Sepsis

Sepsis & Septic Shock

Welcome back to the Nursing School Week by Week Podcast. I’m your host, Melanie, and today we are tackling a big one. We’re talking about Sepsis and Septic Shock. Honestly, I’m a little intimidated by this one, just because it’s a huge topic, but it’s an important one, so I’m gonna try to do it justice. With sepsis, or septicemia, it can get real complicated, real fast. But we’re gonna try to just keep it simple today and talk about what you really need to know. 

So many people have not even heard of sepsis, but it’s actually the 3rd leading cause of death in the US, after heart disease and cancer. Someone dies of sepsis in the US every 2 minutes. That’s crazy! What’s even crazier is that one person gets sepsis every 20 seconds! The good news is that it’s treatable. But treating sepsis is all about TIME. We need to recognize and treat this quickly because for every hour that treatment is delayed, the patient’s risk for death goes up by 8%. And TIME is actually the acronym used by the Sepsis Alliance to remind everyone to watch out for a temperature, an infection, mental decline, or feeling extremely ill. TIME. T-I-M-E. Temperature (or fever), Infection, Mental decline, or Extremely ill. If anyone outside the hospital notices these signs and symptoms, they should go to the hospital right away because it could be sepsis. If a patient is in the hospital already, then we have more specific screening tools that we use to recognize early signs of sepsis, and we’ll talk about those in a bit.

So what is sepsis? Sepsis is when the body has an extreme response to an infection. The body tries so hard to fight off the infection, that it can even damage the patient’s own tissues and organs. Sepsis usually starts with a bacterial infection, but we also see it caused by fungal, viral, or even parasitic infections.

The 4 types of infections that most often lead to sepsis are: pneumonia, UTI’s, skin infections, and infections in the intestines.

The people who are the most at risk for getting sepsis are the elderly and babies, and anyone who already has a weakened immune system. Also, if you’ve been a patient in a hospital before, especially for an infection, then you’re more likely to get sepsis.

So what are the stages of sepsis? Cause if it can start with a little infection and end with death (and I’m not even exaggerating here. For the people that progress all the way to septic shock, they have a 40% chance of dying.) But, there’s obviously a progression and varying levels of severity. So, let’s start by looking at the word sepsis. Sepsis literally means “to rot”, so you can think of it like rotting from the inside out. And historically, back in the olden days, people called this “blood poisoning”, and well-meaning physicians would use leeches, or just straight up cut open a vein or artery for bloodletting. They thought that by letting some of the blood out, it would cleanse the body of sickness. Obviously, we now know this was not effective, and just made things worse. But sepsis starts with some kind of infection, like let’s say you get a cut on your arm. Normally, the skin forms a really effective barrier against infection, but if the skin is broken, then bacteria can get in. In most cases, even if bacteria got in, the body would just mount an immune response, and the white blood cells would rush to the area and take care of it. No problem. And remember, the white blood cells would get to that cut on the arm by going through the bloodstream to that area, and then releasing cytokines to recruit more WBCs and help them break through the side of the blood vessel in order to get to the infected tissue. Also, the immune response would trigger inflammation and vasodilation. The way I picture vasodilation is by thinking of a water hose, like a garden hose. When the hose is on, and you put your thumb over the end, the water pressure gets stronger, and more forceful, but when you take your thumb away, you are dilating it, or making the area that the water goes through bigger, and it decreases the water pressure. It’s less forceful. This is the same with your blood vessels. When they are dilated, the vessel, or tube is bigger, and the blood pressure is going to go down. This normal immune response works beautifully in a normal situation, where the bacteria is just in one part of the body, like a cut on your arm. But, where things get tricky, is when the bacteria goes from one part of your body into your bloodstream. Because then your body is mounting an immune response not just in one area, but all over your body. It mounts a systemic response. Basically, your immune response is going haywire. So now you’ve got white blood cells all throughout your body releasing chemicals in your bloodstream that are dilating your vessels, and making your vessels more permeable, meaning fluids and stuff can move out of your vessels more easily. And this is what happens in Sepsis. The vessels are so permeable, that fluid starts leaking out into the interstitial space. So then you have this situation where, you technically have enough fluids in your body, but you are in a state of relative hypovolemia because the fluids have leaked out of your blood vessels. And remember, if there is less blood in the vessels, then there is less oxygen being circulated to the cells throughout your body. And when your cells are deprived of oxygen, they start to die. And if the tissues go too long without oxygen, we can eventually see fingertips go black and lose limbs, and then see organs completely fail. 

Alright, so let’s talk signs and symptoms. It’s so important to recognize these signs of sepsis early, because the earlier we treat it, the better the outcome. So, I made up this acronym HATTT, it’s hat with three T’s. It stands for hypotension, altered mental state, tachycardia, tachypnea, and temperature. HATTT. They will have hypotension because their blood vessels are all dilated. They often are really restless, or confused. Their body will try to compensate for the hypotension by increasing the heart rate, so you’ll have tachycardia. They will have a fast respiratory rate, or tachypnea, and in the early stage of sepsis, they will have a fever due to the infection. So HATTT, hypotension, altered mental state, tachycardia, tachypnea, and a temperature. 

Most hospitals now use an automated screening tool to help nurses and doctors recognize the early signs of sepsis. There are a few different ones like SIRS, qSOFA, and NEWS or MEWS. So depending on which hospital you wind up working at, they may use something slightly different. But usually, as the nurse, you will be required to look over the patient’s vital signs at least every 4 hours, and input them into the computer system. As you do this, whatever screening tool your hospital uses will evaluate the vital signs, and if the patient is at risk for sepsis, there will be a popup that lets you know that this patient is at risk. Then you will let your charge nurse know, as well as the doctor, and monitor this patient more frequently, and implement any interventions that the doctor orders.

So let’s look at the SIRS screening tool as an example. SIRS stands for systemic inflammatory response syndrome. So if we follow this screening tool, it should let us know if the body is mounting a systemic immune response, or fighting off an infection in the blood. So if the patient has 2 or more of the following: either a high or low temperature. So either a fever above 100.4 degrees, or a temperature below 97 degrees. If they have hypotension, which would be systolic blood pressure below 90 (or even a drop of more than 40 mm than their normal). If they have a heart rate greater than 90, or a respiratory rate greater than 20. Also, looking at their labs, if their WBC is more than 12,000 or less than 4,000 that can indicate an infection. 

So if they have two or more of any of those signs, then we would flag them for sepsis. Now you’ll notice that some of those were on the high or low end of things, like they would be flagged if they had either a high or low temperature, or if they had either a high or low white blood count. That’s because there are two main stages of sepsis. The early and late stages. These are also sometimes called warm and cold sepsis, because in the early stage, the patient will have a fever and will feel warm. But in the late stage of sepsis, the patient’s temperature will drop because they have hypotension and decreased perfusion to the tissues, so they are going to feel cold to the touch. And as far as the white blood count goes, in the early stage of sepsis, the immune response is just starting up, and there are still a lot of white blood cells that are trying to fight the infection, but as that war continues to rage on, the white blood cells get all used up, so in late sepsis, the white blood count will be less than 4,000. Remember a normal white blood count range is between 5 to 10 thousand.

So let’s recap the signs of sepsis. They are HATTT. Hypotension, altered mental state, tachycardia, tachypnea, and a temperature. 

Some other things that we can be on the look-out for are a decreased urine output, because the kidneys are one of the first organs to be affected by sepsis since when the blood pressure drops so low, there is less oxygen getting to the kidneys, and they are used to getting a large amount of blood volume, since they are the washing machines for the blood in the body. So as nurses, we will be measuring the amount of urine our patients are making, and charting that every few hours. If your patient is making less than 30mL of urine per hour, then they could have an acute kidney injury due to sepsis. 

Also, we might see some edema in our patients. Cause remember this massive immune response has made the blood vessels more permeable, so the fluid is leaking out into the surrounding tissues. So we might see some pitting edema, or swelling, especially in the feet and legs. The patient may also become hyperglycemic or hypoglycemic even if they don’t have a history of diabetes, because the body is under a large amount of stress during sepsis, and this can cause big changes in their blood glucose level, so as a nurse, you may see an order to check their blood glucose levels, and you might be like, “Why? They’re not diabetic.” But if the doc suspects sepsis, then they want to keep an eye on the blood sugar. 

And as if all of that wasn’t enough, there’s another terrible thing that can start happening during all of this. When the body mounts an immune response, the inflammation process activates the clotting cascade. So we have platelets floating around in our blood at all times, and when the clotting sequence is activated, these platelets clump together to try to plug up holes that have opened up in blood vessels. That’s normal, but with sepsis, we can see something called DIC, or Disseminated Intravascular Coagulation, and this is where the vessels are leaking out so much blood and fluids and the platelets are forming clots left and right to try to stop the leaking, that the platelets get all used up, and then you can have massive bleeding and clotting going on at the same time. The clots can clog up small vessels, and completely block off the flow of blood to peripheral areas, and put the patient at greater risk for DVTs and pulmonary embolisms. And they can start bleeding out of every opening in their body. I’ve actually heard of people in late stages of septic shock with DIC that were bleeding out of their eyes because they didn’t have enough platelets left to stop the bleeding. So sad. 

But let’s not let it get to that stage, yeah? So how are we going to treat Sepsis and septic shock? The Surviving Sepsis Campaign has come out with a 1-hour bundle. These are  the things that we need to try to do within the first hour after recognizing sepsis in order to give the patient the best chance for survival. Now, you guys know I love my acronyms. For this one, I want you to remember “CALL IT”. C-A-L-L, -I-T. If we see signs of sepsis, we are going to “CALL IT”. We’re going to C for Culture, A for Antibiotics, L for Lactate, then another L for getting another Lactate, then the I in IT is for IV Fluids, and finally the T is for Tissue perfusion. We want to keep the patient’s MAP or mean arterial pressure above 65 to make sure they have adequate tissue perfusion. So, that was “CALL IT”. Culture, Antibiotics, Lactate, Lactate, IV fluids, and Tissue perfusion. Alright, let’s go through this treatment for sepsis.

First we want to take cultures. Blood cultures are the gold standard for diagnosing sepsis, cause if the patient has bacteria in their blood, then they are by definition septic. So in order to get accurate blood cultures, we need two sets of cultures. That means we will wind up with 4 bottles in all. 1 aerobic bottle and 1 anaerobic bottle from each side of the body. We’ll draw blood from one arm, then wait 15 minutes before drawing blood from the other arm. By drawing blood from two different sites and waiting 15 minutes between, this gives us the best chance of drawing up some of that bacteria if there is any in the bloodstream. Also, and remember this, you must get the blood cultures before you start any antibiotics. Because once you start the antibiotics, that means you can no longer get accurate blood cultures. We also want to get a urine sample and culture since the source of infection that leads to sepsis is often a urinary tract infection. And then we want to look the patient’s skin over really carefully, and if we find any abscess, or pressure ulcer, anything that we could swab and get a culture of, we want to do that. Or, if they are coughing up phlegm, send that to the lab for a culture since pneumonia is a common reason for sepsis. 

So after the cultures, you will quickly start a broad spectrum antibiotic. Now we’re giving a broad spectrum antibiotic because those blood cultures are gonna take a while to come back. They have to go to the lab, and then the lab techs have to smear some out onto petri dishes and put them into incubators, and wait for something to grow, and all that takes time. So, until we have a better idea of what kind of bacteria we’re fighting, we use a broad spectrum antibiotic, something that is known to kill many different types of bacteria. 

Next we are going to check their serum lactate level. We’re going to check this at least twice. Once right away, and then another time between 2-6 hours later. This gives us an idea of how severe the sepsis has gotten. And remember when the cells in the body aren’t getting enough oxygen, they switch to a state of anaerobic metabolism, and the byproduct of that is lactate. So we want to check their lactate level, and if it’s over 4 mmol/L, that’s a red flag. Also, a blood sample that will be tested for lactate is only good at room temperature for 15 minutes, so usually we will need to stick this tube in a plastic bag full of ice and send it to the lab like that, otherwise we could get falsely elevated lactate levels. 

Alright, so if the lactate is over 4 mmol/L or if the patient is hypotensive, so a blood pressure less than 90 systolic, we are going to start them on IV fluids. We want to use a crystalloid fluid, so like normal saline or lactated ringers, and we want to match the amount to their weight. We are going to give them 30 mL of fluid per kg. So, for a normal 70 kg adult, that would be about 2 liters of fluid. And as nurses, giving IV fluids is one of the main interventions you will do over and over again to fix low blood pressure. Because by increasing the amount of fluids in their blood vessels, this will increase the pressure in their blood vessels, and increase overall blood pressure. One thing we want to remember is to keep assessing your patient during all of these interventions. While giving them antibiotics, we are assessing them for any allergic reactions, and while giving them IV fluids, we are listening to their lung sounds, particularly for sounds of crackles which would warn us that their lungs are getting fluid overloaded. 

Alright, finally, the T in “CALL IT” stands for tissue perfusion. If you are giving the IV fluids and their MAP, or mean arterial pressure, is still under 65, then the patient is officially in septic shock, and you want to give vasopressors. Something like norepinephrine. The mean arterial pressure just means the average blood pressure during a single cardiac cycle. And we know if this is less than 65, then the tissues are not getting enough oxygen. So we want to give norepinephrine quickly because the faster we can correct this, the less likely the body's organs are to start shutting down. Vasopressors work by constricting your blood vessels. They make them narrower and increase the blood pressure. 

Those are the main interventions you will do for sepsis. Just remember the acronym, “CALL IT”. Cultures, Antibiotics, Lactate, a second Lactate, then IV Fluids, and Tissue perfusion. And then you’ll  just be supporting any organs that start to fail. Like if the patient’s kidneys go out, they may need dialysis to clean their blood for them. Or if their lungs fail, they may need to be intubated and put on mechanical ventilation. We will also be checking their labs frequently. We want to look at their arterial blood gas, because they can often develop metabolic acidosis, and we want to look at their CBC, or complete blood count to see how many white blood cells and platelets they still have. If they are having blood clotting issues, we may put them on anticoagulant therapy, like heparin. 

And at the same time we’re doing all these interventions, we’re trying to find the source of the infections, cause all the interventions in the world are not gonna save this person if we don’t find and fix the source of the infection. The most obvious things to look at are skin infections, and then if they have any lines going into their body, like if they have a Foley catheter, or a central line. We would want to remove those because they could be the source of the infection. 

Alright y'all, if nothing else, I hope I’ve made you aware of how crazy severe sepsis can get, and how important it is to screen for it and treat it early. Because 1 in every 3 patients that die in the hospital has sepsis. That’s a scary statistic. But, knowledge is power, and now you know what to look for. Make sure you hit that follow button to get next week’s episode, cause we’re doing another verbal simulation case study, that will make you that much more prepared for the Next Generation NCLEX.

Alright, have a great week, and I’ll talk to you next time!