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DETOUR OFF THE SEPIS ROAD: EARLY RECOGNITION IS KEY

Angela Buckles, RN, CNS-S
Murray State University

Introduction

Sepsis is the systemic inflammatory response to infection (Howell & Tisherman, 2006). The pathophysiology of sepsis is complex and typically involves the following components: inflammatory, procoagulant, antifibrinolytic, and microvascular (Wheeler, 2007). The occurrence of sepsis has increased dramatically. In the 1970’s, the US estimated 164,000 cases (Neviere, 2009). At present, the US reports approximately 750,000 cases a year and estimates 1 million cases by 2020 (O’Brien, Ali, Aberegg, & Abraham, 2007). With a mortality rate of 30%, an estimated 250,000 annual deaths, and hospital costs exceeding $16 billion, sepsis has become a burden (O’Brien et al, 2007, Kaplow & Hardin, 2007). It is imperative to increase the awareness and early recognition of sepsis. This article will review the definition, pathophysiology, and the current treatment plan for sepsis. Utilization of the Synergy Model and a case study will illustrate how early identification of sepsis can lead to improved patient outcomes.

Definition

The definition of sepsis ranges from the start of the systemic inflammatory response to multiple organ failure. Knowledge of the different stages of sepsis gives healthcare personnel the ability to intervene and choose appropriate treatment interventions. The following definitions are from Neviere, 2009. Systemic inflammatory response syndrome (SIRS) is clinically identified by the presence of two or more of the following:

· Temperature > 38.5 degrees C or < 35 degrees C

· Heart rate > 90 beats/min

· Respiratory rate > 20 breaths/min or PaCO2 < 32 mmHg

· WBC > 12,000 cells/mm3, < 4000 cells/mm3, or > 10 percent immature band forms

Sepsis occurs when the clinical signs of SIRS are present along with a visible infection or culture-proven infection. Severe sepsis occurs with sepsis plus at least one of the following signs of organ hypoperfusion or dysfunction:

· Areas of mottled skin

· Capillary refilling requires three seconds or longer

· Urine output <0.5 mL/kg for at least one hour, or renal replacement therapy

· Lactate > 2 mmol/L

· Abrupt change in mental status

· Abnormal electroencephalographic (EEG) changes

· Platelet count <100,000 platelets/mL

· Disseminated intravascular coagulation

· Acute lung injury or acute respiratory distress syndrome (ARDS)

· Cardiac dysfunction, as defined by echocardiography or direct measurement of the cardiac index

Septic shock exists when severe sepsis is present plus one or both of the following:

· Systemic mean blood pressure is < 60 mmHg (or <80 mmHg if the patient has baseline hypertension) despite adequate fluid resuscitation

· Maintaining the systemic mean blood pressure > 60 mmHg (or > 80 mmHg if the patient has baseline hypertension) requires dopamine > 5 mcg/kg per minute, norepinephrine < 0.25mcg/kg per minute, or epinephrine < 0.25mcg/kg per minute despite adequate fluid resuscitation.

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