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An elderly woman tells you she’s been ill for several days and has very low blood pressure, but her vital signs are otherwise normal. Would you suspect impending septic shock in this patient? Do you have a way to determine if this patient is getting sicker?

Cutting-edge protocols boost care of severe sepsis

June 1, 2005

Cutting-edge protocols boost care of severe sepsis

ED nurses playing an ever-increasing role in care

(Editor’s note: This is the first of a two-part series on sepsis in the ED. This month, we cover protocols using updated approaches for care of septic patients in the ED. Next month, we’ll report on effective strategies to educate nurses on new monitoring procedures being used in the ED.)

An elderly woman tells you she’s been ill for several days and has very low blood pressure, but her vital signs are otherwise normal. Would you suspect impending septic shock in this patient? Do you have a way to determine if this patient is getting sicker?

Severe sepsis occurs in more than 750,000 patients a year and has a mortality rate of 28%.1 "We are now understanding that sepsis is responsible for as many deaths as myocardial infarction in this country," says Stephen Trzeciak, MD, an ED and critical care physician at Cooper University Hospital in Camden, NJ.

However, this life-threatening condition often is overlooked in the ED, which can have devastating results, says Nathan Shapiro, MD, research director for the department of emergency medicine at Beth Israel Deaconess Medical Center in Boston.

Evidence-based guidelines from the Surviving Sepsis Campaign call for aggressive early goal-directed therapy (EGDT) for sepsis patients beginning in the ED, and research has shown a 16% reduction in mortality rates when ED patients were treated with EGDT.2 However, many EDs have not yet adopted these recommendations, he says.

"Unfortunately, although there is a lot of interest starting to stir, many EDs have been slow to adopt EGDT," says Shapiro.

However, the number of EDs using early protocols for sepsis will increase dramatically in the near future, Shapiro predicts. "ED nurses are playing an ever-increasing role, especially when EGDT is involved," he says. "In our ED, the nurses truly drive the protocol and take a large share of the responsibility." (See the ED’s protocol.)

Your ED’s sepsis protocol should address early identification, treatment goals, and a plan to transition care to the appropriate setting, says Shapiro. You need to maintain a high index of suspicion for identifying patients with sepsis or who may develop sepsis, he adds. "Looking for hypotension and tachycardia is a start, and we advocate routine lactate screening in patients with infection to detect patients with hypoperfusion," Shapiro says. "In our ED, we use the mantra blood culture equals lactate.’"

Example of a protocol

At Cooper University Hospital, a severe sepsis EGDT protocol was developed based on the new guidelines. The following steps occur for patients who present with clinical symptoms of sepsis and evidence of hyperfusion:

  • Patients are given supplemental oxygen and fluid resuscitation.
  • Central venous pressure is measured, and if less than 8 mm mercury (Hg), aggressive resuscitation is given with crystalloid fluid boluses.
  • Mean arterial pressure or systolic blood pressure is assessed. If the reading is under 65 mmHg or systolic blood pressure is under 90 mmHg, vasopressor therapy is started using norepinephrine or dopamine.
  • Saturation of central venous oxygen is determined, and if under 70% and hematocrit is under 30%, red blood cells are transfused and inotropic support is given.

Tools to spot deterioration

Septic patients often don’t appear terribly sick, but frequently deteriorate rapidly after leaving the ED, says Karen Slutsky, RN, ED clinical manager at Cooper University Hospital.

"They don’t necessarily present as ill as they actually are. And previously, we didn’t have very good markers or indicators to tell us that patients would get so sick," Slutsky says. "By the time you recognized how sick they were, patients were often past the point of return."

With acute myocardial infarction, an electrocardiogram is a clear-cut indicator that will identify when a patient’s ST segment is going up, says Trzeciak. "We do not yet have that type of a diagnostic tool for predicting acute multiorgan dysfunction in severe sepsis," he notes.

Instead, you have to look for signs of systemic inflammation, such as elevation of temperature, heart rate, respiratory rate, and white blood cell count, and in addition, look for markers of acute organ dysfunction and hypoperfusion, he says.

Monitoring in the ED allows nurses to catch signs of deterioration, such as persistently low central venous pressure or very low saturation of central venous oxygen, says Trzeciak. "This currently represents best practice for severe sepsis management and motivated us to be early adopters of this therapy," he says.

The sepsis protocol has a dramatic impact on patient outcomes, but this may not become apparent until after the patient has left the ED, notes Trzeciak. "We can’t necessarily expect to see dramatic things right in front of our eyes, because the way sepsis patients die is from persistent multiple organ failure later on, with withdrawal of support down the line in the ICU," he says.

In the past, the patient would have gone to a medical/surgical floor without being monitored, and the condition would have been picked up by the critical care team only after the patient started to decompensate, which could be a day or two later, explains Slutsky. With the new protocol, EDs are able to respond to patient’s changes much more quickly, she says.

"This was not even an option in the past," says Slutsky. "This was all totally new to everyone, but it’s now become the norm in our ED — just like t-PA for stroke a few years ago."

References

  1. Angus DC, Linde-Zwirble WT, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29:1,303-1,310.
  2. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1,368-1,377.

Sources

For more information on caring for sepsis patients in the ED, contact:

  • Nathan Shapiro, MD, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, CC2-W, Boston, MA 02215. Fax: (617) 754-2350. E-mail: [email protected].
  • Karen Slutsky, RN, Nurse Manager, Emergency Department. Cooper University Hospital, One Cooper Plaza, Suite 901A, Keleman Building, Camden, NJ 08103-1489. E-mail: [email protected].
  • Stephen Trzeciak, MD, Cooper University Hospital, UMDNJ-Robert Wood Johnson Medical School at Camden, One Cooper Plaza, D363, Camden, NJ 08103. E-mail: [email protected].