Today we have another fabulous guest post from Courtney over at From New to ICU. In this post, she talks about a topic that comes up A LOT in the clinical setting…sepsis. So, without further ado…here’s Courtney!
In my medical ICU, the vast majority of patients are in septic shock. Have you ever had a patient’s family ask you about septic shock? “Why is my family member’s blood pressure SO low?” Is there an easy way to explain this to them or do you just say, “their body is reacting abnormally to a widespread infection?”
So this is how I like to explain it, plain and simple. Say that you have a splinter in your finger–what happens to it? It becomes red, hot and infected. Why is it red and hot? The body has opened up the veins around the splinter (making your finger hot!) to let white blood cells out and fight the infection. Just like this, when someone has a horrible enough infection, all of the patient’s vessels open up (decreasing the blood pressure) to try and fight the infection. The problem is that the body is fighting the infection systemically. So what causes this widespread response?
The Mayo Clinic states that “sepsis occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail.” Common causes are pneumonia, urinary tract infections, cellulitis, and abdominal infections. Sepsis can be caused by bacteria, viruses, or fungal infections.
There are three different stages of sepsis.
- Sepsis: During this phase, infection has reached the bloodstream and causes an inflammatory response.
- Severe Sepsis: The infection has now become so severe that it is disrupting blood flow to a person’s organs, causing organ failure.
- Septic Shock: The body is trying to combat the infection in any way it can. As a result, the person’s blood pressure drops significantly. This can lead to organ failure and death.
The usual presentation for sepsis is tachypnea (breathing quickly), tachycardia (fast heart rate), fever, and hypotension (low blood pressure). Patients can also exhibit organ dysfunction if the sepsis becomes severe enough. Symptoms of organ dysfunction include decreased urine output, lactic acidosis, hypoxemia, elevated liver enzymes, and an increased white blood cell count. Renal failure causes the decreased urine output as well as electrolyte imbalances. Respiratory failure causes the hypoxemia and lactic acidosis. Lactic acid forms when the body breaks down carbohydrates for energy in times of low oxygen levels. When a patient’s oxygen levels are too low, the lactic acid level rises and the patient exhibits a lactic acidosis.
Many hospitals have protocols in place to detect sepsis early. One system used is called the MEWS (Modified Early Warning System) score. This takes into account respiratory rate, heart rate, systolic blood pressure, level of consciousness, temperature, and urine output. Patients receive points for abnormal values in any of those categories. If they meet a certain point value, the emergency nurse for the hospital is contacted and the treatment plan is adjusted to help this worsening patient. What would they do to help them?
Blood cultures are one of the first diagnostic tests performed when sepsis is suspected. They should be drawn prior to starting any antibiotic, antiviral, or antifungal treatment. A broad spectrum antibiotic will be ordered to try and treat whatever infection is suspected. If the blood drawn grows out bacteria, the antibiotic will most likely be adjusted to something more specific to that type of infection.
Doctors will also usually start the treatment of a septic patient with hypotension by giving fluid boluses to increase blood pressure or “fill their tank.” Think of it this way, if you have take a straw that is full of fluid and then put that same amount of fluid into a one inch pipe, what is going to happen? The one inch pipe is going to seem like there is a lot less fluid than the straw. The pressure that the fluid puts on either the straw or the pipe is your blood pressure. The straw is totally full of fluid (normal blood pressure) where the pipe is only a quarter full (low blood pressure). Fill up the pipe with more fluid (fluid boluses) and the blood pressure should rise accordingly.
If a fluid challenge does not increase the blood pressure (meaning that the pipe is getting bigger in diameter faster than we can fill it up), patients may need vasopressor therapy to increase blood pressure. This , in essence, takes our one inch pipe and squeezes it back down to the size of a straw. There are risks associated with these very potent medications. These are administered only in an intensive care unit. In my ICU, the usual vasopressor of choice is Norepinephrine (Levophed). The patient’s blood pressure is monitored every fifteen minutes and the medication is titrated accordingly by the nurses. Patients may also need surgery to remove an infection in the case of an abscess of localized infection.
As a new nurse, it can be daunting seeing the life threatening effects that sepsis can have on patients…and at a very alarming rate! How can you keep your patients safe? Make sure to be aware of your patient’s vital signs! This is one easy intervention that could save your patient’s lives. When inputting your next vitals, look at the last set to see how your patient was. Sometimes their vitals may still be within normal limits, but they are much lower than the last set.
So there you have it…another great guest post from Courtney. If you’d like a handy reference sheet you can take with you to the hospital, then here you go!