Early detection and prevention of Sepsis HW

QGiven all the changes in sepsis definitions,

what is the best way

to know if a patient is

at risk for sepsis?

be used in the ICU as part of the

diagnostic criteria for sepsis.1

The key clinical point is the need

for ongoing monitoring of patients

for indications of organ dysfunction.

If a patient has indications of organ

dysfunction (regardless of the cause

or which screening tool is used), fur-

ther assessment is required.

The challenge is that there is no

consensus on how to screen for or

diagnose sepsis. The 2016 Surviving

Sepsis guidelines,5 which were

based on evidence using the old

sepsis definitions, did not include

the Sepsis-3 criteria. Rather, those

guidelines recommend ongoing

screening, without specifying the

criteria. Because the debate about

the appropriate screening criteria

for sepsis is ongoing,6-10 it is import-

ant to know what each score does

and does not tell you (Table 3).

ORDER CUSTOM, PLAGIARISM-FREE PAPER

An important consideration is

that a normal qSOFA or SOFA score

does not rule out sepsis,9 because

no screening tool is “perfect” (ie,

has 100% diagnostic accuracy).

Additionally, the accuracy of each

score varies depending on whether

the patient is in the emergency

department, the ICU, or a non-ICU

setting.1,13,14 Several excellent

review papers address this challeng-

ing question, including the use of

AElizabeth Bridges, PhD, RN, CCNS, FCCM, FAAN, and Sheryl Greco, MN, RN, reply:

This is an important question, as

the early recognition and treatment

of patients with sepsis and septic

shock are associated with improved

outcomes. Unfortunately, there is

no clear answer to this question.

In 2016, the Third International

Consensus Definition for Sepsis

and Septic Shock (Sepsis-3) was

published.1-3 As part of Sepsis-3,

the definition of sepsis was revised

from an inflammatory process in

response to an infection to “life-

threatening organ dysfunction due

to a dysregulated host response to

infection.”3 One outcome of this

revision was that systemic inflam-

matory response syndrome, as an

indicator of sepsis in combination

with concern for infection, was

replaced with the quick Sequential

(Sepsis-Related) Organ Failure

Assessment (qSOFA; Table 1) or

the SOFA score (Table 2) as an

indicator of organ dysfunction.

The Sepsis-3 committee recom-

mended that qSOFA be used in set-

tings other than the intensive care

unit (ICU) to identify patients at

risk for sepsis and the SOFA score

Identifying Patients at Risk for Sepsis

Authors Elizabeth Bridges is a clinical nurse researcher at the University of Washington Medical Center and a professor at the University of Washington School of Nurs- ing, Seattle, Washington.

Sheryl Greco is a clinical nurse specialist in critical care and cardiology at the University of Washington Medical Center.

Corresponding author: Elizabeth Bridges, PhD, RN, CCNS, FCCM, FAAN, University of Washington School of Nurs- ing, 1959 NE Pacific, Box 357266, Seattle, WA 98195 (email: ebridges@uw.edu).

To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809- 2273 or (949) 362-2050 (ext 532); fax, (949) 362- 2049; email, reprints@aacn.org.

BRIDGES GRECO

72 CriticalCareNurse Vol 38, No. 6, DECEMBER 2018 www.ccnonline.org

www.ccnonline.org CriticalCareNurse Vol 38, No. 6, DECEMBER 2018 73

manual versus automated screen-

ing.5,15-17 A recent review paper,18

which summarized the literature

on the identifi cation of patients with

sepsis on hospital wards, noted

that although automated screening

decreases time to diagnosis and

intervention for sepsis, the mortal-

ity benefi t has been mixed and the

most accurate screening tools (sin-

gle time or automated) remain to

be identifi ed.

Case Study A 48-year-old woman was trans-

ferred to the acute care surgical unit

after gastric conduit surgery on post-

operative day 2. She experienced

multiple minor regurgitation events

and aspiration of gastric contents.

Assessment on postoperative day 5

showed disorientation, anxiety, pull-

ing at catheters, heart rate 110/min,

respiratory rate 30/min, blood pres-

sure 86/60 mm Hg (mean 65 mm Hg

via noninvasive blood pressure

measurement), and normal body

temperature. The cause for these

symptoms was thought to be delir-

ium from receiving a combination

of benzodiazepines and opioids.

Yellow fl uid draining from the jeju-

nostomy site was attributed to bili-

ary drainage. Blood and surgical

site samples were cultured; no

other laboratory samples were col-

lected and antibiotics were not

administered. The patient’s condi-

tion deteriorated and the rapid

response team was called, after

which the patient was transferred

to the ICU. Sepsis was then recog-

nized, and the bundle elements

were initiated. Unfortunately, these

actions had been delayed, and the

patient could not be resuscitated

from septic shock.

Discussion The case study illustrates the

challenge in differentiating sepsis

from other disorders, resulting in a

delay in implementing potentially

lifesaving interventions. Examine

the data gathered on postoperative

day 5—did the patient have indica-

tions of end-organ dysfunction? Yes

(mental status change, tachypnea,

hypotension: qSOFA score = 3). Did

the patient have indications (or risk)

for infection? Yes, aspiration and

possible wound infection or leak-

age. At this point (positive qSOFA

with risk of infection), further

assessment of the patient for sepsis

Table 1 Quick Sequential Organ Failure Assessment (qSOFA) score1,2

Systolic blood pressure ≤ 100 mm Hg Respiratory rate ≥ 22/min Any change in mental status

Each parameter is scored as 1 point, for a total of 0-3. For patients outside the intensive care unit with a suspected infection, a score of ≥ 2 indicates an increased risk for a prolonged stay in the intensive care unit or death.

Table 2 Sequential Organ Failure Assessment (SOFA) score4 Early detection and prevention of Sepsis HW

Respiration: PaO2/FIO2 (P/F)

Coagulation: Platelet count, 103/μL

Liver: Bilirubin, mg/dL

Cardiovascular: Blood pressure and vasopressor use

Central nervous system: Score on Glasgow Coma Scale

Renal: Creatinine, mg/dL, or urine output < 500 mL/d

Points are assigned based on abnormality of each parameter. For example, a P/F ratio of 400 is scored as a 0, < 300 as a 2, and < 100 as a 4. An online SOFA score calculator is available at www.mdcalc.com/sequential-organ-failure-assessment -sofa-score.

Table 3 General considerations for SIRS, qSOFA, and SOFA scores

SIRS

qSOFA

SOFA

Indication of infl ammation Not a specifi c indicator of sepsis—other causes of infl ammation1

47% of non-ICU patients were SIRS positive during hospitalization11

Sole dependence on SIRS criteria may miss 1 in 8 patients with sepsis12

The presence of SIRS should alert the clinician to the need for additional assessment, as these signs may precede clinical deterioration.

Recommended for use in non-ICU patients as indicator of risk for prolonged ICU stay and mortality1-3

Not a diagnostic tool to rule out sepsis Positive qSOFA suggests the presence of organ dysfunction that requires

additional evaluation

Used in ICU to evaluate end-organ dysfunction4

Accurate predictor of in-hospital mortality in ICU patients1

In the presence of infection, an increase in SOFA score by > 2 points (indicating worsening end-organ function) is diagnostic of sepsis

Abbreviations: ICU, intensive care unit; SIRS, systemic infl ammatory response syndrome; qSOFA, Quick Sequential Organ Failure Assessment; SOFA, Sequential Organ Failure Assessment.

www.ccnonline.org

should have been undertaken,

including evaluating for other

causes of end-organ dysfunction.

This case demonstrates the need

to maintain constant vigilance for

sepsis and the potentially beneficial

use of a systematic process to iden-

tify patients at risk for sepsis. In the

absence of a single test or tool to

detect sepsis definitively, patients at

risk depend on the astute assessment

of the bedside nurse to recognize

the significance of a change in their

condition. For further information,

access the AACN website19 for

Resources for Sepsis. ��

Financial Disclosures None reported.

References 1. Seymour CW, Liu VX, Iwashyna TJ, et al.

Assessment of clinical criteria for sepsis: for the Third International Consensus Defi- nitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774.

2. Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):775-787.

3. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.

4. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;(11)22:707-710.

5. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3): 486-552. Early detection and prevention of Sepsis HW