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    Careplan

    Sepsis or Septic Shock (Adult ED)

    Nov.08.2021

    Sepsis or Septic Shock (Adult ED)

    Clinical Description

    • Care of the Emergency Department patient seeking treatment for sepsis or associated septic shock.

    Key Information

    • Signs of early sepsis include increased heart rate and decreased blood pressure, as well as changes in mental state, respiratory pattern or peripheral perfusion; signs and symptoms may progress rapidly.
    • Outcomes are improved by early identification of sepsis and the immediate initiation of evidence-based therapy following sepsis recognition, including aggressive fluid resuscitation and antimicrobial therapy.
    • A change in mental status may be the first or only symptom of infection in older adults.
    • Elevated lactic acid levels may indicate tissue hypoxia and poorer outcomes.
    • ARDS (acute respiratory distress syndrome) is highly associated with sepsis, whether it is the cause or result of sepsis. Suspect ARDS (acute respiratory distress syndrome) if PFR (ratio of partial pressure of arterial oxygen to fractional inspired oxygen) is less than 300 mmHg.

    Threats to Life, Limb or Function

    • acute renal failure
    • ARDS (acute respiratory distress syndrome)
    • DIC (disseminated intravascular coagulation)
    • failure to recognize sepsis
    • multiple-organ-dysfunction syndrome
    • sepsis-associated encephalopathy
    • septic shock

    Clinical Goals

    By transition of care

    A. The patient will achieve the following goals:

    • Goal: Acute Signs/Symptoms are Managed

    • Goal: Acceptable Pain Level Achieved

      Correlate Health Status

      • Correlate health status to:

        • history, comorbidity
        • age, developmental level
        • sex, gender identity
        • baseline assessment data
        • physiologic status
        • response to medication and interventions
        • psychosocial status, social determinants of health
        • barriers to accessing care and services
        • health literacy
        • cultural and spiritual preferences
        • safety risks
        • family interaction
        • plan for transition of care

      Sepsis or Septic Shock

      Associated Documentation

      • Sepsis/Septic Shock Management

      Presentation

      • chills, rigors
      • hypotension
      • level of consciousness altered
      • mental status altered
      • peripheral perfusion altered
      • tachycardia
      • tachypnea
      • temperature variation (increased or decreased)

      Associated Signs/Symptoms

      • abdominal distension
      • anorexia
      • arthralgia, myalgia
      • cough
      • cyanosis
      • diaphoresis
      • diarrhea
      • dysuria
      • edema
      • fatigue
      • nuchal rigidity
      • pain
      • pallor
      • petechiae, purpura
      • rash
      • shortness of breath
      • urinary frequency
      • urine output decreased
      • vomiting
      • work of breathing increased

      Potential Causes

      • bone or joint infection
      • endocarditis
      • chemotherapy-induced neutropenia
      • implanted device infection
      • intra-abdominal infection
      • meningitis
      • respiratory infection, pneumonia
      • skin or soft tissue infection
      • urinary tract infection
      • wound infection

      Initial Assessment

      • airway patency
      • cardiovascular status
      • fluid status
      • gastrointestinal status
      • musculoskeletal status
      • neurologic status
      • pain evaluation
      • respiratory status
      • skin and soft tissue status

      History

      • allergies
      • comorbidities (acute or chronic)
      • immunization status
      • last menstrual period (females of child bearing age)
      • medications
      • hospitalizations
      • recent antimicrobial therapy
      • recent childbirth
      • recent infection or exposure
      • recent injury or trauma
      • recent procedure or surgery
      • recent travel
      • symptom onset

      Laboratory Studies

      • ABG (arterial blood gas)
      • albumin, prealbumin
      • amylase
      • blood glucose level
      • BUN (blood urea nitrogen)
      • CBC (complete blood count) with differential
      • cerebrospinal fluid analysis
      • coagulation studies
      • CRP (C-reactive protein)
      • cultures and gram stain
      • lipase
      • liver function tests
      • procalcitonin level
      • serum creatinine
      • serum electrolytes
      • serum lactate
      • urinalysis

      Diagnostics

      • ECG (electrocardiogram)
      • x-ray (abdomen, chest)

      Potential Additional Testing

      • CT (computed tomography) scan
      • lumbar puncture
      • MRI (magnetic resonance imaging)
      • pregnancy test (females of childbearing age)
      • radiographic studies for joint pain
      • ultrasound (abdomen, chest)

      Problem Intervention

      Provide Respiratory Support

      • Assess and monitor airway and breathing for effective oxygenation and ventilation; maintain close surveillance for deterioration.
      • Maintain open and patent airway with use of positioning, airway adjuncts and secretion clearance.
      • Position to minimize the risk of aspiration, ventilation-perfusion mismatch and breathlessness.
      • Minimize oxygen consumption and demand; limit activity, reduce fever and utilize breathing techniques.
      • Provide oxygen therapy judiciously; titrate to prevent hyperoxemia; adjust to achieve oxygenation goal.
      • Consider positive pressure ventilation to support oxygenation, ventilation and relieve respiratory distress.
      • Recognize the need for intubation for airway protection and respiratory support; utilize lung protective strategy.

      Problem Intervention

      Provide Hemodynamic Support

      • Provide prompt fluid therapy to improve blood flow, perfusion and tissue oxygenation.
      • Evaluate and address responsiveness to fluid resuscitation during and following each bolus; include blood pressure, peripheral perfusion, breath sounds, mentation and level of consciousness and urine output.
      • Monitor for fluid overload.
      • Anticipate administration of albumin when a large amount of intravascular fluids is needed for resuscitation.
      • Anticipate use of vasoactive agent to support microperfusion and oxygen delivery; titrate to response.
      • Monitor cardiovascular status; observe for, and address, cardiac dysrhythmia.
      • Monitor and manage electrolyte imbalances; monitor other laboratory value trends, such as lactate.
      • Monitor and address end-organ dysfunction; consider using a standardized tool to assess for organ failure.
      • Prepare for supportive therapy, such as corticosteroid therapy, coagulopathy management and urgent intervention in the presence of hemodynamic instability.

      Problem Intervention

      Minimize and Manage Infection

      • Anticipate antimicrobial therapy administration; do not delay in the presence of high suspicion or clinical indicators.
      • Obtain cultures prior to initiating antimicrobial therapy when possible.
      • Determine and address underlying source of infection aggressively; consider vascular access device, invasive devices, meningitis, pneumonia or wound.
      • Initiate precautions to prevent the spread of infection.
      • Monitor blood glucose level and maintain glycemic control.

      Problem Intervention

      Promote Comfort and Manage Pain

      • Use a consistent pain assessment tool; include assessment of functional ability.
      • Evaluate pain and treatment response at regular intervals.
      • Involve patient and family/caregiver in the management plan.
      • Provide nonpharmacologic strategies, such as positioning, quiet and calm environment, as well as minimal stimulation.
      • Consider multimodal pharmacologic measures, such as an analgesic, antipyretic or antianxiety agent.
      • Evaluate risk for opioid use and dependence.

      Problem Intervention

      Facilitate Procedures

      • Evaluate need for NPO (nothing by mouth) status.
      • Prepare for, or assist with, procedure, such as urinary catheter placement, gastric decompression, lumbar puncture, cultures, debridement, incision and drainage, thoracentesis or thoracostomy.
      • Anticipate and prepare for surgical intervention.

      Problem Intervention

      Provide Psychosocial Support

      • Proactively provide information; encourage questions and address concerns.
      • Provide calm, reassuring presence. Monitor for increasing anxiety.
      • Recognize, identify and allow expression of emotions.
      • Promote family/caregiver presence at bedside.
      • Offer choices to enhance a sense of control.
      • Honor spiritual and cultural preferences.
      • Recognize and utilize personal coping strategies.
      • Consider conversation around goals of care; involve palliative care team, if available.

      Problem Intervention

      Initiate Consult or Referral

      • Facilitate consult, such as surgeon, intensivist or infectious disease specialist.
      • Coordinate transition, such as hospital admission, facility transfer or home follow-up.

      Education

      General Emergency Education

      Teaching Focus

      • symptom/problem overview

      • risk factors/triggers

      • self-management

      • assistive device

      • diagnostic test

      • diet modification

      • medical device/equipment use

      • medication administration

      • opioid medication management

      • orthopaedic device

      • safe medication disposal

      • smoking cessation

      • wound care

      Population-Specific Considerations

      Forensics and Legal

      • Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

      Human Trafficking

      • Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
      • Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration, undocumented immigrant status and other vulnerable and minority populations.

      Geriatric

      • Two-thirds of all sepsis cases occur in people 65 years of age and older.
      • This population does not always display physiologic symptoms, such as tachycardia or fever, making identification of sepsis difficult.
      • Older adults require more frequent reassessments to prevent fluid overload.

      Pregnancy

      • Beyond 20 weeks gestation, supine position should be avoided. Patient position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
      • Patient stabilization is a priority, as fetal status is impacted by patient status.
      • A secondary assessment should include fetal heart rate, contraction activity, presence of vaginal bleeding and membrane status.
      • Normal physiologic changes during pregnancy should be considered when treating a pregnant patient with sepsis. Hemodynamic parameters should be carefully monitored.
      • Infection during pregnancy can result in the increased production of prostaglandins, which may lead to preterm labor.

      Quality Measures

      • NQF 0495. Median Time from ED arrival to ED Departure for Admitted ED Patients
        Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department.
        Steward: Centers for Medicare and Medicaid Services
        Care Setting: ED, Hospital
        National Quality Forum-endorsed measure
        Last Edited: 10/11/2017
      • NQF 0496. Median Time from ED arrival to ED Departure for Discharged ED Patients
        Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department.
        Steward: Centers for Medicare and Medicaid Services
        Care Setting: ED, Hospital
        National Quality Forum-endorsed measure
        Last Edited: 10/11/2017

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