When a teen-ager came to Children’s Hospital Medical Center in Cincinnati with a sunburn-like rash, a life-threatening cause was identified by an emergency department (ED) nurse. "He was septic and had meningococcemia, which can kill in just a few hours," reports Lynn Daum, RN, BSN, the ED nurse who cared for the patient. A good assessment and rapid treatment made all the difference in the boy’s outcome, Daum says. "We gave megadoses of antibiotics in the ED," she reports. "He went home a week later, with no unfortunate sequela."
If you were asked to name a leading cause of mortality, sepsis might not come to mind immediately. However, sepsis is the 10th most common cause of death in the United States, and it is increasing due to growing numbers of elderly patients and interventional procedures.1 If sepsis is overlooked, adverse outcomes may include the loss of fingers, toes, tips of noses and ears, deafness, blindness, renal failure, and even death, Daum warns.
Here are effective ways to assess patients for sepsis:
• Have a high index of suspicion for patient at risk.
The young, the elderly, and anyone who is immunocompromised are at greatest risk for sepsis, and that neonatal sepsis is a leading cause of infant mortality, says Laura M. Criddle, MS, RN, CS, CEN, CCRN, CNRN, emergency, trauma, and neurological clinical nurse specialist at Oregon Health and Sciences University in Portland. (See chart listing patients at risk for sepsis, below.)
| Patients at High Risk for Sepsis | |
| Sepsis is most likely to develop in patients who: | |
| • | have a compromised immune system, often because of treatments such as chemotherapy for cancer steroids for inflammatory conditions; |
| • | are very young or very old; |
| • | have wounds or injuries such as those from burns, a car crash, or a bullet; |
| • | are addicted to alcohol or drugs; |
| • | are receiving treatments or examinations such as intravenous catheters, wound drainage, or urinary catheters. |
| Source: International Sepsis Forum, London. | |
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Since sepsis may progress very rapidly to shock, early identification and intervention are essential, says Criddle. She advises doing a quick visual inspection and urine dipstick for any patient with an indwelling urinary catheter, since this is a common source of infection.
Assist with collection of specimens for culture and sensitivity testing, establish good intravenous access, and facilitate the rapid initiation of intravenous antibiotics, Criddle also advises. For patients who arrive in septic shock, airway and ventilatory management, large amounts of fluids, and inotrophes are essential, she says. The early signs of sepsis are subtle and nonspecific, and they frequently are missed in the early phase, she emphasizes. "In general, this is the patient who just looks sick, often with little else that can be pointed to initially," she says.
Assess for subtle increases in respiratory rate and heart rate in the patient at rest, she says. Any level of consciousness changes — such as an infant sucking poorly, failing to make eye contact, and behaving listlessly, or an elderly patient who is agitated, confused, or less responsive than usual — are significant, Criddle adds. Skin signs such as flushing, pallor, mottling, and even petechiae and purpura are indicators of an advanced condition, she says.
Very young infants are at risk because they have immature immune systems and an inability to thermoregulate, Daum explains. When young infants get cold, they have a tendency to slow down their breathing or even have apnea spells that can lead to life-threatening bradycardia, she explains. "We worry about a cold baby as well as a febrile one," she says.
Use an infant warmer, Daum advises. "When we strip infants to do our procedures, we are exposing them to a cool environment," she explains. "We have to help them regulate their body temperature." Many times a fever is associated with sepsis, but fever is not the only indicator, cautions Daum. "If the whole picture isn’t clear, sepsis can be missed," she says. "A neonate may by hypothermic instead of hyperthermic and be septic." The child may have a high-pitched cry and be very irritable, says Daum. When doing an assessment, you may notice a sunken anterior fontanel, or a bulging one, she says. Here are other clues she advises you to look for:
- a history of increased sleepiness;
- decreased intake by mouth;
- decreased urine output;
- sudden onset of fever, rash, or lethargy;
- a pinpoint, nonblanching rash below the nipple line;
- any change in mental status;
- purpuric rash anywhere on the body.
• Support the cardiovascular system.
Septic patients often need fluid boluses followed by vasopressors to maintain blood pressure, Daum says. If the cardiovascular system is not supported, the patient can very quickly go into shock, she warns. "This can be a life-threatening event," she says.
• Don’t delay in giving antibiotics.
Pediatric advanced life support teaches that in a code situation, the drug of choice is "epinephrine, epinephrine, epinephrine," Daum notes. "For sepsis, it should be antibiotics, antibiotics, antibiotics," she says.
Ideally, antibiotics should be administered within 30 minutes of patient arrival, says Criddle. Daum’s ED’s septic workup is given to any infant younger than 60 days old presenting with a fever or history of a fever. It includes a urinalysis, blood culture, complete blood count, serum glucose, and cerebrospinal fluid. (See clinical pathway for fever of uncertain source.) The pathway ensures that antibiotics are given quickly, Daum says. "Most of the time we will leave a saline well in the child, as we anticipate giving antibiotics and we don’t want to stick the child any more than we have to," she says.
Reference
1. Hoyert DL, Arias E, Smith BL, et al. National Vital Statistics Reports, vol. 49, No. 8. Hyattsville, MD: National Center for Health Statistics; 2001.
Sources
For more information about sepsis, contact:
• Laura M. Criddle, MS, RN, CS, CEN, CCRN, CNRN, Emergency, Trauma, and Neurological Clinical Nurse Specialist, Oregon Health and Sciences University, Mail Code UHS8Q, 3181 SW Sam Jackson Park Road, Portland, OR 97201. Telephone: (503) 494-1350. Fax: (503) 494-7441. E-mail: [email protected].
• Lynn Daum, RN, BSN, Emergency Department, Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229. Telephone: (513) 636-4718. Fax: (513) 636-8724. E-mail: [email protected].
If you were asked to name a leading cause of mortality, sepsis might not come to mind immediately. However, sepsis is the 10th most common cause of death in the United States, and it is increasing due to growing numbers of elderly patients and interventional procedures
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