.
• Monitor superior vena cava (SVC) saturation for sepsis with shock.
"We were told for years that you could only get this from a pulmonary artery catheter, but research shows that you can measure it from a central venous catheter," says Harvey. "That is good enough to use for early goal-directed therapy in the ED."2
Putting in a triple lumen catheter allows you to measure the central venous pressure, administer a significant amount of fluid, and measure venous saturation, she advises. "If the SVC is still under 70% after doing all of the above, give inotropes and possibly blood cells."
• Consider the use of drotrecogin alpha.
This is a recombinant protein with anti-inflammatory, antithrombotic, and profibrinolytic properties used to treat severe sepsis and septic shock, says Leavitt, who cautions that the drug can cause bleeding.3
"The patient receiving this drug should meet the definition of severe sepsis or septic shock and be screened for possible contraindications," she says. (For a complete list of contraindications, go to www.xigris.com/safety.shtml.)
• Measure serum lactate.
"We now know that about 25% of patients have cryptic shock, which means they are not hypotensive, yet their lactate is up, so they are in shock," says Harvey. "Some EDs are set up to do stat lactate, and some are not. So again, this is a collaborative effort with the lab."
- Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004; 32:858-873.
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1,368-1,377.
- Bernard GR, Vincent GL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344:699-709.
For more information about caring for sepsis patients in the ED, contact:
- Steven D. Glow, RN, MSN, FNP, Nursing Faculty, Salish Kootenai College, P.O. Box 70, 52000 N. Highway 93, Pablo, MT 59855. Telephone: (406) 275-4922. Fax: (406) 275-4806. E-mail: firstname.lastname@example.org.
- Maurene A. Harvey, RN, MPH, CCRN, FCCM, President, Consultants in Critical Care, Box 91, Glenbrook, NV 89413.
- Victoria Leavitt, RN, Regional Nurse Educator, Emergency Services Franciscan Health System, St. Francis Hospital, 34515 Ninth Ave. S., Federal Way, WA 98003-6799. Telephone: (253) 942-4139. E-mail: VictoriaLeavitt@chiwest.com.
The complete guidelines for sepsis can be downloaded at no cost on the Society of Critical Care Medicine’s web site (www.sccm.org). Click on "Professional Resources," "Guidelines," "Guidelines and Practice Parameters," and "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock." The Institute for Healthcare Improvement has developed "Four-Hour Sepsis Bundles" for patients with and without septic shock. The Sepsis Bundle is a group of interventions that, when implemented together, achieve significantly better outcomes than when implemented individually. The Sepsis Bundle currently is being tested by several organizations across the United States. They can be accessed at no charge at www.qualityhealthcare.org. Under "Topics," click on "Critical Care," "Sepsis," "Emerging Content," and "Sepsis Bundle."