Sepsis: Signs, Symptoms and qSOFA

How does a patient die from sepsis? What happens to their body, vessels and organs?

When someone experiences an infection, every cell of their body is compromised. With the right clinical assessment skills and knowledge it is possible to identify sepsis early and save lives.

What is Sepsis?

Sepsis is an overactive response to an infection causing the body to damage its own organs and tissue (Sepsis Alliance 2017).

Sepsis can be caused by any infectious pathogen (WHO 2018).

When chemicals are released from the infection into the systemic circulation, the body then recognises the foreign body and the inflammatory process begins, leading to coagulation (blood clotting) and hypoperfusion (decreased blood supply to the organs). This impaired blood supply starves the organs of oxygen, causing significant damage (NIH 2019).

Sepsis is a life-threatening medical emergency that can lead to septic shock, multiple organ failure and potentially death. It affects approximately 30 million people globally, every year, resulting in about 6 million fatalities, and is one of the leading causes of hospital patient death (WHO 2018; Nursing Times 2014).

Who is at Risk of Sepsis?

Sepsis doesn’t discriminate; anyone from babies to older adults, males to females, can develop it. It is, however, more common and dangerous in those with weakened immune systems, older adults with multiple comorbidities, the very young, and individuals who are already unwell (Mayo Clinic 2018).

What Are the Signs and Symptoms of Sepsis?

The many signs and symptoms of sepsis include abnormalities in the individual’s body temperature, heart rate, respiratory rate, hypotension and white blood cell count, in addition to hypoxaemia, oliguria, lactic acidosis, elevated liver enzymes and altered cerebral function (Sepsis Alliance 2018).

The Importance of Identifying Sepsis

Early identification and treatment of sepsis is crucial in preventing patient death.

Sepsis is often misdiagnosed, as it generally comprises non-specific symptoms. The longer sepsis is left untreated, the more severe it becomes and the risk of mortality increases. Therefore, it is crucial to adhere to protocol designed to identify and treat sepsis as soon as possible (D'Orazio Peterson 2013).

Nurses play an essential role in the care of patients with sepsis, with nurse-led initiatives having demonstrated a decrease in mortality, ICU readmission and length of hospital stay (Kleinpell et al. 2019).

Sequential (Sepsis-Related) Organ Failure Assessment (SOFA)

Whenever a patient infection is suspected, the Society of Critical Care Melbourne (2016) recommends undertaking a Sequential (Sepsis-Related) Organ Failure Assessment (SOFA) to assess for organ dysfunction.

This is a simple diagnostic tool comprising three tests. A patient displaying two or more of the following warning signs is at an increased risk of morbidity or mortality and should be assessed for organ failure.

Note: These symptoms must be new to the patient, not pre-existing, in order to be counted.

1. An altered mental state;
2. A decrease in systolic blood pressure of less than 100 mm Hg; and
3. A respiration rate greater than 22 breaths per minute.

(SCCM 2016)

If a patient presents with two or more of these warning signs, it is also recommended that care is escalated (as appropriate), referral to critical care is considered and the patient is monitored frequently (SCCM 2016).

Recognising Sepsis

1. At the commencement of each shift, a head to toe assessment is recommended on every patient to ensure you are completely informed about their condition.
2. Analyse the patient’s vital signs on every encounter and be mindful of sepsis.
3. If an infection is suspected, you should undertake a SOFA and identify any warning signs.
4. Treat any of the patient’s signs and symptoms. Support their emotional and physical requirements - for example, lay the patient down if they are hypotensive, or apply oxygen if they are hypoxic.
5. If the patient is demonstrating early signs of sepsis, escalate care to the medical team and apply continuous haemodynamic monitoring such as 5-lead cardiac monitoring, blood pressure cuff, oxygen oximetry etc.

(SCCM 2016)

What to do When Sepsis is Recognised

The Surviving Sepsis Campaign is an international initiative aimed at reducing the global mortality of sepsis. Their ‘Hour-1 Bundle’ guideline sets out five tasks that should be commenced (though may not necessarily be finished) within the first hour of sepsis recognition as part of the initial resuscitation. They are:

1. Measure the patient’s lactate level.
   • Remeasure lactate if the initial level is elevated (> 2 mmol/L).
2. Obtain blood cultures.
3. Administer broad-spectrum antibiotics.
4. Begin rapidly administering crystalloid as per your organisation's policy.
5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥ 65 mm Hg.
   • Vasopressors must be administered by a medical practitioner. The administration of this medicine should be considered in a critical care environment, however, if the patient is hypotensive, the objective is to maintain perfusion to all vital organs. Therefore, continuous blood pressure monitoring is imperative. The frequency of observation should be increased.

(SCCM 2019)

Sepsis and septic shock are medical emergencies. It is imperative that you act quickly and minimise the amount of time spent before commencing treatment. You must perform a thorough head-to-toe assessment and investigate any obvious signs of infection, increasing the frequency of observations and assessing if the patient is responding to the treatment (e.g. fluid resuscitation). You must inform colleagues about the patient’s status during handovers (SCCM 2019).

You should be able to locate the Surviving Sepsis Campaign’s guidelines at any time, along with your organisation’s own policies and protocols.

Complications

The Hour-1 Bundle should be ideally commenced as soon as possible. Sepsis is an emergency and becomes more life-threatening the longer it is left untreated. Immediate intervention after sepsis has been identified is crucial (SCCM 2019; Torborg 2018).

Untreated sepsis can cause the patient’s blood pressure to drop dramatically, causing it to progress into septic shock. The organs are starved of adequate blood supply, resulting in hypoperfusion and leading to multiorgan dysfunction.This is an extremely severe condition that can lead to fatality (Torborg 2018).

In sepsis, hypotension is caused by nitrous oxide production that increases after activation of the endothelium by pro-inflammatory mediators, responsible for vasodilation (Greer 2015).

If the early signs of sepsis have not been identified, the patient can deteriorate rapidly, requiring basic life support. Call for assistance as per hospital protocol. Remember to act quickly to save lives.

Post-Sepsis Outcomes

50% of people who survive sepsis develop post-sepsis syndrome (Sepsis Alliance 2016). This can be caused by a variety of factors, including any resulting permanent disability from the sepsis and also the psychological effects of both the illness and their prolonged hospitalisation.

Symptoms of Post-Sepsis Syndrome

• Insomnia;
• Nightmares, vivid hallucinations and panic attacks;
• Disabling muscle and joint pains;
• Extreme fatigue;
• Poor concentration;
• Decreased cognitive functioning; and
• Loss of self-esteem and self-belief.

(Sepsis Alliance 2016)

Following recovery from sepsis, healthcare professionals must ensure that the patient’s treatment takes a holistic approach. This is essential as the individual may be feeling not only the physical effects of being ill, but also the psychological and cognitive effects of having sepsis and social isolation following a prolonged hospital stay.

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Note: This article is intended as a refresher and should not replace best-practice care. Always refer to your facility's policy on recognising and responding to sepsis.

Additional Resources

• ACSQHC, Recognising and Responding to Acute Deterioration Standard, https://www.safetyandquality.gov.au/standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard
• Surviving Sepsis Campaign, Hour-1 Bundle, https://www.sccm.org/getattachment/SurvivingSepsisCampaign/Guidelines/Adult-Patients/Surviving-Sepsis-Campaign-Hour-1-Bundle.pdf?lang=en-US
• Surviving Sepsis Campaign, COVID-19 Guidelines, https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/COVID-19
• Sepsis Alliance, https://www.sepsis.org/
• Infectious Diseases: How Do You Break the Chain?, https://www.ausmed.com.au/cpd/articles/infectious-diseases

References

• D'Orazio Peterson 2013, Failure to Diagnose Sepsis, D'Orazio Peterson, viewed 5 May 2020, https://www.doraziopeterson.com/failure-to-diagnose-sepsis
• Greer, JR 2015, ‘Pathophysiology of Cardiovascular Dysfunction in Sepsis’, BJA Education, vol. 15 no. 6, viewed 7 May 2020, https://academic.oup.com/bjaed/article/15/6/316/356327
• Kleinpell, R, Blot, S, Boulanger, C, Fulbrook, P & Blackwood, B 2019, ‘International Critical Care Nursing Considerations and Quality Indicators for the 2017 Surviving Sepsis Campaign Guidelines’, Intensive Care Medicine, viewed 5 May 2020, https://link.springer.com/article/10.1007/s00134-019-05780-1
• NIH 2019, Sepsis Fact Sheet, NIH, viewed 5 May 2020, https://www.nigms.nih.gov/education/Documents/Sepsis.pdf
• Nursing Times 2014, Early Identification and Treatment of Sepsis, Nursing Times, viewed 5 May 2020, https://www.nursingtimes.net/clinical-archive/infection-control/early-identification-and-treatment-of-sepsis-17-01-2014/
• Sepsis Alliance 2016, Post-sepsis Syndrome, Sepsis Alliance, viewed 6 May 2020, https://www.sepsis.org/sepsis-basics/post-sepsis-syndrome/
• Sepsis Alliance 2018, Symptoms, Sepsis Alliance, viewed 6 May 2020, https://www.sepsis.org/sepsis-basics/symptoms/
• Sepsis Alliance 2017, What is Sepsis, Sepsis Alliance, viewed 5 May 2020, https://www.sepsis.org/sepsis-basics/what-is-sepsis/
• Society of Critical Care Medicine 2016, Sepsis Definitions, Society of Critical Care Melbourne, viewed 5 May 2020, https://www.sccm.org/Research/Quality/Sepsis-Definitions
• Society of Critical Care Medicine 2019, Hour-1 Bundle: Initial Resuscitation for Sepsis and Septic Shock, Society of Critical Care Melbourne, viewed 5 May 2020, https://www.sccm.org/getattachment/SurvivingSepsisCampaign/Guidelines/Adult-Patients/Surviving-Sepsis-Campaign-Hour-1-Bundle.pdf?lang=en-US
• Torborg, L 2018, Mayo Clinic Q and A: Understanding Sepsis and Septic Shock, Mayo Clinic, viewed 5 May 2020, https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-understanding-sepsis-and-septic-shock/
• World Health Organisation 2018, Sepsis, World Health Organisation, viewed 5 May 2020, https://www.who.int/news-room/fact-sheets/detail/sepsis