Page 44 nursing.elitecme.com Complete Your CE Test Online - Click Here The newest changes are moving away from previous early goal-directed therapy in which there were specific goals for central venous pressure (CVP), mean arterial pressure (MAP), and central venous oxygenation (Howell & Davis, 2017). The new guidelines recommend the use of frequent clinical reassessment and dynamic fluid responsiveness measures instead, such as arterial pulse pressure variation or stroke volume induced by mechanical ventilation or passive leg raise test (DeBacker & Dorman, 2017; Howell & Davis, 2017). This allows the approach to be more patient centered in monitoring fluid responsiveness rather than keeping to strict and static protocols that may not be beneficial to all patients. Infection source control and administering early antimicrobial therapy continue to be the standards of practice (DeBacker & Dorman, 2017). Nursing consideration: Nurses should visit http://www. survivingsepsis.org/Guidelines/Pages/default.aspx for the complete list of treatment guidelines and recommendations from the Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock: 2016. Here nurses will have access to all of the latest treatment recommendations and rationales for those recommendations based on the latest evidence. Treatment recommendations Treatment for sepsis should start immediately. The term time zero refers to the time when it is documented that a patient has signs and symptoms of sepsis. This may be in the emergency room upon triage, or it may be when signs and symptoms are documented on the floor. The 3-hour and 6-hour bundle treatment recommendations previously discussed should start at the point of time zero. In addition to the 3-hour and 6-hour bundle recommendations that are time sensitive, other treatment recommendations include the clinician immediately addressing oxygenation, perfusion, fluid resuscitation, and antimicrobial therapy. Support oxygenation The first priority in any patient is to stabilize breathing and maintain oxygenation. The clinician should address hypoxemia by stabilizing the airway and supplementing with oxygen. Oxygenation should be monitored with pulse oximetry; intubation and mechanical ventilation may be required (Schmidt & Mandel, 2017). Sepsis causes increased work of breathing. The airway may need to be secured for patients who have a decreased level of consciousness (Schmidt & Mandel, 2017). Chest X-rays and arterial blood gases should be obtained in the initial stages of treatment to confirm the presence of acute respiratory dysfunction syndrome (ARDS), which can be present in the patient with sepsis or septic shock (Schmidt & Mandel, 2017). Guidelines for specific mechanical ventilation settings – such as tidal volume, the use of PEEP, and plateau pressures – can be found in the new Surviving Sepsis Campaign International guidelines linked here: http://www.survivingsepsis.org/Guidelines/Pages/default.aspx Assess perfusion Hypotension is the most common sign for sepsis and septic shock, but it might not be evident in the beginning stages of sepsis and might not accompany hypoperfusion (Schmidt & Mandel, 2017). Blood pressure should be monitored early and reassessed frequently. During the early stages of sepsis, skin may be warm and flushed, but as the blood is redirected to core organs, the skin may become mottled and cool. Other signs of hypoperfusion include tachycardia, obtundation, restlessness, oliguria, and anuria (Schmidt & Mandel, 2017). Hypoperfusion can be indicated in patients who show signs of hypotension, high lactate levels, evidence of acute organ dysfunction, and even tachycardia (Rhodes et al., 2017). Evaluation of lactate levels is part of the 3-hour SSC bundle recommendation. Lactate levels can be important in assessing hypoperfusion even in the absence of hypotension (Schmidt & Mandel, 2017). Nursing consideration: Nurses should be aware that patients with preexisting conditions may present differently. For example, older patients, diabetic patients, and patients on beta blockers might not exhibit tachycardia as blood pressure decreases. Younger patients may have a severe and prolonged tachycardia without hypotension that may appear later and suddenly (Schmidt & Mandel, 2017). Patients presenting with signs and symptoms of sepsis or septic shock will need immediate intravenous fluids and intravenous antimicrobial therapy at a minimum. In addition to IV fluids, patients may need blood products; frequent medication administration, including vasopressors; or blood draws, which may require reliable central venous access at some point during their treatment (Schmidt & Mandel, 2017). Central venous pressure and oxygenation (ScvO2) can be measured from central venous access. Peripheral IV access must be obtained in the first stages of treatment. Provide fluid resuscitation The SSC guidelines for 2017 recommend that patients with hypoperfusion resulting from sepsis should receive at least 30 ml/ kg of IV crystalloid fluid within the first 3 hours and that the patient be reassessed through such variables as heart rate, blood pressure, respiratory rate, temperature, arterial oxygenation saturation, and urine output (Rhodes et al., 2017). Fluids should be administered as necessary based on the hemodynamic status of the patient. The SSC guidelines also recommend that albumin be added in addition to crystalloids for patients requiring large amounts of crystalloids for fluid resuscitation (Rhodes et al., 2017). Hydroxyethyl starches are no longer recommended for volume replacement in patients with sepsis or septic shock (Rhodes et al., 2017). It is important that the patient be reassessed frequently. Fluid replacement should be taken into account of the patient’s response and clinical presentation, including the presence of cardiogenic pulmonary edema. Oxygen saturation, hematocrit, electrolytes, BUN, and creatinine should be monitored closely. EBP alert! Hydroxyethyl starches (HES) are synthetic colloid starches that have been used in the past for fluid resuscitation. HES are no longer recommended for volume replacement. Evidence has shown that use of HES in critically ill patients does not reduce mortality but actually increases mortality and acute kidney injury (Zarychanski et al., 2013). Provide antimicrobial therapy Antimicrobial therapy is part of the 3-hour bundle recommendation and should begin quickly and, ideally, directly after appropriate cultures have been drawn. Empiric broad-spectrum therapy should begin within 1 hour after recognition of sepsis or septic shock (Rhodes et al., 2017). Increased mortality rates have been correlated to a delay of antibiotic administration (Ferrer et al., 2014). The use of empiric broad-spectrum antibiotics that have one or more antimicrobials has been suggested to ensure that all likely pathogens be covered, including bacterial, viral, or fungal causes (Rhodes et al., 2017). If the pathogen is identified, the antimicrobial therapy should be changed to target that particular pathogen. Nursing consideration: The nurse is often responsible for ensuring that microbiologic cultures (blood cultures, sputum, wound, urine cultures) are obtained once ordered. It is imperative that the nurse prioritize the obtaining of these cultures before initiating antimicrobial treatment so that rapid treatment can begin. The cultures should be obtained in less than 45 minutes (Rhodes et al., 2017). Typically, antibiotic administration is continued for 7 to 10 days, depending on patient response. Antibiotic therapy for sepsis can include the following. Therapy can be a broad-spectrum or combination therapy until a source of infection is realized. ● ● Vancomycin. ● ● Ceftriaxone. ● ● Meropenem. ● ● Ceftazidime. ● ● Cefotaxime. ● ● Cefepime.