Sepsis is the leading cause of death in non-coronary intensive care units (ICUs). The mortality rate is estimated to be between 28 to 50%. Sepsis, however, does not refer to a specific bacteria, but rather to the body's immune response to an overwhelming infection. Infections, at any point on the body, can lead to sepsis. Within health care systems, the most common sites of infection are IV catheters, surgical sites, and pressure ulcers.
Pathophysiology
Within normal circumstances, the body's immune response seeks to increase blood flow and the capabilities of macrophanges to control an infection. But in sepsis, an exaggerated response is creates its own dangerous situation.
In response to the foreign antigen, the body releases pro-inflammatory mediators such as prostaglandins, tissue necrosis factor, cytokines, and platelet-activating factors. These factors proceed to damage the endothelial lining and lead to capillary leakage. They also activate neutrophils, releasing nitric oxide, a potent vasodilator, leading to edema. The platelet-activating factors circulate systemically, increasing coagulation. Combined, these factors create symptoms of hypotension, edema and microthrombi which proceed to impar the perfusion of tissues and lead to multi-organ failure.
Symptoms
Hypothermia, tachycardia, tachypnea, peripheral vasodilation/edema, unexplained shock, and unexplained mental status chages all can indicate sepsis. The CBC will indicate infection and clotting factors will be noted.
Sepsis Prevention
The most effective way to reduce the incidence rates of sepsis in an organization is to prevent infection. Strict adherence to policies regarding IV site care and careful monitoring and treatment of surgical site infections are the best way to prevent healthcare-associated infections leading to sepsis.
Surviving Sepsis
Sepsis Bundles refer to evidence based guidelines for the treatment of sepsis and septic shock within a healthcare organization. They were introduced by The Surviving Sepsis Campaign after research was done showing that by following these specific protocols in patients with severe sepsis, outcomes were improved and mortality was reduced.
The term "bundle" refers to a series of evidence based protocols that are used together. When implemented together, these elements have greater results than any of the interventions used alone. Hospitals are meant to use the bundles as a framework for creating sepsis protocol in their institutions.
What's in the Bundles?
Once a patient is triaged in the ED or identification is made of symptoms consistent with severe sepsis, the following steps are to be taken:
TO BE COMPLETED WITHIN 3 HOURS:
1) Labs: Lactate levels
2) Obtain blood cultures
3) Administer broad spectrum antibiotics after blood cultures are done
4) Give 30 ml/kg of crystalloid for hypotension or lactate =4 mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Give vasopressors (for hypotension not responding to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) =65 mmHg
6) In the event of persistent hypotension after fluid resuscitation (MAP < 65 mm Hg) or if initial lactate was =4 mmol/L, re-assess volume status and tissue perfusion and document findings
7) Re-measure lactate if initial lactate was elevated.
DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH
• Repeat focused exam by independent licensed provider (vital signs, assessment of perfusion, fluid status)
OR TWO OF THE FOLLOWING:
• CVP
• ScvO2
• Bedside cardiovascular ultrasound
• Assessment of fluid responsiveness using passive leg raise (does the patient show an increase in stroke volume?)
Successful sepsis bundles should seek to achieve the goal of a 25% reduction in mortality from sepsis called for by The Surviving Sepsis Campaign.
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