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University of South Wales Open Access RepositoryArticle Title: Assessment and management of the septic patient: Part 1Authors: Vaughan, J.; Parry, A.Journal: British Journal of NursingCitation: Vaughan, J?& Parry, A?2016, 'Assessment and management of the septic patient: Part 1'?British Journal of Nursing, vol 25, no. 17, pp. 958-964. DOI:?10.12968/bjon.2016.25.17.958This is the accepted manuscript for the published article and may not contain all changes from the editorial process, the version of record is available from the publisher at the following DOI link 10.12968/bjon.2016.25.17.958 Assessment and management of the septic patient: Part 1The incidence of septicaemia is ever increasing within the clinical setting, with the rise attributed to more invasive procedures being performed and the ageing patient population (Singer et al, 2016). Despite being a long standing cause of mortality, it is only in the last few years that sepsis has moved to the forefront of clinical strategies to reduce avoidable deaths within hospitals. This has gone some way in enabling nurses to identify sepsis and provide early aggressive intervention, an approach that is known to reduce mortality in patients suffering a septic event (Dellinger et al, 2008, Burney et al, 2012). The early identification of sepsis is vital to optimise the chances of patient survival, as a patient admitted to hospital with sepsis has the same mortality rate as a patient admitted with a myocardial infarction in the 1960’s (Dellinger et al, 2013).Therefore this two part series explores the assessment and management of a patient presenting with sepsis and aims to provide nurses with the knowledge required to identify and deliver early intervention. As sepsis varies in severity depending on the systemic effects being exerted by the exaggerated inflammatory response that is associated with sepsis, this first part will explore the definition of sepsis and the criteria associated with the septic cascade (fig 1.). This first part will also explore systematic assessment and escalation of care for the septic patient. Part two will explore the interventions used in the treatment of sepsis and the evidence base that underpins the mainstay of current to sepsis care, the ‘sepsis six’. Figure 1. The septic cascade. (Adapted from Porth and Matfin, 2008, McCance and Huether, 2014). All nurses need to understand the pathophysiological changes caused by sepsis, and how these may present in patients (McClelland & Moxon, 2014). Without this knowledge, the nurse is less likely to recognise signs and symptoms of sepsis, increasing the risk of the patient developing septic shock which is associated with a high mortality rate. Systemic inflammatory response syndrome (SIRS)Robson & Daniels (2013) states that sepsis normally starts with the signs and symptoms of infection known as Systemic Inflammatory Response Syndrome (SIRS). The body responds to SIRS by increasing metabolic rates, (indicated by tachycardia and tachypnea in an effort to maintain perfusion to vital organs) and inflammation, while an immune response results in pyrexia and an increase in white cell production respectively (McClelland & Moxon, 2014). Prompt identification of a patient with SIRS is vital to optimise outcome with those presenting with two or more of the criteria in box 1. Patients who fit this criteria should be considered as acutely unwell with a high likelihood of further deterioration. SIRS criteriaTemperature <36?C or >38?CHeart rate >90 bpm Respiratory rate >20/minutePaCO2 (partial pressure of arterial carbon dioxide) below 4.3kpaAltered mental stateGlucose >7.7mmol/L in the absence of diabetesWhite cell count of >12,000 or <4,000 per mlBox 1. (Adapted from Mitchell & Whitehouse, 2010). SepsisSepsis is usually caused by bacterial, viral, or fungal infections, with the infections most likely to develop into sepsis being pneumonia, abdominal and kidney infections (McCance &b Huether, 2014). Sepsis involves a complex array of inflammatory responses that results in tissue injury and haemodynamic deterioration that fails to adequately perfuse vital organs (Singer et al, 2016) Tazbir (2012) states there is an abnormal distribution of body fluid as a result of inflammatory responses causing vasodilation and capillary leakage that leads to a state of distributive shock. This results in increased oxygen demand, and together with intravascular losses results in hypoperfusion and ischaemia at cellular level (Perrin et al, 2012). Hypotension can lead to inadequate perfusion of major organs, therefore perfusion must be assessed clinically through the measurement of blood pressure and mental state (Tazbir, 2012). In the absence of the blood results in box 1, Singer et al (2016) recommends using a simplified version of the sequential organ failure assessment score system (SOFA) on any patient with a suspected infection, stating it can aid in the rapid identification of sepsis at the bedside (see box 2). Indeed the Surviving Sepsis Campaign response to the updated classification of sepsis is to recommend the qSOFA method be used to screen patients for signs of infection (Antonelli et al, 2016). Patients showing two or more of these criteria should be screened for infection as they are at a 10% chance of mortality or significant deterioration (Singer et al, 2016).Quick SOFA (qSOFA) Respiratory rate ≥22 breaths/minAltered mental stateSystolic blood pressure ≤100 mmHg Box 2. (from Singer et al, 2016).Septic shockSeptic shock has been described as sepsis associated with organ dysfunction, hypotension, poor perfusion or an acute change in mental state (Burney et al, 2012). Patients admitted to hospital with septic shock have greater mortality rates than if they were admitted with an acute myocardial infarction or acute stroke (Robson & Daniels, 2013), this is because when a patient develops septic shock, the function of major organs such as the cardiovascular system, lungs, liver, kidney and brain can be adversely affected (Lovick, 2009). Septic shock is diagnosed on the identification of three conditions; a known or suspected infection, two or more symptoms of the systemic inflammatory response; and evidence of at least one organ dysfunction (Urden et al, 2015). A patient with septic shock will present with two or more of the criteria outlined in box 3.Septic shock criteriaSystolic blood pressure <90mmHg or a mean arterial pressure <60mmHg Oxygen saturation <93% or partial pressure of arterial oxygen <9kpa Altered mental state Hyperglycaemia in the absence of diabetes; glucose level >7.7mmol/LAcute olguria; urine output <0.5ml/kg/hr and or a raised creatinine Coagulopathy International Normalised Ratio> 1.5Serum lactate >4mmol/LBox 3. (Adapted from Dellinger et al, 2012).Septic shock has been recognised as the most severe end of the spectrum. Updated criteria have made slight alterations to the criteria above by stating that a MAP ≥65 mmHg and serum lactate of >2mmol/L indicates septic shock associated with a mortality of 40% (Singer et al, 2016). Those in septic shock display persistent hypotension despite fluid resuscitation of 500-2000ml and the need for vasopressors to maintain a mean arterial pressure (MAP) ≥65 mmHg (Jones, 2014, Singer et al, 2016). Other clinical indications may be a positive fluid balance, an unexplained metabolic acidosis; a blood pH <7.35 with a bicarbonate level less than 20mmol/L, a base >2.5mmol/L and a capillary refill time of >2 seconds (Lever & McKenzie, 2007). The most effective method to assess a patient with sepsis is by using the ABCDE approach (airway, breathing, circulation, disability and exposure) (Brunker, 2010). By using this systematic approach the nurse is more likely to identify sepsis criteria, enabling them to escalate care and ensure the patient is managed appropriately (Jevon, 2010). The ABCDE approach should be used as soon as acute deterioration is suspected as it can be a systemic way for initial assessment and resuscitation (Nichol & Ahmed, 2014). However, the ABCDE approach is not always adopted by nurses and other health professionals and signs of deterioration are often missed. Findlay et al (2012) (National Confidential Enquiry into Perioperative Deaths (NCEPOD)) reported that 75% of in-hospital cardiac arrests showed clear signs of deterioration before-hand yet were not managed appropriately, with some of these cases (38%) resulting in potentially avoidable cardiac arrest. Furthermore Goodwin et al (2015) (NCEPOD) found that patients presenting with sepsis were inadequately assessed or were delayed in being assessed. Therefore two NCEPOD reports suggest that assessment and escalation of care is poor and a cause for concern, resulting in poorer outcomes such as patient deterioration and death. It is important to point out, that the ABCDE approach must not be used if the patient is in cardiac arrest; if the patient is in cardiac arrest, it is the nurse’s responsibility to call for help and start cardiopulmonary resuscitation according to guidelines set by the Resuscitation Council (Koster et al, 2010). The Resuscitation Council (UK) (2016) recommends the ABCDE approach to assess deteriorating patients as it helps the nurse and other healthcare professionals to address life-threatening issues, aiming to manage symptoms thus allowing time to identify the primary cause of sepsis.Airway A patient with sepsis is at risk of depressed level of consciousness, which is the most common cause of airway compromise; so assessment of the airway must be the first priority in any patient with sepsis (Nichol & Ahmed, 2014). An immediate simple way of checking a patients airway is simply by asking the patient a question and waiting for a response, a clear logical answer implies that the airway is patent (Thim et al, 2012). A complete airway obstruction is silent, where as a partial airway obstruction could result in loud breathing; this has been described as a gurgling or snoring sound (Robertson & Al-Haddad, 2013). Due to developing hypotension and hypoxia a septic patient’s airway may become compromised, so a more thorough and accurate assessment may be needed, using a ‘look, listen and feel’ approach (Clarke & Ketchell 2011). To do this the nurse should look in the mouth for any visible obstruction, listen to the sound of breathing and feel for breath against their hand or cheek. Airway obstruction must be dealt with immediately and high flow oxygen should be administered as soon as possible (Resuscitation Council UK, 2016). In the case of any airway obstruction the nurse must position the patient appropriately, by using the head tilt chin lift technique, however if the patient is conscious they will usually adopt a position in order to maintain their own airway (Jevon, 2010). BreathingAssessment of breathing and respiratory rate is paramount when assessing patients with sepsis as this is the first sign of physiological deterioration (Jevon, 2010). The ‘look listen and feel’ approach should also be used as it enables the nurse to look at the patient to assess the work of breathing, listen to the sound of the breathing, and feel for chest movements and lung expansion (Resuscitation Council UK, 2016). Breathing should be monitored for one minute (Jevon, 2009), with one rise and fall of the chest equaling one breath (Dougherty & Lister, 2008). The respiratory rate in a healthy adult should be 12-20 breaths/min, however a septic patient will display tachypnea and increased depth of breathing (Elliot & Conventry, 2012). The nurse should assess chest rise, ensuring the patient has bilateral chest rise, poor chest expansion could indicate a number of problems such as pneumonia, or pleural effusion (Steen, 2010). Tachypnea is a compensatory response to lactic acidosis, whereby the increased volume of breathing eliminates carbon dioxide with the aim of normalising serum pH (McGloin & McLoed, 2010). Due to the hypoxia associated with sepsis the respiratory system responds by increasing the respiratory rate to increase oxygenation (McClelland & Moxon, 2014). Therefore the peripheral oxygen saturation level should be monitored using pulse oximetry and saturations, if saturations are ≤94% (≤88% for those with respiratory disease) oxygen therapy should be instigated to reverse the effects of hypoxia (Dellinger et al, 2013). which results in tissue damage which can lead to multi organ failure (Jevon, 2010). Oxygen should be administered via a non-rebreathe facemask, or Venturi mask for those with respiratory disease, and pulse oximetry used to monitor for effect (Urden et al, 2014). Arterial blood gases may also be taken to obtain an accurate measure of arterial gas tensions and pH. If however if the patient is unable to maintain oxygenation due to severely compromised level of consciousness (GCS ≤8) then the patient should be intubated and ventilated (Peate & Nair, 2016). Nichol & Ahmed (2014) argue that if a patient with sepsis presents with respiratory distress, severe hypoxaemia, pronounced acidosis or loss of consciousness interventions such as early intubation and ventilation must be considered immediately. CirculationThe circulatory assessment includes a general observation of the patient while recording a number of vital signs. The aim of the circulatory assessment is for the nurse to determine if the patient’s circulation is effective (Perrin et al, 2012). A strong bounding pulse and a low blood pressure can be a sign of a hyperdynamic state that occurs when a patient is in the initial stages of sepsis (Clarke & Ketchell, 2011). This happens as a result of an increased cardiac output and drop in peripheral resistance, which demonstrates the hearts attempt to compensate for the loss of vascular resistance by increasing cardiac output (Porth & Matfin, 2008). Even though the blood pressure appears satisfactory, there is still widespread tissue hypoxia due to poor distribution of blood flow (Copstead and Banasik, 2013). The nurse must look at the colour of the patient’s skin; what many perceive as the ‘classical’ signs of cardiovascular compromise include a pale pallor, cyanosis, and cold peripheries (Perrin et al, 2012). However in sepsis, the patients colour can be pink, flushed and warm to touch due to high serum CO2 (hypercapnia) and vasodilation (Urden et al, 2015). The nurse must manually assess a radial pulse, assessing the rate, quality and rhythm; a fine and faint pulse can sometimes suggest low cardiac output whereas a strong bounding pulse can be a clinical indication of sepsis (Elliot & Coventry, 2012). The pulse rate should be monitored for one minute, a normal adult pulse should be 60-100 beats/min, where as a patient with sepsis may present with tachycardia of ≥90 beats/min (Marieb, 2009). Tachycardia or an alteration in pulse volume can be an indication of cardiovascular distress (Dunkly & McLoed, 2015). The capillary refill time should be monitored as it can be prolonged in sepsis, a capillary refill time longer than 2 seconds can indicate reduced peripheral perfusion as a result of hypotension, other factors such as old age, cool temperature and poor lighting could also cause a delayed capillary refill time so need to be considered in every case (Resuscitation Council UK, 2016). The nurse should check the patient’s blood pressure as soon as possible. The most accurate and reliable way to check a patient’s blood pressure is the manual technique, this has been recognised as one of the most important skills for a nurse when assessing acutely ill patients (Clarke & Ketchell, 2011). In the initial hyperdynamic phase the patients systolic pressure may increase, but the diastolic will be decreased, the latter indicating vasodilation (Levick, 2010). However, the patients ability to compensate is limited, and eventually the systolic pressure will decrease coupled with a decrease in urine output. The renal system relies upon adequate blood pressure and vascular volume to filter blood and produce urine. If blood pressure and vascular volume falls, compensatory mechanisms in the form of the renin-angiotensin-aldosterone system, causes water to be reabsorbed into the circulation manifesting as a reduced urine output (?0.5ml/kg/hr) (Porth and Matfin, 2008). Therefore the assessment of urine output and fluid input is vital in assessment and management of a patient with suspected sepsis. Disability Disability assessment involves evaluating the central nervous system (Resuscitation Council UK, 2016). A quick efficient way to check a patients conscious level is by using the AVPU scale; Alert, Voice, Pain, Unresponsive (Jevon, 2010). A deteriorating patient with sepsis can become unresponsive or have a reduced level of consciousness; therefore the patient is at greater risk of life threatening complications such as airway obstruction, hypoxia and aspiration (Cooper et al, 2006). A patient with sepsis can appear confused or have a reduced level of consciousness due to hypoxaemia and cerebral hypoperfusion which is due to distributive shock related to sepsis (Lovick, 2009). The nurse must check pupils; size, equality and reaction to light, and if unresponsive or unconscious the patient should be nursed in the lateral position (Resuscitation Council UK, 2016). The stress response associated with sepsis results in hyperglycaemia, and poorly controlled blood glucose in sepsis has an adverse effect on outcome (Hirasawa et al, 2009). Therefore the nurse should perform a point of care blood glucose, with the normal range being 4-7 mmol/L (Mulryan, 2011) with any results exceeding this range being treated with a sliding scale insulin regime aiming for blood glucose of ≤10 mmol/L (Dellinger et al, 2012).ExposureThe exposure assessment allows the opportunity to find the possible source of infection. The nurse must look for any wounds that may be infected, skin rashes or invasive devices (McCelland & Moxon, 2014). Surgical patients are likely to have dressed wounds so it is important for the nurse to regularly assess wounds to promptly identify any changes. Patients are at high risk of infection if they have intravascular catheters, haemodialysis catheters or central lines (Lai et al, 2013), so it is important for the nurse to check the surrounding area for redness or swelling as this could be a sign of infection. The nurse must assess any stomas or catheter sites, wounds or drains as a change in the quantity and nature of the fluid may indicate infection. The nurse must ensure the patient is covered as soon as possible after assessment to maintain their dignity but most importantly to prevent heat loss (Perrin et al, 2012). Temperature should be monitored as a high or low core temperature can be the first indication that a patient has sepsis (O’Grady et al, 2008). Pyrexia enhances immune cell function, thus inhibiting growth of some pathogens, however an increase in body temperature and resultant vasodilation can contribute to hypotension (Porth & Matfin, 2008). Once the initial ABCDE assessment is complete, continuous ABCDE assessment should be repeated until the patient is stable or transferred to a suitable treatment area such as critical care.Patient assessment is key when caring for a patient with sepsis, including accurate recording and documentation of all vital signs, early recognition and appropriate intervention (Robertson & Al-Haddad, 2013). There are assessment tools available to the nurse to help identify patients with sepsis who are at risk of deteriorating known as early warning scoring (EWS) system. EWS enables the nurse to highlight a problem, intervene early, and prevent acute deterioration in patients with sepsis and potentially save lives (Roberson & Al-Haddad, 2013). If the patient triggers a high score on the EWS, the patient should be screened for sepsis and care must be escalated immediately to an appropriate health care professional such as a doctor or a member of the critical care outreach team (Robson & Daniels, 2013). Early indicators of sepsis can be missed, and it is important to emphasise that patients can deteriorate even when vital signs are within their normal limits. However it must be emphasised that the results of the ABCDE systematic assessment will inform the EWS, it will also provide a richer source of information that are not part of a EWS system, such as peripheral temperature, general pallor, work of breathing, and so on. Therefore the ABCDE assessment must be the first step in identification. Together with EWS, the UK Sepsis Screening Tool should be used to identify any clinical suspicion of sepsis (Hancock, 2014) (Box 4). Box 4. (Taken with kind permission from UK Sepsis Trust, 2016).Screening for SIRSSIRS is confirmed if ANY TWO of the following are present:ImmediateNew onset of Confusion or Altered Mental StateTemperature >38.3 or <36?CHeart Rate >90 beats per minuteRespiratory Rate (counted over 60 seconds) >20 breaths per minutePoint of Care Test (POCT) (commonly available)Blood Glucose >7.7mmol/L in the absence of known diabetesLaboratory (unless POCT available)WCC >12 or <4 x109/Lb.) Sepsis Risk Stratification Commence Sepsis Six immediately if ANY ONE of the following are present:ImmediateSBP <90mmHg or >40mmHg fall from baselineMAP <65mmHgHeart rate >130 per minuteNew need for supplemental oxygen to maintain saturations >90% should prompt emergent chest radiographRespiratory rate >25 per minuteAVPU = V, P or UPOCT (commonly available)PaO2/FiO2 ratio <300 (mmHg) or <39.9 (kPa)Lactate >2.0mmol/LRadiology (only if clinically indicated, e.g. SpO2 <90%)Bilateral pulmonary infiltrates AND new need for supplemental oxygen to maintain oxygen saturations >90%Laboratory (unless POCT available)Creatinine >176.8μmol/LINR >1.5aPTT >60sPlatelet count <100 x109/LBilirubin >34.2μmol/LUrine output monitoringUrine output <0.5mL/kg for two consecutive hoursBox 4. (Taken with kind permission from UK Sepsis Trust, 2016).It is worthy to note that the nurse can stratify a patient’s risk of developing sepsis by using the components in part b.) of box 4. These risk stratification parameters can aid the nurse in identifying patients that are developing sepsis, but are currently compensating, thus showing relatively acceptable physiological parameters. This would enable the nurse to take steps to instigate the sepsis six detailed in box 6 (see also part 2 of this series). The first step after risk is identified is to escalate care effectively As soon as 2 or more signs of SIRS are identified using the Sepsis Screening Tool, the medical emergency team and outreach should be notified immediately using the SBAR tool (Box 5). The SBAR tool should be used to ensure the nurse communicates effectively and provides health care professionals with a structured, concise handover of the patient (Christie & Robinson, 2009).SBAR toolSituation?State you location and identify patient of concern?State why you think the current problem is?State what advice you are seekingBackground?Patient background?Reason for admission?Past medical historyAssessment?Airway, Breathing, Circulation, Disability, Exposure ?Outline vital observations, highlighting any abnormal findings Recommendation?State what you want the doctor to do e.g. attend to review patient, refer to another specialist ?State a specific time frame for this to happen?State what you wish to do next e.g. start oxygen, fluids, take bloodBox 5. (Adapted from Resuscitation Council (UK) 2016). An example of a nurse’s handover using SBAR when sepsis is identified could be as follows;- Situation; the nurse should give all personal details of the patient and clearly state that the patient has presented with 2 or more signs of SIRS and indicate any likely infection that may be the source. Background; the nurse must state the patients resus status, any allergies the patient may have, past medical history, and current medication. Assessment; the nurse must use the ABCDE approach and state current EWS score and abnormal vital signs, the nurse must state if the patient is receiving oxygen or is ventilated, fluid balance; stating if the patient has low urine output, if the patient has intravenous access, if the patient has any wounds or drains, and if the patient is any pain. Recommendations would be for the patient to be reviewed by the medical team immediately, antibiotics, iv fluids and oxygen to be prescribed as soon as possible so that the Sepsis Six care pathway (Box 6) can be commenced immediately. Should further deterioration occur it would be entirely reasonable for the patient to be transferred to a critical care environment, as the level of care they require necessitates low nurse to patient ratios. Critical care is the only environment that can offer this level of care and provides the patient with the best opportunities for recovery. Sepsis sixAdminister high flow oxygenTake blood cultures and consider infective sourceAdminister intravenous antibioticsGive intravenous fluid resuscitationCheck haemoglobin and serial lactatesCommence hourly urine output measurementBox 6. (Taken from UK Sepsis Trust, 2014).Conclusion The ability to identify developing sepsis is fundamental to optimising the chances of patient survival, the rise in invasive procedures and the ageing population is increasing the challenge to effectively counter the effects of sepsis in vulnerable patients. However this challenge can be met if nurses possess a good level of knowledge relating to the presenting symptoms of sepsis. Although it is widely accepted that these symptoms can be mild despite significant physiological deterioration, a systematic approach to assessment can aid the nurse in identifying the criteria for sepsis. This article has offered a narrative on what symptoms may be encountered in each of the aspects within a systematic assessment. Furthermore the need for effective escalation of care to ensure the patient is managed by a senior team of healthcare professionals cannot be overstated, as failure on this front leads to unnecessarily high mortality rates. 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