Sepsis best practices: Definitions, guidelines, and updates.

ABSTRACT: Sepsis remains a complex and costly disease with high morbidity and mortality. This article discusses Sepsis-2 and Sepsis-3 definitions, highlighting the 2021 Surviving Sepsis International guidelines as well as the regulatory requirements and reimbursement for the Severe Sepsis and Septic Shock Management Bundle (SEP-1) measure.

[Ethical décision making and septic shock]. / Décision éthique et choc septique.

Nurses can contribute to the decision-making process in emergency situations in cases of septic shock, particularly if the patient has not drawn up advance directives and/or nominated a health care proxy. They can undertake or facilitate the collective decision making on the legal and ethical level. The team's habitus in terms of ethical analysis and the gathering of initial data can help to ensure the patients wishes are respected.

[Septic shock, organisation and nursing care]. / Choc septique, organisation et soins infirmiers.

As septic shock is a life-threatening condition, acting quickly is a crucial element of its treatment. Nurses must be equipped with the skills to be able to recognise the warning signs and notify the doctor quickly.

[From sepsis to septic shock]. / Du sepsis au choc septique.

Septic shock, defined as the combination of sepsis, a requirement for catecholamines to maintain systolic blood pressure above 65 mmHg and a serum lactate level above 2 mmol/L despite adequate volume resuscitation is a life-threatening condition. The Quick Sepsis-related Organ Failure Assessment (qSOFA), which can be used by all nurses with a high-risk patient presenting with infection, enables the patient to be transferred rapidly to specialist care units.

Fluid therapy and shock: an integrative literature review.

BACKGROUND: shock refers to a physiological situation that puts life at risk. Its early identification and the timely institution of therapeutic measures can avoid death. Despite the frequent administration of fluid therapy as a treatment for shock, the type and dose of fluids to be delivered remain undetermined. AIM: to determine the type of fluids to be administered and the type of approach to be performed in the different types of shock. METHOD: integrative literature review. RESULTS: data about fluid therapy in hypovolaemic and distributive shock were obtained, specifically in the haemorrhagic and the septic types. None of the articles addressed cardiogenic shock. CONCLUSION: hypotensive resuscitation, with blood, is the most appropriate approach in haemorrhagic shock. There remains a question regarding the best approach in septic shock. However, conservative fluid therapy seems to be appropriate, with preference given to the administration of balanced crystalloids or albumin as an alternative.

Assessment and management of the septic patient: part 1.

Sepsis has gained increasing publicity in recent years, and is now a strong focus of clinical education and training following the launch of the 'Surviving Sepsis' campaign. The assessment and management of a septic patient are far from simple and requires a systematic approach in both identifying and managing the condition. This two-part series explores the assessment and management of a septic patient, with this article emphasising the need to identify the signs and symptoms of sepsis at the early stages if positive patient outcomes are to be realised. The ABCDE approach to patient assessment is explored in the context of sepsis, as this approach can ensure the nurse will identify sepsis as opposed to the basic method of only performing vital observations.

Reversal of neutrophil-to-lymphocyte count ratio in early versus late death from septic shock.

INTRODUCTION: Septic shock is one of the most frequent causes of admission to the intensive care unit (ICU) and is associated with a poor prognosis. Early and late death in septic shock should be distinguished because they may involve different underlying mechanisms. In various conditions, the neutrophil-to-lymphocyte count ratio (NLCR) has been described as an easily measurable parameter to express injury severity. In the present study, we investigated whether the timing of death was related to a particular NLCR. METHODS: We conducted a prospective, single-center, observational study that included consecutive septic shock patients. Severity scores, early (before day 5) or late (on or after day 5 of septic shock onset) ICU mortality, and daily leukocyte counts were collected during the ICU stay. We assessed the association between leukocyte counts at admission and their evolution during the first 5 days with early or late death. The association between patient characteristics (including cell counts) and prognosis was estimated using Cox proportional cause-specific hazards models. RESULTS: The study included 130 patients who were diagnosed with abdominal (n = 99) or extra-abdominal (n = 31) septic shock. The median (interquartile range) NLCR was 12.5 (6.5-21.2) in survivors and 6.2 (3.7-12.6) in nonsurvivors (p = 0.001). The NLCR at admission was significantly lower in patients who died before day 5 than in survivors (5 [3.5-11.6] versus 12.5 [6.5-21.2], respectively; p = 0.01). From day 1 to day 5, an increased NLCR related to an increase in neutrophil count and a decrease in lymphocyte count was associated with late death (+34.8 % [-8.2 to 305.4] versus -20 % [-57.4 to 45.9]; p = 0.003). Those results were present in patients with abdominal origin sepsis as well as in those with extra-abdominal sepsis, who were analyzed separately. CONCLUSIONS: In the present study, a reversed NLCR evolution was observed according to the timing of death. Septic shock patients at risk of early death had a low NLCR at admission, although late death was associated with an increased NLCR during the first 5 days.

Prevention and treatment of meningococcal disease.

Meningococcal disease is a leading cause of death in children and young people. Part 1 of this two-part series discussed its epidemiology, pathophysiology, signs and symptoms (Dowson, 2014). Part 2 reviews the diagnosis, management and prevention of this disease.

Mixed venous oxygen saturation monitoring revisited: thoughts for critical care nursing practice.

BACKGROUND: Less invasive methods of determining cardiac output are now readily available. Using indicator dilution technique, for example has made it easier to continuously measure cardiac output because it uses the existing intra-arterial line. Therefore gone is the need for a pulmonary artery floatation catheter and with it the ability to measure left atrial and left ventricular work indices as well the ability to monitor and measure a mixed venous saturation (SvO(2)). PURPOSE: The aim of this paper is to put forward the notion that SvO(2) provides valuable information about oxygen consumption and venous reserve; important measures in the critically ill to ensure oxygen supply meets cellular demand. In an attempt to portray this, a simplified example of the septic patient is offered to highlight the changing pathophysiological sequelae of the inflammatory process and its importance for monitoring SvO(2). RELEVANCE TO CLINICAL PRACTICE: SvO(2) monitoring, it could be argued, provides the gold standard for assessing arterial and venous oxygen indices in the critically ill. For the bedside ICU nurse the plethora of information inherent in SvO(2) monitoring could provide them with important data that will assist in averting potential problems with oxygen delivery and consumption. However, it has been suggested that central venous saturation (ScvO(2)) might be an attractive alternative to SvO(2) because of its less invasiveness and ease of obtaining a sample for analysis. There are problems with this approach and these are to do with where the catheter tip is sited and the nature of the venous admixture at this site. Studies have shown that ScvO(2) is less accurate than SvO(2) and should not be used as a sole guiding variable for decision-making. These studies have demonstrated that there is an unacceptably wide range in variance between ScvO(2) and SvO(2) and this is dependent on the presenting disease, in some cases SvO(2) will be significantly lower than ScvO(2). CONCLUSION: Whilst newer technologies have been developed to continuously measure cardiac output, SvO(2) monitoring is still an important adjunct to clinical decision-making in the ICU. Given the information that it provides, seeking alternatives such as ScvO(2) or blood samples obtained from femorally placed central venous lines, can unnecessarily lead to inappropriate treatment being given or withheld. Instead when using ScvO(2), trending of this variable should provide clinical determinates that are useable for the bedside ICU nurse, remembering that in most conditions SvO(2) will be approximately 16% lower.

Situational Awareness in Acute Patient Deterioration: Identifying Student Time to Task.

BACKGROUND AND PURPOSE: Prelicensure nursing students lack the situational awareness to promote timely intervention with a patient in septic shock. This study evaluated a multifaceted educational project that determined the impact on nursing students' knowledge retention and time to task (TTT). METHODS: A quasi-experimental, repeated-measures design was used to evaluate students' knowledge retention and TTT. Eighty-four prelicensure nursing students participated in groups of 4 students to participate in a high-fidelity simulation. RESULTS: Results show knowledge retention was significant between the pretest scores and 2 repeated assessment scores. The repeated-measures analysis of variance time effect P value was .02. The overall TTT group response suggested most (64/84, 76%) students responded within 5 minutes of patient deterioration. CONCLUSIONS: A multifaceted approach was effective to influence knowledge of septic shock over time and demonstrate students' ability to intervene with a septic shock patient in a timely manner.

Study on clinical nursing pathway to promote the effective implementation of sepsis bundle in septic shock.

BACKGROUND: There is still a certain gap between the effective implementation and requirements of sepsis bundle. Our aim is to establish the clinical nursing pathway of the cluster treatment of septic shock in the Intensive Care Unit and promote effective implementation of the cluster treatment of septic shock. METHODS: By means of evidence-based method, quality control index requirements and on-site investigation, the implementation process of clinical nursing pathway of the cluster treatment within 6 h of diagnosis of septic shock was established. RESULTS: After the implementation of clinical nursing pathway, the completion rate of septic shock cluster treatment was 81.4% (66.4%) in 1 h, 89.4% (77.0%) in 3 h, 95.5% (82.3%) in 6 h (P < 0.05), which was significantly improved in the experimental group compared with the control group. CONCLUSIONS: The clinical nursing pathway of septic shock cluster treatment is guided by evidence-based nursing, which emphasizes standardization and standardization of septic shock cluster treatment nursing under the guidance of the guideline, and can promote the effective implementation of septic shock cluster treatment, significantly improve efficiency of septic shock treatment and the quality of medical care.

Prompt and aggressive management of sepsis gives patients the best chance of survival.

This one part unit explains why it is important to recognise the signs and symptoms of sepsis and the action to take if patients become septic.

[Training student nurses in taking blood cultures]. / Formation des étudiants en soins infirmiers à la réalisation des hémocultures.

In cases of septic shock, high quality blood cultures are essential for identifying the causative agent and adapting the antibiotic treatment. Student nurses are relatively unfamiliar with recent guidelines on collecting blood cultures. Improving how they are taught during initial training, a key moment for the learning of best care practices, should help to optimise the global management of septic shock.

Nurse Influence in Meeting Compliance With the Centers for Medicare and Medicaid Services Quality Measure: Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1).

Increased mortality has been identified as the sepsis cascade progresses from sepsis to severe sepsis to septic shock. Estimates reflect sepsis death rates ranging from 10% to 20%, severe sepsis death rates of 20% to 50%, and septic shock fatality rates of 40% to 80%. The high rates of morbidity, mortality, and Medicare costs prompted the Centers for Medicare and Medicaid Services to implement bundled care and public reporting of the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) quality measure in 2015. Sepsis care bundles were identified to be beneficial since the 1990s as the bundle facilitates efficient, effective, and timely delivery of care to support quality improvement. The SEP-1 measure can be challenging and requires the nurse's active participation. Nurses need increased knowledge of the sepsis cascade and treatments as defined in the SEP-1 quality measure. Increased knowledge and application of bundle elements are lifesaving and can influence postdischarge outcomes. This article discusses the nurse's role in meeting the specific elements of each bundle and strategies to improve bundle compliance.

Implementing simulation in oncology emergencies education: A quasi- experimental design.

BACKGROUND: High-fidelity simulation (HFS) as a teaching-learning method has increased, especially in medical programs. OBJECTIVE: This study was conducted to assess the effectiveness of using HFS on the satisfaction, self-confidence, self-efficacy, and knowledge of undergraduate students in oncology care. METHODS: A pre-test post-test quasi-experimental design was utilized. Random sampling technique was used to recruit the participants. The scenarios including septic shock and infusion reaction were implemented. The training program including lectures and the simulation was run in a high fidelity simulation lab. RESULTS: There was a significant difference (t=-5.95, p= 0.001) between the experimental group (M= 13.95, S⁢D= 3.35) and the control group (M= 6.25, S⁢D= 2.65) regarding knowledge, confidence (t=-22.75, p= 0.001) between the experimental group (M= 61.25, S⁢D= 12.10) and the control group (M= 38.50, S⁢D= 6.20), satisfaction level t=-18.25, p= 0.001; experimental group - M= 42.25, S⁢D= 4.25; and control group - M= 28.50, S⁢D= 3.15), and there was a significant difference between the experimental group (M= 35.50, S⁢D= 3.25) and control group (M= 24.25, S⁢D= 2.85) regarding self-efficacy (t=-13.25, p= 0.001). CONCLUSIONS: High-fidelity simulation in nursing increased student knowledge, self-confidence, satisfaction, and self-efficacy in managing septic shock and infusion reaction as common oncology emergencies.

The hemodynamic "target": a visual tool of goal-directed therapy for septic patients.

OBJECTIVE: To improve understanding of the hemodynamic status of patients with sepsis by nursing teams through the attainment of hemodynamic parameters using a pentaxial "target" diagram as a clinical tool. Parameters include cardiac index (CI), arterial oxygen saturation (SaO2), mean arterial pressure (MAP), arterial blood lactate, and central venous oxygen saturation (ScvO2). DESIGN: Prospective descriptive study. SETTING: The intensive care unit of a university hospital. PATIENTS: During a 6-month period, 38 intubated septic shock patients were included in the study. Survivors and nonsurvivors were compared. INTERVENTIONS: MAP, CI, SaO2, ScvO2 and lactate were measured at 0, 6, 12, 24, 36, and 48 h. Measurements were recorded on the target diagram along with the norepinephrine infusion rate and the hemoglobin (Hb) level. The number of lactate and ScvO2 measurements achieved during the target period were compared to a 6-month retrospective control period just before starting the protocol. We assessed the nurse knowledge status prior to the introduction of target diagram. We then performed a post-test after implementing the new recording technique. MEASUREMENTS AND RESULTS: The nursing team expressed a positive attitude toward the target concept. The mean number of lactate and ScvO2 measurements performed for each patient during the control period was significantly lower than during the target period, and those values were rarely used as goal values before the introduction of the target diagram. At 24 hours, 46% of the survivors had achieved all the goal parameter values of the target diagram, compared to only 10% of nonsurvivors (P = .01). CONCLUSION: The target diagram is a visual multiparametric tool involving all the medical and nursing team that helps achieve goal-directed therapy for septic patients. The number of goal values reached at each time point during the first 48 hours was closely linked to mortality.

The role of surgery in the management of septic shock--extra-abdominal causes of sepsis.

Septic shock is a severe inflammatory response to one or more pathogenic micro-organisms. When a person's immune response is excessively intense, a cascade of phenomena may be activated that ultimately is harmful. Appropriate management of septic shock may include surgical intervention to remove or neutralize the septic focus in an effort to treat the inflammatory response cascade. This is the first of two articles presenting current information on the role of surgery in the management of a patient with septic shock. This article describes extra-abdominal sources of sepsis.