Sepsis and Nursing Management in the Intensive Care Unit

Öz

Sepsis is an important problem that is frequently seen in the intensive care units throughout the world and in Turkey, increasing the risk of morbidity and mortality, the length of stay in the unit and the cost of care. Although the incidence of sepsis is high in critically ill patients, the survival rate increases when diagnosed early. However, when the early warning signs of sepsis are missed, the severity of sepsis increases and organ failure occurs due to septic shock in the patient. Therefore, the Sepsis Survival Campaign Guide draws attention to the first hour after sepsis is diagnosed and recommends that treatment be initiated rapidly during this period. Nurses, who have the opportunity to directly observe the acute changes associated with sepsis in patients in the intensive care units, have an important place in the early diagnosis of sepsis. As the awareness of the multidisciplinary intensive care team and especially of the nurses about sepsis increases, the effectiveness of early diagnosis and treatment will also increase. The aim of this review, which was prepared in line with current literature-based data, is to increase the knowledge and skills of critical care nurses for the diagnosis and treatment of sepsis. For this purpose, the epidemiology, etiology, physiopathology, clinical findings, diagnosis and treatment approaches, and nursing management algorithm in sepsis are discussed in the light of current guidelines in this review. It is thought that this review will guide nurses in the diagnosis and treatment process of sepsis and support care protocols.

Anahtar Kelimeler

• Nursing
• sepsis
• critical care nursing
• intensive care unit

Yoğun Bakım Ünitesinde Sepsis ve Hemşirelik Yönetimi

Öz

Sepsis, dünyada ve ülkemizde yoğun bakım ünitelerinde sık görülen, morbidite ve mortalite riskini, hastanın ünitede kalma süresini ve bakım maliyetini arttıran önemli bir sorundur. Kritik hastalarda sepsis görülme insidansı yüksek olmakla birlikte erken tanılandığında sağkalım oranı artmaktadır. Ancak sepsisin erken uyarı bulguları gözden kaçırıldığında hastada sepsis şiddeti artmakta ve septik şok tablosuna bağlı organ yetmezliği gelişmektedir. Bu nedenle Sepsis Sağkalım Kampanya Kılavuzu sepsis tanılandıktan sonraki ilk bir saate dikkati çekmekte ve bu sürede tedavinin hızla başlatılmasını önermektedir. Yoğun bakım ünitelerinde hastada gelişen sepsisle ilişkili akut değişimleri doğrudan gözleme olanağı yüksek olan hemşirelerin sepsisi erken tanılamadaki yeri önemlidir. Multidisipliner yoğun bakım ekibinin ve özellikle de hemşirelerin sepsise ilişkin farkındalıkları arttıkça erken tanılama ve tedavinin etkinliği de artacaktır. Literatüre dayalı güncel veriler doğrultusunda hazırlanan bu derlemenin amacı, yoğun bakım hemşirelerinin sepsis tanı ve tedavisine yönelik bilgi ve becerilerinin arttırılmasıdır. Bu amaçla bu derlemede, güncel kılavuzlar eşliğinde sepsiste epidemiyoloji, etiyoloji, fizyopatoloji, klinik bulgular, tanı ve tedavi yaklaşımları ve hemşirelik yönetim algoritması ele alınmıştır. Derlemenin hemşirelere sepsis tanılama ve tedavi sürecinde yol göstereceği ve bakım protokollerini destekleyeceği düşünülmektedir.

Anahtar Kelimeler

• sepsis
• Hemşirelik
• sepsis
• yoğun bakım hemşireliği
• yoğun bakım ünitesi

Kaynakça

1. Fleischmann C, Scherag A, Adhikari NK, Hartog CS, Tsaganos T, Schlattmann P, et al. International forum of acute care trialists: Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. Am J Respir Crit Care Med. 2016 Feb 1;193(3):259- 72. doi: 10.1164/rccm.201504-0781OC.
2. Reinhart K, Daniels R, Kissoon N, Machado FR, Schachter RD, Finfer S. Recognizing sepsis as a global health priority - A WHO resolution. N Engl J Med. 2017 Aug 3;377(5):414-7. doi: 10.1056/NEJMp1707170.
3. Lelubre C, Vincent JL. Mechanisms and treatment of organ failure in sepsis. Nat Rev Nephrol. 2018 Jul;14(7):417-27. doi: 10.1038/s41581-018- 0005-7.
4. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/ jama.2016.0287.
5. Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990- 2017: Analysis for the global burden of disease study. Lancet. 2020 Jan 18;395(10219):200-11. doi: 10.1016/S0140-6736(19)32989-7.
6. Paoli CJ, Reynolds MA, Sinha M, Gitlin M, Crouser E. Epidemiology and costs of sepsis in the united states-an analysis based on timing of diagnosis and severity level. Crit Care Med. 2018 Dec;46(12):1889-97. doi: 10.1097/ CCM.0000000000003342
7. Ramos Correa Pinto L, Azzolin KO, Lucena AF, Moretti MMS, Haas JS, Moraes RB, et al. Septic shock: Clinical indicators and implications to critical patient care. J Clin Nurs. 2021 Jun;30(11-12):1607-14. doi: 10.1111/ jocn.15713.
8. Machado FR, Cavalcanti AB, Bozza FA, Ferreira EM, Angotti Carrara FS, Sousa JL, et al. The epidemiology of sepsis in Brazilian intensive care units (The Sepsis Prevalence Assessment Database, SPREAD): An observational study. Lancet Infect Dis. 2017 Nov;17(11):1180-9. doi: 10.1016/S1473- 3099(17)30322-5.

9. cdc.gov [internet]. U.S.: Centers of Disease of Control and Prevention; 2020. [cited 2021 April 6]. Avaiable from https://www.cdc.gov/sepsis/ clinicaltools/index.html
10. Shankar-Hari M, Rubenfeld GD. Understanding long-term outcomes following sepsis: Implications and challenges. Curr Infect Dis Rep. 2016 Nov;18(11):37. doi: 10.1007/s11908-016-0544-7.
11. Leviner S. Post-sepsis syndrome. Crit Care Nurs Q. 2021 Apr- Jun;1;44(2):182-6. doi: 10.1097/CNQ.0000000000000352.
12. Baykara N, Akalın H, Arslantaş MK, Hancı V, Çağlayan Ç, Kahveci F, et al. Sepsis study group. Epidemiology of sepsis in intensive care units in Turkey: A multicenter, point-prevalence study. Crit Care. 2018 Apr;16;22(1):93. doi: 10.1186/s13054-018-2013-1.
13. Hajj J, Blaine N, Salavaci J, Jacoby D. The “Centrality of sepsis”: Areview on incidence, mortality, and cost of care. Healthcare (Basel). 2018 Jul;30;6(3):90. doi: 10.3390/healthcare6030090.
14. Liang L, MooreB, SoniA. National inpatient hospital costs: The most expensive conditions by Payer, 2017: Statistical brief# 261. [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; 2020 July [cited 2021Sep5]. Available from: https://europepmc.org/article/ MED/32833416/NBK561141#free-full-text
15. Azap A, Ağırbaş İ, Yörük F, Altıntaş ND, Bayar MK, Bingöl AP. Sepsisli hastaların kanında etken üretilmesinin maliyet üzerine etkisi. KLİMİK Derg. 2019;32(2):132-5.
16. Hakkı M, Dağlı R, Kocaoğlu N, Cantürk M, Ateş H, Erbesler ZA. Erişkin genel yoğun bakım ünitesindeki sepsis hastalarında kaynaklarına göre maliyetlerinin karşılaştırılması. Ahi Evran Med J. 2018;2(2): 21-5.
17. Abe T, Ogura H, Kushimoto S, Shiraishi A, Sugiyama T, Deshpande GA, et al. JAAM FORECAST group. Variations in infection sites and mortality rates among patients in intensive care units with severe sepsis and septic shock in Japan. J Intensive Care. 2019 May;3;7(1):1-9. doi: 10.1186/s40560- 019-0383-3.
18. Chou EH, Mann S, Hsu TC, Hsu WT, Liu CC, Bhakta T, et al. Incidence, trends, and outcomes of infection sites among hospitalizations of sepsis: A nationwide study. PLoS One. 2020 Jan;13;15(1): e0227752. doi: 10.1371/ journal.pone.0227752.
19. Polat G, Ugan RA, Cadirci E, Halici Z. Sepsis and septic shock: Current treatment strategies and new approaches. Eurasian J Med. 2017 Feb;49(1):53-8. doi: 10.5152/eurasianjmed.2017.17062.
20. Laroye C, Gibot S, Huselstein C, Bensoussan D. Mesenchymal stromal cells for sepsis and septic shock: Lessons for treatment of COVID-19. Stem Cells Transl Med. 2020 Dec;9(12):1488-94. doi: 10.1002/sctm.20-0239.
21. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA. 2020 Apr;7;323(13):1239-42. doi: 10.1001/ jama.2020.2648.
22. Karakike E, Giamarellos-Bourboulis EJ, Kyprianou M, Fleischmann- Struzek C, Pletz MW, Netea MG, et al. Coronavirus disease 2019 as cause of viral sepsis: A systematic review and meta-analysis. Crit Care Med. 2021 Dec;1;49(12):2042-57. doi: 10.1097/CCM.0000000000005195.
23. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb;15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5.
24. Qin C, Zhou L, Hu Z, Zhang S, Yang S, Tao Y, et al. Dysregulation of immune response in patients with coronavirus 2019 (COVID-19) in Wuhan, China. Clin Infect Dis. 2020 Jul 28;71(15):762-8. doi: 10.1093/cid/ ciaa248.
25. Cao X. COVID-19: Immunopathology and its implications for therapy. Nat Rev Immunol. 2020 May;20(5):269-70. doi: 10.1038/s41577-020-0308- 3.
26. covid19.saglik.gov.tr [internet]. Ankara: T.C. Sağlık Bakanlığı, COVID-19 (SARS-CoV-2 Enfeksiyonu) ağır pnömoni, ARDS, sepsis ve septik şok yönetimi; 2021 [cited 2021 July1]. Available from: https://covid19.saglik.gov.tr/Eklenti/40781/0/ covid19rehberiagirpnomoniardssepsisveseptiksokyontemipdf.pdf
27. dcyogunbakim.org.tr [Internet]. Ankara: Türk Yoğun Bakım Uzmanları Derneği; 2021 [cited 2021 July 1]. Available from: https://www. dcyogunbakim.org.tr/webinar-sepsiste-sag-kalim-kampanyasi/
28. Gyawali B, Ramakrishna K, Dhamoon AS. Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Med. 2019 Mar 21;7:2050312119835043. doi: 10.1177/2050312119835043.
29. Uysal Ö. Yoğun bakım hemşirelerinin sepsis belirti bulguları ile yönetimine ilişkin bilgi düzeylerinin incelenmesi. Yayınlanmamış Yüksek Lisans Tezi, Hacettepe Üniversitesi Sağlık Bilimleri Enstitüsü, Ankara 2020.
30. Karaca İ,Çankayalı İ, Demirağ K, Uyar M. Protective effect of hypothermia during experimental sepsis. J Turk Soc Intens Care. 2019;17(2):82.
31. Font MD, Thyagarajan B, Khanna AK. Sepsis and septic shock - Basics of diagnosis, pathophysiology and clinical decision making. Med Clin North Am. 2020 Jul;104(4):573-85. doi: 10.1016/j.mcna.2020.02.011.
32. Taeb AM, Hooper MH, Marik PE. Sepsis: Current definition, pathophysiology, diagnosis, and management. Nutr Clin Pract. 2017 Jun;32(3):296-308. doi: 10.1177/0884533617695243.
33. Kocabaş U. Sepsis ilişkili kardiyomiyopati. Türkiye Klinikleri J Cardiol- Special Topics. 2016;(9)5:49-58.
34. Levy MM, Evans LE, Rhodes A. The surviving sepsis campaign bundle: 2018 update. Intensive Care Med. 2018 Jun;44(6):925-8. doi: 10.1007/ s00134-018-5085-0.
35. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-77. doi: 10.1007/s00134-017-4683-6.
36. Keeley A, Hine P, Nsutebu E. The recognition and management of sepsis and septic shock: a guide for non-intensivists. Postgrad Med J. 2017 Oct;93(1104):626-34. doi: 10.1136/postgradmedj-2016-134519.
37. Napolitano LM. Sepsis 2018: Definitions and guideline changes. Surg Infect (Larchmt). 2018 Feb/Mar;19(2):117-25. doi: 10.1089/sur.2017.278.
38. Cecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock. Lancet. 2018 Jul; 7;392(10141):75-87. doi: 10.1016/S0140-6736(18)30696-2.
39. Gauer R, Forbes D, Boyer N. Sepsis: diagnosis and management. Am Fam Physician. 2020 Apr; 1;101(7):409-18.
40. Sarıer M. Sepsis tanı kriterlerinin karşılaştırılması [dissertation on the internet]. Hacettepe: Hacettepe Üniversitesi, 2018. [cited 2021 July 7]. Available from: http://www.openaccess.hacettepe.edu.tr:8080/xmlui/ handle/11655/4306?show=full
41. Ferraris A, Bouisse C, Mottard N, Thiollière F, Anselin S, Piriou V, et al. Mottling score and skin temperature in septic shock: relation and impact on prognosis in ICU. PLoS One. 2018 Aug 16;13(8):e0202329. doi: 10.1371/ journal.pone.0202329.
42. Peach BC. Implications of the new sepsis definition on research and practice. J Crit Care. 2017 Apr;38:259-62. doi: 10.1016/j.jcrc.2016.11.032.
43. Rello J, Valenzuela-Sánchez F, Ruiz-Rodriguez M, Moyano S. Sepsis: A review of advances in management. Adv Ther. 2017 Nov;34(11):2393-411. doi: 10.1007/s12325-017-0622-8.
44. Carnio EC. New perspectives for the treatment of the patient with sepsis. Rev Lat Am Enfermagem. 2019 Jan 17;27:e3082. doi: 10.1590/1518- 8345.0000.3082.
45. Lee J, Levy MM. Treatment of patients with severe sepsis and septic shock: Current evidence-based practices. R I Med J (2013). 2019 Dec; 2;102(10):18-21.
46. Pickkers P, Vassiliou T, Liguts V, Prato F, Tissieres P, Kloesel S, et al. Sepsis management with a blood purification membrane: European experience. Blood Purif. 2019;47:36-44. doi: 10.1159/000499355.
47. Rimmele T, Kellum JA. Clinical review: Blood purification for sepsis. Crit Care. 2011;15(1):205. doi: 10.1186/cc9411.
48. Lat S, Mashlan W, Heffey S, Jones B. Recognition and clinical management of sepsis in frail older people. Nurs Older People. 2018 Feb;26;30(2):35-38. doi: 10.7748/nop.2018.e975.
49. Torsvik M, Gustad LT, Mehl A, Bangstad IL, Vinje LJ, Damas JK, et al. Early identification of sepsis in hospital inpatients by ward nurses increases 30-day survival. Crit Care. 2016 Aug 5;20(1):244. doi: 10.1186/s13054-016- 1423-1.
50. Breen SJ, Rees S. Barriers to implementing the sepsis six guidelines in an acute hospital setting. Br J Nurs. 2018 May 10;27(9):473-8. doi: 10.12968/ bjon.2018.27.9.473.
51. Walters E. Raising awareness for sepsis, sepsis screening, early recognition, and treatment in the emergency department. J EmergNurs. 2018 May;44(3):224-7. doi: 10.1016/j.jen.2017.10.008.
52. Bruce HR, Maiden J, Fedullo PF, Kim SC. Impact of nurse-initiated ED sepsis protocol on compliance with sepsis bundles, time to initial antibiotic administration, and in-hospital mortality. J Emerg Nurs. 2015 Mar;41(2):130-7. doi: 10.1016/j.jen.2014.12.007.
53. Lester D, Hartjes T, Bennett A. CE: A review of the revised sepsis care bundles. Am J Nurs. 2018 Aug;118(8):40-9. doi: 10.1097/01. NAJ.0000544139.63510.b5.
54. Koçan S, Gürsoy A. Septik şok ve hemşirelik bakımı. EGEHFD. 2016;32(1):173-85.
55. Pedrosa KKA, Oliveira SA, Machado RC. Validation of a care protocol for the septic patient in the Intensive Care Unit. Rev Bras Enferm. 2018 May;71(3):1106-14. Portuguese, English. doi: 10.1590/0034-7167-2017- 0312.
56. Bal U. Capillary refill time measurement device. Muğla J Sci Technol. 2018;4(1):37-40.
57. Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et. al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006 Jun;34(6):1589-96. doi: 10.1097/01.CCM.0000217961.75225.E9.