As Sepsis Awareness Increases and Guidelines Change, Timing Remains Crucial

stopwatch/wikimedia commons

September was Sepsis Awareness Month, but the urgency of the issue didn’t disappear when the month ended. I still remember my first day in the medical intensive care unit (MICU) I’d soon call home. I was shadowing the charge nurse, and an admission had just come in from the ED.

“Here, we need a CVP setup.” A crinkly bag of normal saline and a matching package containing something evidently important were shoved into my hands—a medical football passed to the only open player.

Very quickly, I would learn what a CVP, or central venous pressure, was and to monitor it. I would learn all about sepsis, and septic shock, and the treatment of its devastating process. Multiple organ dysfunction syndrome (MODS) was a primer for my care in this unit, and on my first day off of orientation, I was entrusted with one of its full-blown victims: Septic shock from pneumonia, causing respiratory, renal, and heart failure. Learning to spike a bag of saline for a CVP transducer was just my first step into the vast and complicated land of sepsis management.

This was 2007. Sometimes, as in all hospitals, care was delayed and septic patients sat without timely treatment for hours. Back then, we tubed people, snowed people, and flooded people. Now, after two updates to the Surviving Sepsis Campaign’s guidelines, we sometimes tube them, and sometimes we don’t. We use a lot less sedation, and a lot less fluid.

If you’re not familiar with them, it’s a good time to review the updated guidelines. The Surviving Sepsis Campaign Web site offers everything from exhaustive articles to handy cheat-sheets on how to handle patients from the ED who have sepsis in a manner that complies with updated guidelines. Timely sepsis recognition doesn’t just depend on ED nurses or those in the ICU; every nurse needs to know what to look for, as demonstrated by the case in this AJN article, “Recognizing Sepsis in the Adult Patient” (free until November 1).

Timing remains crucial. In the new guidelines, you’ll find a lot of the same treatment goals and procedures, but a lot more stress on rapid recognition and on doing things quickly and in the right order. Timing is so central that the campaign bundled its guidelines into time segments: 3-hour bundle and 6-hour bundle.

For example, within the first three hours, practitioners must draw blood cultures, determine lactate level, hang broad-spectrum antibiotics, and begin fluid resuscitation with a crystalloid. By the time six hours have passed, 30ml/kg of normal saline must be completed, and if the patient’s mean arterial pressure and urine output don’t meet certain parameters, vasopressor infusion (norepinephrine first, please!) must be started.

Close attention to the effectiveness of these basic measures—diagnosis, antibiotics, resuscitation, and stabilization—is key. Other more complex treatment measures such as mechanical ventilation and renal replacement therapy are addressed, but the focus remains on timing and simplicity in care.