SEARCH

SEARCH BY CITATION

Sepsis accounts for 20% of all admissions to intensive care units (ICU) and is the leading cause of death in non-cardiac critical care units (Levy et al. 2009). As a response to the lack of improvement in patient mortality due to sepsis over the previous two decades, the Surviving Sepsis Campaign (SSC) was launched by the European Society of Intensive Care Medicine in collaboration with the Society of Critical Care Medicine (Townsend et al. 2008). The campaign saw the introduction in 2004 of evidence-based guidelines now endorsed by 18 professional societies across the globe (Dellinger et al. 2008). The aim of the campaign is to increase awareness and improve outcome in severe sepsis.

In this editorial, I would like to familiarise the reader with the central themes of the campaign and the guidance subsequently produced. Furthermore, I will discuss methods by which nurses can actively contribute to the successful accomplishment of the campaign’s aims.

The SSC has identified that early recognition and early goal-directed therapy are crucial steps to ensuring improved outcome in the context of sepsis. To facilitate timely introduction of appropriate treatment, the SSC has produced guidelines outlined in what it describes as ‘care bundles’. ‘Care bundles’ is an approach to ensure evidence-based interventions are implemented clinically (Fulbrook & Mooney 2003). Elements of care are ‘bundled’ together, with the aim of ensuring that all elements in the bundle are considered for every appropriate patient each day.

The SSC describes two care bundles of particular significance, shown to reduce mortality from sepsis. The first bundle is termed either ‘the six hour’ or ‘resuscitation’ bundle. The aim of this care package is to limit tissue hypoxia and hypoperfusion, whilst at the same time instituting early antimicrobial therapy. This bundle is particularly crucial as treatment of severe sepsis in the context of reversible organ failure has a much improved prognosis compared to delayed treatment (Steen 2009). Familiarity with the principles of this bundle is important for all doctors and nurses working in an acute care setting, being particularly pertinent to health care workers employed in the emergency department (ED) and in a ward setting, two locations where patients with severe sepsis commonly present and deteriorate.

The steps involved in this bundle include administering high flow oxygen to optimise oxygen delivery to the tissues, and this is an easily instituted therapy that can be delivered by nurses on the ward or ED. The second step involves obtaining blood cultures, this helps to identify the underlying infective organism and its antimicrobial sensitivities. This guides future treatment as specific antibiotics can be administered to target the punitive organism. Blood cultures are obtained by venepuncture which is a task that can be undertaken by appropriately trained nurses. The third step entails administering broad spectrum antibiotics. According to the guidelines, antibiotics should be administered within the first hour of diagnosis of severe sepsis. The initial choice of empiric antibiotics should be broad enough to cover the likely causes of infection. Again, this task can be easily carried out by appropriately trained nurses who can prepare and administer the antibiotics. The fourth step is the administration of IV fluids. This helps maintain an adequate blood pressure to sustain tissue perfusion. The fifth step involves measuring serum lactate and haemoglobin levels, to identify the extent of tissue ischaemia and monitor improvement with resuscitation with successive measurement of lactate. Measurement of haemoglobin is important to identify underlying anaemia which may require blood transfusion to optimise tissue oxygen delivery. The final step is the insertion of a urinary catheter with hourly monitoring of urine output. The purpose of this is twofold: as a guide to renal perfusion and thus identification of early renal failure and as an overall assessment of fluid balance to guide fluid therapy and avoid fluid overload. These tasks should be delivered within the first six hours of diagnosis (Dellacroce 2009).

The second care bundle described by SSC is known as the ‘24-hour (or management) bundle’. This bundle is to be accomplished within 24 hours following admission to ICU and involves the following steps. The first step involves the administration of low-dose steroids, which modulate the inflammatory response which is exaggerated in severe sepsis. The second step is tight glycaemic control at the lower limit but <10 mmols, as blood glucose levels are often deranged in severe sepsis and which is associated with a poorer outcome (Vincent et al. 2002). Finally, to maintain a median inspiratory plateau pressure (IPP) <30 cm H2O for mechanically ventilated patients to prevent ventilator associated lung trauma, it is also linked with a significant reduction in mortality (Acute Respiratory Distress Syndrome Network 2000).

The SSC should involve nurses in all areas of the hospital. Nurses from A&E are well placed to give prompt antibiotics as recommended by the SSC within the first hour of diagnosis of severe sepsis and early goal-directed therapy (Dellinger et al. 2004). However, for nurses to recognise sepsis they first need to be familiar with the signs and symptoms of sepsis and therefore a targeted educational campaign will be required for both pre- and postregistration nurses to achieve this. The reduction in junior doctors working hours in line with the European Working Time Directive (EWTD) may result in the transfer of duties that are traditionally the realm of doctors. Thus, it may be necessary to train senior nurses in ED and Intensive Care to acquire skills such as the insertion of arterial and central venous lines and using a protocol driven approach to initiate early goal-directed therapy. The SSC and the guidance produced offer a sound framework for managing sepsis, empowering nurses to make a difference to patient care.

References

  1. Top of page
  2. References
  • Acute Respiratory Distress Syndrome Network. (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and acute respiratory distress syndrome. The New England Journal of Medicine342, 13011308.
  • Dellacroce H (2009) Surviving Sepsis: The Role of the Nurse. RN Web (online). Available at: http://license.icopyright.net/user/viewFreeUse.act?fuid=NjMxNzA4 (accessed 28 December 2009).
  • Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL & Levy MM (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Critical Care Medicine32, 858873.
  • Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL & Vincent J (2008) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine36, 296327.
  • Fulbrook P & Mooney S (2003) Care bundles in critical care: a practical approach to evidence based practice. Nursing in Critical Care8, 249255.
  • Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, Schorr C, Artigas A, Ramsay G, Beale R, Parker MM, Gerlach H, Reinhart K, Silva E, Harvey M, Regan S & Angus RC (2009) The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Critical Care Medicine38, 367374.
  • Steen C (2009) Development in the management of patient with sepsis. Nursing Standard23, 4855.
  • Townsend SR, Schorr C, Levy MM & Phillip Dellinger R (2008) Reducing mortality in severe sepsis: the Surviving Sepsis Campaign. Clinics in Chest Medicine29, 721733.
  • Vincent JL, Abraham E, Annane D, Bernard G, Rivers E & Van Den Berghe G (2002) Reducing mortality in sepsis: new directions. Crittical Care6(Suppl. 3), S1S18.