Special Article

Nursing considerations to complement the Surviving Sepsis
Campaign guidelines
Leanne M. Aitken, RN, PhD, FRCNA; Ged Williams, RN, MHA; Maurene Harvey, RN, MPH;
Stijn Blot, RN, Cc, RN, MNSc, PhD; Ruth Kleinpell, RN, PhD; Sonia Labeau, RN, MNSc;
Andrea Marshall, RN, PhD; Gillian Ray-Barruel, RN, Grad Cert ICU Nursing, BA (Hons);
Patricia A. Moloney-Harmon, RN, MS, CCNS, FAAN; Wayne Robson, RN, MSc;
Alexander P. Johnson, RN, MSN, ACNP-BC, CCNS, CCRN; Pang Nguk Lan, RN, MSc; Tom Ahrens, RN, DNS, FAAN

Objectives: To provide a series of recommendations based on infections, hand hygiene, and prevention of respiratory, central line-
the best available evidence to guide clinicians providing nursing related, surgical site, and urinary tract infections, whereas infection
care to patients with severe sepsis. management recommendations related to both control of the infec-
Design: Modified Delphi method involving international experts tion source and transmission-based precautions. Recommendations
and key individuals in subgroup work and electronic-based dis- related to initial resuscitation include improved recognition of the
cussion among the entire group to achieve consensus. deteriorating patient, diagnosis of severe sepsis, seeking further
Methods: We used the Surviving Sepsis Campaign guidelines assistance, and initiating early resuscitation measures. Important
as a framework to inform the structure and content of these elements of hemodynamic support relate to improving both tissue
guidelines. We used the Grades of Recommendation, Assessment, oxygenation and macrocirculation. Recommendations related to sup-
Development, and Evaluation (GRADE) system to rate the quality portive nursing care incorporate aspects of nutrition, mouth and eye
of evidence from high (A) to very low (D) and to determine the care, and pressure ulcer prevention and management. Pediatric
strength of recommendations, with grade 1 indicating clear ben- recommendations relate to the use of antibiotics, steroids, vasopres-
efit in the septic population and grade 2 indicating less confidence in sors and inotropes, fluid resuscitation, sedation and analgesia, and
the benefits in the septic population. In areas without complete the role of therapeutic end points.
agreement between all authors, a process of electronic discussion of Conclusion: Consensus was reached regarding many aspects
all evidence was undertaken until consensus was reached. This of nursing care of the severe sepsis patient. Despite this, there is
process was conducted independently of any funding. an urgent need for further evidence to better inform this area of
Results: Sixty-three recommendations relating to the nursing critical care. (Crit Care Med 2011; 39:1800 –1818)
care of severe sepsis patients are made. Prevention recommenda- KEY WORDS: sepsis; severe sepsis; septic shock; nursing care;
tions relate to education, accountability, surveillance of nosocomial guidelines; Surviving Sepsis Campaign

S epsis, including severe sepsis shock have reduced slightly in the past lished by the Surviving Sepsis Cam-
and septic shock, continues to decade, it remains ⬎20% (1, 2). As part of paign (SSC) to facilitate clinicians to
be a major healthcare problem the response to optimize care for this improve the outcomes of patients with
internationally. Although mor- group of patients, evidence-based clini- sepsis and septic shock (3, 4).
tality related to severe sepsis and septic cal practice guidelines have been pub- Although the SSC guidelines (4) pro-
vide a comprehensive review of the med-
ical management of patients with sepsis
and septic shock, they are frequently si-
From the Research Centre for Clinical and Commu- dren’s Services (PMH), Sinai Hospital of Baltimore, Balti-
nity Practice Innovation (LMA), Griffith University, Nathan, more, MD; Patient Safety Programme (WR), Nottingham lent on the nursing care that is essential
Queensland, Australia; Intensive Care Unit (LMA), Princess University Hospitals, UK; Advocate BroMenn Medical Cen- for optimal outcome of these patients.
Alexandra Hospital, Woolloongabba, Queensland, Austra- ter (APJ), Normal, IL; KK Women’s and Children’s Hospital Expert nursing knowledge and skill are
lia; Gold Coast Health Services District (GW), Gold Coast, (PNL), Singapore; and Barnes-Jewish Hospital (TA), St. required for both the identification of the
Queensland; Research Centre for Clinical and Community Louis, MO.
Practice Innovation (GW), Griffith University, Gold Coast, This project was conducted under the auspices of the deteriorating patient as a result of newly
Queensland, Australia; Consultants in Critical Care (MH), World Federation of Critical Care Nurses (WFCCN), and no developed sepsis and the ongoing imple-
Glenbrook, NV; General Internal Medicine and Infectious sponsorship or funding was received for this project. mentation of competent care for the
Diseases (SB), Ghent University Hospital, Ghent, Belgium; Dr. Blot received honoraria/speaking fees from known severe sepsis patient. The World
Faculty of Medicine and Health Sciences (SB, SL), Uni- Covidien and Cook Critical Care. The remaining authors
versity Ghent, Ghent, Belgium; Faculty of Healthcare (SB, have not disclosed any potential conflicts of interest. Federation of Critical Care Nurses, as the
SL), University College Ghent, Ghent, Belgium: Center for For information regarding this article, E-mail: premier organization for critical care
Clinical Research & Scholarship (RK), Rush University l.aitken@griffith.edu.au nurses worldwide, consequently formed
Medical Center, Chicago, IL; Faculty of Nursing and Mid- Copyright © 2011 by the Society of Critical Care
wifery (AM), University of Sydney, NSW, Australia; Nursing Medicine and Lippincott Williams & Wilkins
an international group of interested ex-
Practice Development Unit (GRB), Princess Alexandra perts in the area to provide guidance for
DOI: 10.1097/CCM.0b013e31821867cc
Hospital, Woolloongabba, Queensland, Australia; Chil- nursing care of severe sepsis patients.

1800 Crit Care Med 2011 Vol. 39, No. 7

and authorization. or Sepsis (also referred to as Infection (documented or suspected) and some of the following: Consultant) who practice in the acute systemic inflammation General variables: Fever (⬎38. the aim of this review is sibility with other members of the health. scope. the scope of immature forms. we strategies before implementing the recom. capillary refill or mottling jority of interventions not tested in the Severe sepsis Sepsis complicated by organ dysfunction pediatric patient. hypotension despite adequate volume resuscitation and plicable to the pediatric setting. hyperbilirubinemia (plasma total bilirubin ⬎4 mg/dL or 70 mmol/L) Most of these recommendations relate Tissue perfusion variables: Hyperlactatemia (⬎1 mmol/L). nizational sponsor (G.. many of Septic shock Acute circulatory failure characterized by persistent arterial the recommendations are likely to be ap. to frequently influence which central ve. not to replicate or replace. dations specific to the pediatric septic pa. ⬍100. the cur- is essential that nurses are familiar with rent SSC guidelines (4) and have been devel. age. Although this article is designed to in this document. care team. heart rate hospital setting. in response to ⬎90/min or ⬎2 SD above normal value for age.R. thrombocytopenia (platelet count role. necessary. Development. ad.) and an orga. as well as provide any published literature that informed the care related to the device after insertion. we have iden. although most nurses do not METHODS authors searched the literature referred to in order drugs.g. creatinine increase provided only by registered nurses. mean arterial pressure ⬍60 mm Hg. rate the quality of the evidence (Table 2). 7 1801 .5 mg/dL.5 or activated partial thromboplastin time ⬎60 secs).3°C). but ⬎0. Despite this. tient are contained within a section later in the article. and queries were Rigorous and comprehensive implemen. in children. and then with the entire author team when sential but constitute a separate body of ute to the guidelines. known experts in discussed electronically with the subgroup tation and evaluation strategies are es. many plasma procalcitonin ⬎2 SD above normal Hemodynamic variables: Arterial hypotension (SBP ⬍ 90 mm Hg. Recommen. Clinical Nurse Specialist. white blood cells. education.B. Al. Consequently. Definition of sepsis (4. standard deviations. they do participate in proto. an additional section relating ument. it Evaluation (GRADE) system (5) was used to augment. Assessment. and guidelines for nursing care are designed to comes in severe sepsis. pendent reviewer (G. ini- the best available evidence. Internationally. with the ma. These medications important to patient out.000 ␮L⫺1). the structure and content of these guidelines garding practice in areas of joint respon. appointed a coordinator (L. Clinicians are encour. each sub- guide clinicians providing nursing care to nous catheters or endotracheal tubes are group of authors undertook searches to locate patients with severe sepsis. For example. with searches expand- col development and often advocate for Sepsis. to prevention of infection and subsequent sep- to provide a series of recommendations. tachypnea. analogous to the timely ordering and administration of the SSC guidelines (4). altered vanced practice nursing roles vary in infection) mental state.). nurses sis was added in recognition of the pivotal role based on the best available evidence. SBP. of the SSC guidelines (4) was used to inform also have provided recommendations re- mendations outlined throughout this doc. the Grades of Recom- and inform these guidelines (Table 1). the field of sepsis care were invited to contrib. team to develop guidelines for the nursing the subgroups. or reduction in SBP ⬎40 mm Hg from baseline firming or denying application to patients in specific age groups exists. Given this vari. care of patients with sepsis. nursing care of patients with severe sepsis. plasma C-reactive protein ⬎2 SD above normal. mendation. significant edema or positive fluid balance. for example. some of these roles are designated by leucopenia (WBC ⬍4000 ␮L⫺1). the organization viewed by the coordinator as well as an inde- tice is based on these recommendations.M.5 l/min/m2 tempted to limit the recommendations Organ dysfunction variables: Arterial hypoxemia (PaO2/FIO2 ⬍300).5 mL/kg/hr). hypothermia (⬍36°C). ommendation. SBP ⬍90 mm Hg or. contained within this document to care acute oliguria (urine output ⬍0. systolic blood pressure. cardiac index country to another. the broad structure cares for patients with severe sepsis. whenever possible.A. 137) tered nurse. this document is not designed Federation of Critical Care Nurses formed a evidence was undertaken electronically within to provide information regarding strate. WBC. a See pediatric considerations section for further clarification of diagnosis in children.a ⬍2 SD below normal for their tified where specific information con. practice of the nurse practitioner. all nurses. ⬎3.W. 39. or SBP decrease ⬎40 mm the registered nurse role. Hg from baseline or in childrena ⬍2 SD below normal for their ation in nursing roles from one region or age). regardless of their specific ileus (absent bowel sounds). has been well-defined in the literature ing based on the section topics. hypotension is defined as: Throughout the document. authors worked in sub. as outlined in the rationale. No. all recommendations were re- gies for implementation to ensure prac. Nurse Prac- titioner. the evidence supporting each rec- knowledge and as such are not reviewed groups of two or three. for nursing care. SD. Table 1. normal WBC with ⬎10% legislation. Therefore.000 ␮L⫺1). saturation of oxygen in venous blood ⬎70%. the SSC guidelines (4). unexplained by other causes.). coagulation abnormalities (international normalized have extended it to cover the practice of ratio ⬎1. oped using the following methodology: World tial discussion of relevance and quality of the Of note. decreased to the adult septic patient. hyperglycemia though the scope and requirements for Inflammatory variables: Leukocytosis (WBC ⬎12. This care is provided by every regis. we have not at. Crit Care Med 2011 Vol. these authors represented different geograph- provide guidance for every nurse who aged to become familiar with appropriate ical regions of the world. In addition. of the roles are professional extensions of mean arterial pressure ⬍70 mm Hg. including severe sepsis and septic shock. purchased and used. as well as many of the ad- Term Definition vanced practice nurses (e. that nurses provide in this area.

Hand wash- dissemination through conferences. erance toward hospital-acquired infection cause gloves may have imperceptible de- proaches. hand rub is particularly effective. shifting. A systematic review found that in. ir- respective of the use of gloves. worker are responsible and accountable ineffective in the presence of organic ma- 2. sure infection control guidelines are fol. The use of alcohol-based unit (ICU) (8) toward personal account. 13). upgraded observational studies Rationale. tions. Rationale. Education ability and a goal of zero tolerance in trast with hand washing. 10).Table 2. has proven to result in reduced infection I. 10). ing direct contamination of hands. use of alcohol-based hand rub remains ated infection rates (grade 1C). Hand disinfec- to enhance guideline implementa. well-done observational studies (eventually integrated in a national sur- D: Very low. Precision of estimate of treatment effect: Highly precise results are likely to increase rating Inconsistency of results: Multiple studies with inconsistent results are likely to decrease rating Directness of evidence: Indirect evidence (e. 21). terial. Importance of outcome: Highly desirable outcomes are likely to increase rating Surveillance systems combined with ap- Magnitude of treatment effect: Relative risk ⬎2 with no plausible confounders is likely to propriate feedback contribute to reduced increase rating nosocomial infection risk (14 –19). All authors report no conflict of interest with respect to the clinical accountability (grade 2D). 39. We recommend educational initia. and exploration of additional evidence until care-associated infections (7). or not. and non- recommendations or consensus-based evidence Rationale. faceted. 3.. different populations) is likely to decrease rating Risks associated with therapy: Significant known risks or burden of therapy are likely to decrease D. More specifically. use of nonsterile. e. Adequate hand antisepsis associated infection as an inevitable out. in con- A. We suggest the promotion of a cul.g. INFECTION PREVENTION come of admission to the intensive care rates (20. Educating and empowering nurses to en. with soap and water when hands This project was conducted under the aus. fection prevention and control (9. system (5). Surveillance of Nosocomial Infections Strength of Evidence Quality of Evidence 1. and no sponsorship or funding was re- ture of patient safety and individual tentially infectious materials. a systematic review that tact that potentially results in hands mary of evidence in line with the GRADE investigated the effect of education on the becoming contaminated (grade 1B). 7 . and after any activity or con- mendation based on the rationale and sum. secre- ceived for this project. fections (12. e. 21).g. This attitude is in contamination of hands. Education is generally con. and every recommendation that reduction in infection rates concluded that 2. enhance guideline implementation (6). the tives to reduce healthcare-associ. major impediment to achieving zero tol. are management and every healthcare dirty because alcohol-based hand rub is often not effective (grade 1A). it kills suscep- relation to hospital-acquired infections tible bacteria more rapidly and to a 1.. with recognition that hospital ing is necessary when hands are visibly web sites. resulting sive education and information levels of hospital staff (9). pices of the World Federation of Critical Care 4. Hand Hygiene rating Costs: Significant costs associated with therapy are likely to decrease rating 1. A moisturizers are added. including in.. well-fitting gloves is 1802 Crit Care Med 2011 Vol. longitudinal educational of nosocomial infection found that at and skin health is better preserved when programs and educational outreach least 20% could be preventable (11). after hand washing. We recommend interactive.g. A systematic review of 30 reports greater extent.. ratings. has been a lack of accountability of all fects or may be torn during use. mucous membranes. such as incorporated pas. be- tween caring for different patients or between different care activities for and the associated level of recommendation. (9. for ensuring patient safety. The change. However. We recommend a continuous sur- 1 ⫺ Strong A: High. Local surveillance systems C: Low. the same patient. a first step toward sidered as a first step to increase awareness lowed by all staff has the potential to adequate hand hygiene consists of avoid- of a problem and as crucial for processes of positively impact on hospital-acquired in. rub (grade 1A). teractive. We recommend washing hands consensus by all members of the author team was achieved. transition from accepting healthcare. Traditional education ap. Grade criteria (4. downgraded randomized control trial or of nosocomial infection (grade 1B). and didactic lectures. We recommend the use of gloves 1. their support for each recom.. We recommend hand antisepsis. when contact with blood or other po- Nurses. tion after glove removal is necessary be- tion. e. We recommend hand antisepsis by did not receive 100% agreement for the grade the implementation of educational inter. tional programs and educational outreach and after each episode of direct patient firmed. mandatory (20. Recent trends have seen a intact skin could occur (grade 1D). e. B. is less time-consuming.g. immediately before was then forwarded to all authors who con. longitudinal educa.g. means of an alcohol-based hand of support was subject to e-mail discussion ventions may considerably reduce health. 5) C. multifaceted. contact. multi. No. As a rule of thumb. Rationale. well-conducted randomized control trial veillance program for the detection 2 ⫺ Weak B: Moderate. Accountability are visibly soiled (grade 1A). case series or expert opinion veillance program) allow benchmarking Factors influencing strength of evidence of nosocomial infection data and there- Methodologic quality: Poor planning and implementation increasing likelihood of bias is likely to fore are essential to guide and evaluate decrease rating interventions to reduce infection rates.

51. We suggest the use of a silver.9) (47). visible and ventilator bundles (30. catheter-related blood- complished through use of a specially de. and urinary tract infection with a separate dorsal lumen that opens pared to every 5 to 7 days (49. 27).. We suggest the use of an endotra. sidered (grade 2A). There is insufficient despite a target of 45 degrees. Impaired gag reflex leads to ture exchangers.recommended whenever the risk of con. bronchial and upper airway secretions be- or changing sheets. and saline lavage ing the risk of VAP (37). Special attention should be Rationale. ized. 31) have contrib- as VAP in patients intubated 24 hrs or or audible signs of respiratory se- uted to a reduction in VAP incidence. ventilator circuits should be used for each cial airway may affect 10% to 48% of patients coated endotracheal tube be con. We recommend endotracheal cuff Rationale. condition that may be attributable 1. Strate- more (44. but not ⬎30 cm H2O Suctioning should only be performed normal healthy adults (33). tious. 0. gies to prevent VAP should be considered in all patients with severe sepsis (32). and application of dotracheal tube was demonstrated to re. be effective in preventing VAP (relative except between patients (grade 1B). take no longer than 15 Rationale. cretion drainage in patients ex. bated patients (grade 1C). and tube patency com- 5. 95% confidence interval [95% Infections Rationale. VAP is associated with a higher mor. formed only if the circuit becomes visibly tality rate and significantly longer ICU length soiled or damaged (32). random. 57). tube with a polyurethane cuff was shown frequently require removal of tracheo- bed elevation. head-of-bed therapy showed that a persistent intracuff peroxygenation should be provided before elevation is especially effective in reduc- pressure ⬍20 cm H2O was an independent and after suctioning. No benefit in infection rates or func- devices. Rationale. operative pneumonia in cardiosurgical cause of increased mucus production and stances.e. 8. 95% CI. We recommend ventilator circuits Subglottic secretions drainage appears to should not be changed routinely.71) in patients expected to be routine ventilator circuit changes can re- The development of pneumonia in pa. and use continuous rather than in- patients has been associated with lower risk factor for microaspiration of oropha. demonstrated when heat and moisture stream infection (CR-BSI). 50). Subglottic secretion drainage is ac. patients (46). One observational study among in. 53). clinical signs (56). tionality of ventilator circuits has been pneumonia (VAP). Secretion removal may reduce infec- maintained. 41). Song et al (40) achieved head-of-bed ele. respiratory deterioration. E1. Humidification of inspired patient (when going from a dirty/contam. There is no evidence that CI]. Prevention of Respiratory risk. with microaspira. duction for any humidification device the ICU are related to the use of therapeutic tion of subglottic secretions leading to (48). Inadequate cuff pressure is a secs. should be avoided (55. However. termined but should be in response to head-of-bed elevation of only 28 degrees 6. In a single-center. evidence to recommend the benefits of Crit Care Med 2011 Vol. More studies that confirm a decreased ability to clear secretions (52. Site-Specific Considerations Rationale.37– 0. hy- receiving enteral nutrition. patient. Cuff pressure should be The optimum frequency of endotra- tioned by some authors (40. controlled trial. pected to require mechanical heated humidifier with a heated wire cir- ventilation for ⬎72 hrs (grade 1A). predictor of VAP (relative risk. 51). In such circum. In multicenter. the suction cathe- levels of aspiration into the lower airways ryngeal secretions and subsequent pneu. random- of stay and hospital costs (24. These include ventilator-associated VAP. or other changes in the patient’s 4. or passively using a heat and mois- E.1–15. 3. a tween different patients (20 –22). achieved by using a heated humidifier. Gloves must be vation ⬎30 degrees in 43. However. Recommendations for their prevention are outlined. 4. 7. ter should occlude less than half the lu- (34 –36) and lower VAP incidence than monia. (UTI) (23. evation in daily practice has been ques. when necessary. directly above the endotracheal tube cuff. New tients mechanically ventilated with an artifi. 7 1803 . and mechanically ventilated patients (grade 1B).4% of patients. men of the endotracheal tube and be the supine position (37–39). We recommend the use of an en. a silver-coated en. and circuit changes should be per- (25–27). ized. Aspiration of upper airway pressure be maintained at least 20 plications (54 –56). such as during bed bath to significantly reduce early-onset post. We recommend head-of-bed eleva- cheal tube with a polyurethane cuff to respiratory secretions in intu- tion 30 to 45 degrees for all critically ill (grade 2B). We suggest heat and moisture ex. We recommend the aspiration of VAP is often preventable. i. 1. mechanically ventilated for ⬎72 hrs (43). (grade 1C). duce the incidence of VAP (25. secretions is a common event even in cm H2O. 45). an endotracheal chanically ventilated via a tracheal tube ficult to achieve a 30-degree head-of. whereas changers should be changed be. termittent suctioning. More studies that confirm cretions. endotracheal secretions in re- practices such as education strategies (28. tween patients. Critically ill patients me- given to maneuvers in which it is dif. No. Rationale. Rationale. vation of at least 10 degrees should be this result are required. air to prevent mucosal injury may be inated to a clean body site) and in be. 29) duce bacterial airway colonization as well sponse to clinical signs. the current findings are required. There are insufficient pooling of secretions in the posterior part data to demonstrate a benefit in VAP re- Most healthcare-associated infections in of the oropharynx (42). or tamination exists. using the lowest possible bent position in mechanically ventilated suction pressure. cuit. dotracheal tube with subglottic se. In patients tubated patients not receiving antibiotic inserted no further than the carina. we recommend back-rest ele. changed between separate tasks on one 2. the feasibility of maintaining head-of-bed el.2. Semirecum. Van maintained at the lowest pressure ⬎20 cm cheal suctioning has not been clearly de- Nieuwenhoven et al (41) achieved average H2O that prevents cuff leak. surgical site in- signed endotracheal or tracheotomy tube exchangers are changed every day com- fection (SSI). 39. 24). every 5 to 7 days. controlled trials. as clinically indicated (grade 2C). 0. respiratory.

When a fluid that among patients who had hair removal not recommended for oral care in the enhances microbial growth is infused before surgery and those who did not critically ill (63). Chlorhexi. infections (76). Providing regular oral care. and sterile gloves. a fre- (grade 1A). In 2003. designated oral care protocol. Nurses play a key role in population by the Food and Drug Admin- changes in the oral flora. 0. and daily CVCs in comparison with standard cath- provided to all critically ill and in. (lipid emulsions. tion set replacement was increased from reported no difference in SSI rates search is indicated (65. The increased 1. and barriers is to be covered with a large sterile drape of vancomycin and fluoroquinolo- to mouth care delivery (63). incision to prevent antibiotic-associated dine (2%) solution consistently has been reactions (106. 7 . compared to other impregnated CVCs pharynx by pathogens is a potential risk tral venous catheter (CVC) insertion and care (12. Prevention of CR-BSI been identified as independent risk fac. 83) has proven to be (105).2%. in associa. is an im. No. We suggest the replacement of ad. eters (101–104). necessary. and to substantially de. 2. In general. (108). in which case Rationale.12%. preparation before insertion and sub. Critical illness contributes to effective in substantially reducing the rate of CR-BSI. sequent catheter care (grade 1A). and the patient are allowed for the administration mucus membranes. 81). and when a fluoroquino- Rationale. 90). blood products. 107). sterile barriers during CVC inser- portant part of providing comfort to the tion (grade 1A). lished evidence. except when used for (grade 1B). Although the use of depilatories 1804 Crit Care Med 2011 Vol. the Surgical Infec- tion with an education program for nurses led to reduced infection rates (87. assessment of possible catheter re. zors. We recommend the use of minocy. sion should begin within 120 mins before intubated patients (69 –72). depilatory cream (112). and its use in oral care found to be superior to both 10% povi- has been proven to decrease dental done iodine and 70% alcohol for prevent. includ. more (112).either an open or closed suctioning ence to evidence-based guidelines. 82. ies have not been conducted in children. During the CVC insertion prophylaxis be administered within onstrated to contribute to a decrease in procedure. pharynx (73. Because the risk of CR-BSI crobial dose should begin within 60 mins increases with the density of microorgan. removed. 1 hr before incision to maximize VAP (63– 67). all healthcare personnel in. Colonization of the oro. Rationale. incorpo. clin-rifampin impregnated cathe. gown. formation of microscopic cuts in the catheter insertion cart. infection risk associated with the tech- of a central line care bundle. 1. 74). 62). We recommend the use of a chlo. tion Prevention Guideline Writers Work- in its importance in preventing VAP. creation of a 5. tongue. moval is associated with increased SSI quency of three to four times daily is rates (108 –111). Minocycline-rifampin impregnated factor for the development of VAP (58 – CVCs are approved for use in the pediatric 60). We recommend the use of maximal E3. Studies have repeatedly system (57). The 4. gums. We recommend that antimicrobial critically ill patient (63) and is also dem. 13. Assessment should include volved must wear a mask. cycline-rifampin– coated CVCs when Rationale. or lipids. We recommend regular mouth insertion procedures when a guide. A Cochrane systematic re. nique of shaving is attributed to the ing staff education. and an increase istration (United States). review compared a variety of hair re- tooth brushing in critically ill patients as view found no increase in the risk for moval methods (depilatory cream. 66). moval (grade 1B). more virulent organisms may occur (61. Aqueous chlorhexi- dine effectively decontaminates the oro. We recommend that only hair that plaque (75) and incidence of respiratory will interfere with the operation be ing CR-BSI (91–93). empowering nurses to stop catheter demonstrated a significant reduction in 9. 80. We recommend the implementation tors for CR-BSI in both adults and neo. no hair removal and demonstrated efficacy. Although several authors for oral care with chlorhexidine has not sets must be changed within 24 hrs have reported preoperative hair re- been demonstrated. cap. but additional re. Tap water is 72 hrs to 96 hrs (94). 89. vention of infection. The benefit of Rationale. and that if hair removal is crease the incidence of VAP (77–79). sterile tissue concentration. Prevention of SSI rating oral cavity assessment. stud- in Gram-negative flora that includes preventing CR-BSI through these activi- ties outlined. before incision. the workgroup con- dine-based antiseptic for oral care in cluded that infusion of the first antimi- intubated patients (grade 1A). then it should be re- optimal concentration of chlorhexidine ministration sets every 96 hrs moved by using electric clippers solution (0. Use of maximal sterile barrier nes (grade 1A). clippers) vs. The use of a (84 – 88). nates (95–100). undetermined. or 2%) remains (grade 2A). ters (grade 1B). blood products). and lips. Rationale. implementa. in surgery (106). On the basis of pub- 10. ra- a component of oral care protocols has CR-BSI when the interval for administra. 39. The optimum frequency the administration of blood. We recommend the use of chlorhexi. however. tion rates has been greatest with mino- Rationale. The same review found that shav- frequent changes of administration sets ing led to statistically significantly are indicated because these products have more SSIs compared with clipping or E2. 2. site antisepsis is crucial in the pre. a Cochrane systematic proposed (69. A bundle approach to cen. skin that later act as foci for bacteria tion of a checklist to ensure adher. can 3. this reduction in infec- tubated patients (grade 1C). CR-BSI with the use of impregnated care and oral cavity assessment be line violation is observed. Two hours the condition of the teeth. precautions during CVC insertion have Rationale. Chlorhexidine is widely isms at and around the insertion site used and investigated in the oral care of lone or vancomycin is indicated the infu- (21). Rationale. group meeting reviewed the various increase compliance and assessment of rhexidine-based antiseptic for skin guidelines for antimicrobial prophylaxis mouth care (68).

Standard precautions are re- Rationale. nurses will be respon- of discharge to home (122). 7 1805 . III. Errors in maintaining sterile 1. systems are pivotal in preventing UTI (21. quired for all patients. Failure to remove the catheter was diagnosis are pivotal. as well as a decreased likelihood for mechanical complications (134). We recommend transmission- operative day 0 (grade 1C). postoperative period for patients un. There Rationale. 95% ing and interpreting clinical observa- (121). should stress the importance of glucose obstructed urine flow (grade 2C). Prompt removal of contam. Many of the pro- prevalent source of nosocomial infection demonstrated to be an independent pre. the management of device-related infec. closed drainage and opening the closed based precautions for patients who Rationale. mented to predispose patients to infec. is recommended (123. 2. (124 –126). contin. and ini- most important risk factor for development removed for suspected CR-BSI. quent catheter tip culturing in pa- tients with proven bloodstream in. If. dle) are operational only from the point tion of urinary catheterization inated invasive devices is a cornerstone in that severe sepsis/septic shock is diag- (grade 1C). seeking further assistance. We recommend that all attempts pected CR-BSI (grade 1C). 4. fection associated with severe E4. If the catheter is tions. be infected or colonized with infec- operative period (ⱕ48 hrs) are associ. 131. bacterial contamination can be expected 114). Infection Source Control sion. they can produce hypersensitivity 2.10 – 0. Increased glucose levels drainage system have been well-docu. 39.28 –9. We recommend that blood glucose lev. Most episodes of UTI are 48 hrs of surgery had more than three. tious agents. then tiating early resuscitation measures are of UTI (121). tions to prevent cross-infection. mortality. INFECTION MANAGEMENT airborne precautions (136). droplet. 0. tial resuscitation (6-hr resuscitation bun- should be made to limit the dura- Rationale.22. all infections remote to eases with multiple routes of transmis- the surgical site should be identified A. We recommend prompt removal of intravascular catheters and subse. glyco- sponsibilities. We suggest the maintenance of un. Reflux of urine is associated ing Enterobacteriaceae. We recommend that a sterile. In addition. uously closed drainage system be shown to be an independent risk factor 3. with procedure day being post. nosed. II. precaution categories and the particu- postponed until the infection has re. The role of terization ⬎2 days is associated with an cumstances in which catheter insertion is the nurse in initial resuscitation will vary increased likelihood of UTI and 30-day problematic because this reduces the risk according to the clinical area concerned. 126 –129). Because the SSC guidelines (4) for ini- 1. therefore. The risk of infection reduces from blood glucose level (⬍200 mg/dL) on B. are known to be or are suspected to (⬎200 mg/dL) in the immediate post. 132). the catheter tip culture appears sible for monitoring clinical observations advocate for prompt removal of urinary to be positive. Issues based precautions category may be and elective operations on patients recommended. Regular monitoring of glucose levels cally important pathogens. peptide-resistant Staphylococcus aureus. for the development of CR-BSI in an ob- els be controlled during the immediate servational study (odds ratio. We recommend regular perineal idemiologically important patho- One study found that patients with a hygiene measures (grade 1C). guide wire exchange is acceptable in cir. blood glucose level ⬎300 mg/dL within Rationale. drainage bags tant nonfermenting Gram-negative bac- and treatment of infections remote should be positioned below the level of teria. On a general ward. The urinary tract is the most tion. Nurses should however. 0. if possible. We recommend the identification with infection. multidrug-resis- 4. gens (grade 1A). Concurrent remote site are three categories of transmission- infections are considered to increase based precautions: contact. extended-spectrum ␤-lactamase produc- control in preventing SSI.has been associated with a lower SSI catheters (123) and discourage long-term should be replaced a second time because risk than shaving or clipping (113. nursing education 4. 116). No.86) (133). patients caused by the patient’s own flora (121). and guide wire exchange on itself was reactions (114). Closed urinary drainage CI. tion (124. maintained (grade 1A). For dis- ever possible. in detail elsewhere (136).3) (133). vancomycin-resistant enterococci. 130). Transmission-based with remote site infections should be 1. back-flow and unobstructed urine flow ity (135) and require additional precau- should be maintained (21. the processes that lead to early Rationale. Prevention of UTI sepsis as well as in hemodynami. including certain ep- ated with increased SSI risk (115. hyperglycemic agents are direct nursing re. more than one transmission- and treated before elective operation. dergoing cardiac surgery: controlled 123). Transmission-Based 97% using open systems to 8% to 15% postoperative day 1 and postoperative Precautions when sterile closed systems are used day 2. 95% Rationale. and Clostridium difficile may pose a to the surgical site before elective the bladder at all times to prevent urine potential threat to patients in their vicin- surgery (grade 1B). therefore. Duration of catheterization is the CI.59. cesses that support compliance with the and there are several recommendations to dictor of mortality in an epidemiologic 6-hr resuscitation bundle such as record- prevent or reduce the incidence of UTI study on CR-BSI (odds ratio. catheterization. lar measures they include are described solved (108). Therefore. times the likelihood of a wound infection colonized or infected with epidemiologi- Daily cleansing of the urethral meatus (117). INITIAL RESUSCITATION cally unstable patients with sus. often the domain of nurses. when. Postoperative urinary cathe. the newly inserted catheter and administering antibiotics and fluid Crit Care Med 2011 Vol. including me- using soap and water or perineal cleanser and timely administration of insulin and thicillin-resistant Staphylococcus aureus. 3. and SSI risk (118 –120). Rationale.

However. ship between nursing and failure-to. 144). No.04) but [SBAR] and Reason. 39. We recommend the use of early tance is crucial in implementing the re- A. heart rate. A national sepsis consistent use in clinical care. Successful resuscitation depends recent multi-national performance im. not always communicate effectively with healthcare assistants) be educated to 3. The recognition of pa. Assessment. Early recognition of sepsis rescue (139. We recommend that all staff with a promote prompt treatment to en. There is evi- direct responsibility for patient care able best patient outcomes (grade dence that nurses and medical staff do (including nursing assistants and 1C). 157).Table 3. 39. tidisciplinary team. p ⫽ . B. can improve patient outcomes if a rapid outcomes of providing sepsis education 148). also be incorporated into the assessment the taking of vital signs. however. indicating the early onset of se- Respiratory rate ⬎20 breaths/min or PaCO2 ⬍32 mm Hg (⬍4. We suggest that communication nurses may be also be involved in moni. Vital in initial resuscitation does not end when did not demonstrate sustained improve. Adapted from Levy et al (137). Signs. ate attention to implement the resuscita- officer.. are not interpreted correctly. We suggest the use of sepsis each other (145. ness of EWS is needed to recommend goal-directed therapy (EGDT) and the tants is inconclusive. 149). Sepsis screening tools may sponsibility for patient care. or ⬎10% immature (band) forms can be added to observation charts or Additional signs and symptoms: EWS charts. response is initiated (156. whereas in a critical care area education program in Spain for medical 1. but the clinical review leading to spite this. toring hemodynamic status and adminis. patient outcomes (grade 2C). Plan [RSVP]) be used to im- medical staff members arrive on the ment after 1 yr (141). Rationale. are not documented. there is evidence that clinical tion bundle. Communication recognize the Systemic Inflamma. and communication and Diagnosing Severe Sepsis the early recognition of sepsis to delays can result in poorer outcomes for 1. improvement in both compliance and pa. diagnosis usually will be facilitated by a nurse who recognizes signs and symp. EWS. must be able to tient deterioration and diagnosis of sepsis (SBAR) or vital signs (RSVP to ensure the recognize the clinical findings of SIRS relies on the detection of abnormalities in nurse cogently relays the message that and sepsis (Table 3). Recommendations tering vasoactive agents. confirmed sepsis (grade 2D). prompting nurses to use a Chills Hypotension sepsis screening tool if the patient trig- Decreased skin perfusion gers one or more of the SIRS criteria of Decreased urine output temperature. SSC guidelines have demonstrated effi- 1806 Crit Care Med 2011 Vol. Background. EWS (155) that incorporate objective. Additional verification of the useful. Summoning medical assis- 2. The definitive diag- physiologic data. Numerous in the detection of deterioration by high. 153). prompt identification and treat- on collaborative integration of the skills provement study demonstrated sustained ment of patients with suspected or and expertise of all members of the mul. Sepsis screening White blood cell count ⬎12. screening tools to assist in the early between disciplines can be improved by tory Response Syndrome (SIRS) cri.g. including vival from sepsis. vations (146). response systems (grade 2B). De. Seeking Further Assistance challenges. ger systems. ⬍4000 cells/mm3. 140). Early for all nurses including nursing assis. and respiratory Significant edema or positive fluid balance (⬎20 mL/kg over 24 hrs) rate (149). We suggest that the initial resusci- patients and prompt management of sep. 1.000 cells/mm3.7%. One study reported a decrease Decreased capillary refill or mottling Hyperglycemia (plasma glucose ⬎120 mg/dL) in the absence of diabetes in mortality of one-third after the intro- Unexplained change in mental status duction of a three-step sepsis screening tool (150). lighting abnormalities in clinical obser. have been promoted to aid tation of patients with sepsis be sis to enhance recovery (138). Early diagnosis of sepsis is unambiguous language to convey patient Rationale. C. 7 . The effect on patient their effectiveness is inconclusive (147. Situation. The nurse’s role tality rates (44. or are not Measures Nurses therefore play a pivotal role in reported when abnormalities are found the early identification of deteriorating (145). Rationale. RSVP(154). and nursing staff marginally improved tools (e. Story. the patient meets the consensus defini- nosis of sepsis or severe sepsis in hospital umentation of clinical observations is an tion for severe sepsis and needs immedi- patients will often be made by a medical important nursing role (143. 151). and septic shock (grade 1C). information. The collection and doc. guideline compliance and hospital mor. observations sometimes are performed toms indicative of the onset of SIRS or poorly or not at all. recognition of sepsis to promote using structured communication tools teria and signs of severe sepsis or prompt treatment to enable best such as SBAR (152. tient mortality at 2 yrs (142). Recognizing Deterioration warning systems (EWS) to assist in suscitation bundle.0% vs. patients with severe sepsis. the evidence of Rationale. a more prove communication and promote scene. Initiating Early Resuscitation sepsis or both (137). Clinical signs of sepsis The addition of sepsis screening tools have been recommended in promoting Systemic inflammatory response syndrome: two or more of the following conditions can indicate early recognition of patients at risk for sepsis: Temperature ⬎38°C or ⬍36°C development of or those who have SIRS Heart rate ⬎90 beats/min criteria. provided through the use of rapid studies have demonstrated the relation. All staff with a direct re- linked to improved outcomes and sur.3 kPa) vere sepsis (146. also known as track and trig.

cation and treatment of severe sepsis with cryptic shock (raised lactate in the fying patients eligible for EGDT (those absence of hypotension) who otherwise (144) (grade 2D). not responding to fluid resuscitation or having a lactate ⬎4 mmol/L or both) and may be overlooked. 159. 158. Although nurses may iden- arranging prompt transfer to a higher 3. We suggest that nurses be empow- bundle is poor. 159). The impact of registered sets and established protocols have been grating the SSC guidelines in nursing practice (138). ratios intravenous fluid resuscitation. gest barriers to implementation include in. dle interventions such as administering timely treatment for severe sepsis. 7 1807 .cacy in improving mortality outcomes in mum of two nurses in the initial phase erative pulmonary and infectious complica- severe sepsis (4. Nurses play an important role in each Check hemoglobin and lactate nurse caring for one or two patients (ⱕ1:2) of these interventions. venous lactate assessment. obtaining blood cultures. promoting implementation of the guidelines. and administer intravenous fluids adequate facilities (162) and inadequate ing lactate levels such as serum lactate via standing orders for hypotension numbers of nurses (163). although some clinical settings tions (167). Consider the use of a daily goal sheet to ensure that the components of the hypotensive patients via standing orders Surviving Sepsis Campaign guidelines. one nurse caring for three or more pa. A recent U. No. with lower nurse-to. nurse staffing levels on patient outcomes utilized to facilitate early implementation is well-documented. Strategies for integrating the Surviving Sepsis guidelines in nursing practice Many nurses perform venipuncture and can rapidly obtain blood for cultures and Create a multidisciplinary team and map out a timeline for implementing the strategies. Integrate the use of the Surviving Sepsis Campaign guidelines as a performance improvement Because a medical officer may not be initiative for the intensive care unit and noncritical care areas. poor uptake of resources to enable prompt identifi. 168. UTI (169). obtaining are 1:1 because of not having personnel laboratory work including hemoglobin Administer high-flow oxygen and lactate levels. grand rounds. All nurses should be plored the poor uptake of EGDT and sug. We suggest the provision of adequate patient ratios being associated with In the United Kingdom. Many of the equipment is available promptly if they recommendations involve aspects of nursing care. starting Table 4.K. antibiotics and fluid boluses without a 5 outlines additional strategies for inte. Performing EGDT can be Europe typically range from 1:1 to 1:3. We recommend that adequate nurse tify signs of severe sepsis. tion (182). Despite this. The focus then should be on identi. 2005 (138) becoming more commonplace and has Crit Care Med 2011 Vol. sis resuscitation. The sepsis six interventions Zealand. Rationale. care areas to promote early identifi- critical care areas to help identify those apy. or can ensure Enlist the participation of nurse champions in leading the initiatives. 2. as well as ered by staff without specialist skills and acute medical units found that only 12% infection (172) and sepsis (167. We suggest that the sepsis six ap- able about the 6-hr bundle components proach be promoted in noncritical tate monitors should be available in non- to begin prompt implementation of ther. higher rates of pneumonia (167–171). 179) (Table Administere intravenous antibiotics Start intravenous fluid resuscitation patients. signs of severe sepsis and be knowledge. A number of studies have ex. Nurse-to-patient ratios of one 4). Table tient outcomes (grade 1B). compliance with the 6-hr resuscitation can incorporate EGDT into their regular 4. they may be level of care area such as the high. always readily available. EGDT in emergency departments (178) cation of patients with actual or sus. some hospitals Target processes to ensure successful adoption of the guidelines. whereas in countries such as Australia. Table 5. 181). flow oxygen. with severe sepsis (166). Standing order Rationale. 159). depending on patient acuity levels. Promote early identification of sepsis. cardiac concentrate on care that could be deliv- Rationale. and measuring hourly Take blood cultures such as respiratory therapists to assist in the management of acute and critically ill intake and output (144. tors. deep vein thrombosis. and failure to rescue. Recommended re. or increased lactate or both (grade Nurses must be able to recognize pendent predictor of mortality in patients 2C). and critical care nurses to administer fluid challenges for conference. cannulate. This has been called the sepsis six and to comply with the 6-hr resuscitation in the United States and some parts of includes six crucial interventions in sep- bundle (162). including starting high- labor-intensive and may require a mini. and the United Kingdom. and nurses can play an important role in are unable to perform venipuncture. specific physician order. survey of arrest. therapy is not currently included in the SSC guidelines (4) but is universally rec- Adapted from Surviving Sepsis Campaign tients (⬎ 1:2) in the ICU have been found to ommended as being an important aspect (144. 39. sources include arterial blood gas moni. trained to take blood. (164). Nurse-to-patient ratios in ICUs sis. staffing levels be ensured to provide unable to initiate the resuscitation bun- dependency unit and ICU to ensure quality patient care and improved pa. and laboratory facilities for measur. of the bundle components (177). including the sepsis bundles. Protocol-directed care in the areas of fluid and vasopressor therapy is Adapted from Kleinpell. have introduced measures to empower Include discussion of the guidelines in venues such as daily rounds. have been demonstrated to be an inde. ranging from 19% to 52% clinical duties without the allocation of ered to initiate the 6-hr resuscita- (160. bleeding. High-flow oxygen Measure accurate hourly urine output vs. Hand-held lac. 5. equipment in the first hour after diagno- appeared to have the minimum facilities 173–176). 170. New administering antibiotic therapy. be associated with increased risk of postop- of resuscitation of the critically ill and should be initiated by nurses (180. additional staff (165). upper gastrointestinal led to a change in focus on education to pected sepsis (grade 2D). tion bundle. shock. are addressed on a ongoing or patient group directions to reduce de- basis. Early identification of sepsis can help to promote prompt lays in patients receiving fluid resuscita- treatment. 161).

nurses therapies for severe sepsis are essentially with continuous monitoring. and serve as an sis is expected (grade 2D). system teams may also reduce delays in im. rapid response several factors mitigate this disadvantage. Reasons for may be somewhat managed by restoring imal to the thumb. some data suggest that ment of severe sepsis en route to hospital focus on treatment centers on improving macrocirculation. ready-mixed antibiotics lines. tis. We suggest further research on Rationale. Alert. fluids. for some patients and is recognized as a continue to develop and hemodynamic and improved ability to detect changes serious threat to patient safety. nurses performing clinical observations measurement of tissue oxygenation con- advanced practice nurses independently and calculation of EWS. ble for EGDT (192). Hence. below-normal values may identify sepsis and to promote “alerting” of emergency earlier (198). We suggest ER nurses should liaise be obtained via an easy-to-use. and vasopressors on confirmed. No. the literature remains onary syndrome and major trauma. tive at this point. Continuous United Kingdom and the United States. Al- Oxygenation mon practice for patients with acute cor. thus helping currently being developed by many differ. We suggest the institution of track. EGDT incorporates blood transfusion Hemodynamic monitoring techniques avoidance of clinician exposure to blood. aimed at improving both data suggest continuous ScvO2 monitor- patients who require transfusion receive macrocirculation and microcirculation. gan dysfunction (199). ment of tissue oxygenation vs. in the early phase of sepsis. Newer technology allows Rationale. ScvO2 alternative. present with a relative hypovolemia that tissue oxygenation via an electrode prox- stream infection (188. modynamic disturbances. to facilitate early resuscitation measures (184. We suggest consideration of noninva- 6. outcome A. 187). evidence recommendations (186. ent biotechnology companies. 1808 Crit Care Med 2011 Vol. questions remain in terms of the central venous access is less desired or un- should be available in all acute wards nursing care of septic patients with he. 189). specifically ficer has prescribed them. time with continuous measurement. 7.been shown to be safe (177. and others. unlike gross measures of hemo- be considered (190). We suggest continuous measure. However. Further treatment of the macro- tein C. Measures such as disturbance that centers on the microcir. Biosign. predict development of or- ing flow rather than pressure. e. inter. and it 1. areas (grade 2C). Central venous catheter care lactate values as a quicker alter- technology to aid the detection of use is associated with trends in mortality native to traditional serum lactate as sepsis (grade 2D). is in patient status and treatment efficacy in ders for sepsis management. 3. mittent measurement (grade 2D). a hemodynamics at revealing information being available (188). cellular dys- ing systems including the use of lower survival rates. 7 . Situations in- itor patients for signs of sepsis or auto- mated computer-based sepsis alert pro. Technology that alerts compliance exists (142). However. moving toward measur. available (grade 2D). regarding the microcirculation. StO2 is a con- antibiotic administration can be delayed ple. Leone et al (197) indicated lem of the microcirculation. reduction as long as resuscitation bundle appropriate (grade 2D). Preliminary play an important role in ensuring that supportive care. size and phase of sepsis utilized. the hemodynamics of sepsis. HEMODYNAMIC SUPPORT These factors include reduced nursing plementing the 6-hr bundle. of the benefit of this trend is yet to be monitoring technology is higher than the scribe antibiotics. Data suggest that such delays include lack of intravenous blood volume. critical care outreach teams. 2. patients tinuous. Unfortunately. However. volving severe sepsis in which central ve- grams (191) can enhance identification of circulation and microcirculation. such as Sepsis tributes to earlier recognition of changes prescribe medications and can initiate or. Including nurses who are able to pre.g. sepsis. data using StO2 are still lacking. i. Although not defini- staff to facilitate diagnosis and initial treat. At this point. and cell stunning (194). Two key areas are developing in the One of the main values of StO2 is its Rationale. IV. as sepsis progresses. unclear on how best to use StO2 in severe may help to identify those patients eligi. or inappropriate should be considered for tral venous oxygen saturation (ScvO2). StO2 monitoring. though promising. Evidence Whereas the cost of continuous ScvO2 185). We suggest consideration of point-of- 9. ing tissue oxygenation. marily based on an evidence-based prac- tice guideline published in 2004 (193). transcutaneous measurement of up to 6 hrs in some patients with blood. both of oxia. circulation does little to address the prob- dynamics. Donati et having commonly used antibiotics and culation is usually detected. nous catheter insertion is less desirable patients with sepsis. management of the hemodynamics of se- vere sepsis (194). noninvasive application. such as cen. ing may be more cost-effective for insti- blood in a safe manner guided by best The current SSC guidelines (4) are pri- tutions overall (195). Despite these excellent practice guide. In the Rationale. sive monitoring of tissue oxygenation when monly used. both in the macro.. For exam. restoring macrocircu. 39. StO2 may be a better marker than gross access and the prescribed antibiotic not lation. We recommend that supplies of com. StO2 values ⬍78% were correlated with microcirculatory clotting. Vitalpac. Usually it is nurses who Complicating the care of patients with noninvasive monitoring of tissue (periph- administer antibiotics after a medical of. near-infrared spectroscopy. cost of processing intermittent samples. relation to periodic central line sampling. and departments (grade 1D). Improving Tissue Rationale. The treat- daily sepsis rounds in critical care these studies were limited in both sample ment for this latter stage is unclear. should namic. The second neous application. al (196) showed that StO2 was responsive ready-mixed antibiotics available. tissue oxygenation end points. and lactate are tak- ing on increased importance.. 183). severe sepsis is the multimodal nature of eral vascular) oxygenation. transcuta- with medical colleagues and prehospital sue oxygenation (StO2). as well the macrocirculation becomes hyperdy- to identifying the impact of activated pro- as training nurses to cannulate. This system is already com. Use of check sheets to mon. Rationale. One focus is on improv.e. StO2 measurement can 8. departments that a patient with severe sep.

A similar re- example. offer more pre. specifi. more port has been on caloric intake. 225). Whereas no evidence specifically B.. Malnutrition in predict 28-day outcome better than tra. noninvasive attenuated. incorporating serum lactate laboratory results exceed tion for patients with sepsis are ongoing. improved outcomes. A vented. i. this has at dangerous levels while normal moni. of barrier function and potential micro- central line can be placed (grade 2D). all critically ill patients and a brief review evation correlates directly with morbidity tervention group that was associated with follows. 7 1809 . Degree of blood lactate el. blood volume or preload in response to accepted standards of fundamental nurs- fluid resuscitation (205). added advantage of the ScvO2 in the in. glutamine. reduce the risk of CR-BSI. and teral nutrition may prevent intestinal Rationale. enteral nutrition therapies such as fluids and inotropes inserted central catheter to allow for ScvO2 measurement is perhaps its most (226). should receive patients with severe sepsis (219). In addition. Lactate can be tation of a stroke volume estimate. who meet the criteria for central with intestinal mucosal atrophy with loss tation measure. (217. The parameter decrease the risk of sepsis. outcome studies using improve the provision of enteral nutri- knowledge of the danger a patient faces if stroke volume and stroke volume varia. Using point-of-care the esophageal Doppler. links many components of fundamental tion group and the control group in the nursing care to the outcomes of patients 1. 1. Rationale. caution should be exercised in is recommended as a resuscitation end distinct advantage compared to periph- eral lines. Early detection of elevated ume. these parameters have been shown enteral nutrition. Independent of V. traditional emphasis of nutritional sup- few indicators of hypoxia. with severe sepsis. In the perioperative setting. Rationale. and pulmonary peripherally inserted central catheter use. Additional advantages include the in. Critical illness is associated stroke volume variation as a key resusci. cellular injury may be pre- lactate as the catalyst to implementation Doppler. as surrogates for blood flow (204). is one of the pulmonary artery catheter enable compu. cise evaluation of the effectiveness of compared to delayed. 201). 2. Extensive mortality and 4-day reduction in length of efficacy of stroke volume optimization guidelines provide recommendations for stay was achieved (202. Nutrition Therapy lactate facilitates early recognition and suring stroke volume has clearly shown treatment in addition to being a more to improve patient outcome (183. between central laboratory and point-of. lipid emulsions) capillary wedge pressure have been used and. these aspects of care ability of the ICU patient to main- cle (158). as such. Enhanced catheter flow bial translocation. of central venous pressure is limited in such as arginine. such guidelines into the care of patients turnaround times of approximately 1 hr with severe sepsis is recommended. patients not yet resuscitated from septic point in the SSC guidelines (4). Improving Macrocirculation central venous access cannot be ob. Cen. power injection capability are among some of the most recent developments in trition can reduce the need for parenteral ondary markers such as blood pressure. urine output. Elevated lactate.. OTHER SUPPORTIVE in using immune-modulating enteral for- sepsis. independent of whether a line placement (grade 2D). and the immune response may be of a sepsis algorithm. However. preload responsiveness compared to cen. Although central venous pressure trition. Early initiation of en- rates. and pulse contour techniques. All critically ill patients. when compared to par- ever. Consequently.e. direct measurements of stroke volume evolved to nutrition as a therapy in which toring parameters like vital signs remain are made possible by such innovations as the metabolic response to stress may be within normal limits. A. Sec. bacterial growth (e. sertion capability of advanced practice nurses or trained registered nurses. hemodynamic monitoring. a traditional central venous catheter (216). Although the cally type A lactic acidosis. 213). Even though data from the bidity and mortality (218). blood pressure. stroke volume. Because central ing care. Many have been shown to reduce and mortality in severe sepsis (200. has been shown to re- to be inaccurate and slow to change. Crit Care Med 2011 Vol. admission) (grade 2A). Enteral nutrition. Stroke volume optimization has a hypermetabolic state and increased nu- Howell et al (201) indicated lactate would been shown to be a much better metric of tritional requirements. Despite the benefits of enteral nu- (194). 203). nutrition with substances that enhance central venous pressure. enteral nu- key strategy during resuscitation. mea. Improving blood flow is the mucosal atrophy. one could argue that it was the have been shown to improve outcomes in tain eyelid closure (grade 2D).g. clinicians shock when gut perfusion may be com- must be aware of the limitations of treat. promised. clinical decisions regarding fluid man. and antioxidants) in agement because of inability to predict patient with severe sepsis. that changes before ScvO2 is stroke vol- care values. We suggest insertion of a peripher- (200. and and is associated with an increase in mor- blood pressure. it is recognized that the usefulness NURSING CARE mulations (supplemented with agents. an 18% reduction in growing body of literature supports the favorably modulated (219). tral venous pressure accuracy has been found to be similar when compared with duce the risk for infectious complications More direct measures of blood flow. No. We suggest use of stroke volume or tained in patients with severe sepsis Rationale. Caution should also be taken ing right atrial pressure. 206 – Critical illness is often associated with accurate triage tool than vital signs (201). including the omega-3 fatty acids. ally inserted central catheter 1. not improving the risk of infection and therefore may and high correlation also has been shown central venous pressure. 39. 215). We suggest early enteral nutrition (PICC) in the event that subclavian (initiated within 24 to 48 hrs of ICU B. nucleic acid. We suggest and stroke volume variation in sepsis nutrition therapy for the critically ill that point-of-care lactate measurement be (214. How. 201). We suggest daily assessment of the original early goal-directed therapy arti. the ability of peripherally duction has also been found with early. the critically ill is not uncommon (217) ditional monitoring parameters such as tral venous pressure. tion (223). 220 –222) and have been shown to considered to accelerate the clinician’s ciple is clear. Eye Care venous pressure was in both the interven. Although the theoretical prin. for by 30% to 40% (224.

reduce the incidence. changing lateral leukocyte count elevated or decreased for rotation support to a support system with age (not secondary to chemotherapy- C. include: core temperature of ⬎38. vealed that a multitude of pressure ulcer clinical syndrome associated with a high nutrition. problematic and there is little evidence In 2002. with a prevalence rate of 14. tion will allow some reperfusion in normal for age in the absence of external idence that a range of methods reduce patients who cannot tolerate major shifts stimulus. but there is insufficient evi. if there is cular disease or general anesthesia. pants modified the adult SIRS criteria consciousness. We recommend the maintenance of can be avoided. Many criti. tachycardia. or congenital thalmologic examinations using fluores. the incidence Sepsis tends to peak at two primary ment of ICU patients for iatrogenic of pressure ulcers in the critically ill has times in the child’s life and corresponds to ophthalmologic complications and been reported to be between 5. defined as a mean (228 –230). strategies can be used to per 1000 neonates. Although variable. turned regularly. cally ill (233. SIRS is defined as the presence of ing in an increased risk of injury such as surfaces for patients who cannot be at least two of the following conditions. prevention of complications of bed rest petechial or purpural rash. imaging. or otherwise unexplained cein drops and a cobalt blue pen torch Special considerations related to man. hemato- at risk for the development of pressure ⬎4300 deaths annually (244). The role ical examination. or painful stim- the incidence of corneal damage (227. Whereas not all pressure ulcers the neonate stage. neurologic. result. and ⬎10% immature neutrophils (246). mortality of approximately 20%. lateral rotation therapy uli or otherwise unexplained persistent 230 –232). These recommendations dictive validity of risk assessment scales is ond peak is at approximately age 2 yrs. Severe sepsis accounts for (respiratory. the International Pediatric ing those with severe sepsis. (233). 2. or bradycardia. mean respiratory rate ⬎2 stan- genic ophthalmologic complications will patients include: positioning to minimize dard deviations above normal for age or facilitate timely referral to ophthalmol. renal.3 3. large pediatric population and is the most acute respiratory distress syndrome. logic. hepatic) (246). with insuf. apply to all critically ill patients. includ. abrasion. fulminans) (246). 241). of pressure ulcer staging and treatment or proven (by positive culture. proven infection (246). We recommend the implementa. Worldwide. the development of pressure ulcers be. heart disease. The patient with severe sepsis of. vention include: use of special support (246). defined as a mean patient’s ability to maintain eyelid clo. 39. PEDIATRICS ence of or as a result of a suspected or circulation.2% and significant times in the maturity of the prompt referral for suspicion of 20%.. No. may be considered. heart rate ⬎2 standard deviations above have been described and tested. perfora. de. 1810 Crit Care Med 2011 Vol.4% immune system (245). Daily assessment of the quire regular turns and skin assessment age. The incidence while assessing patient tolerance for the ature or leukocyte count. two recent systematic reviews re. probability of infection. and associated definitions for children protective mechanisms of the eye. in body position. elevation over a 30-min to 4-hr time pe- dence to recommend any single method eral rotation therapy will continue to re. Sixty percent of cases eyelid closure for intensive care pa. or polymerase chain reaction test) and treatment bundle including ever. Assessment of risk occur in the first 5 days. skin assessment. Evidence of in- support surfaces (grade 1D). Patients receiving lat. The sec- Rationale. these patients (233). ␤-blocker drugs. Documentation An infection is defined as a suspected 1. or for children older than 1 yr of as being superior. corneal dehydration. ficient evidence to recommend a specific fection includes positive findings on clin- Extensive recommendations for both classification system (240. 234). chest specific recommendations for the criti. tests (e. use of inotropic drugs. it affects a ing: cardiovascular organ dysfunction. with ev. (235). Severe sepsis is creased mobility. inspecting mechanical ventilation for an acute pro- ogy specialists and potentially improve pressure ulcer and surrounding area with cess not related to underlying neuromus- patient outcomes. without rotation (234). age in the absence of external vagal stim- also be trained to perform weekly oph. disturbed sensory per. and infection (227). ster pads may prevent sacral shearing in ulus. Shear injury is a potential conse. gradual turns.5°C or affect up to 60% of intensive care patients modynamic and oxygenation compro. promotion of skin integrity as well as radiograph consistent with pneumonia. stain. riod.g. chronic drugs. (236). how. ulcers. because early detection of iatro. slow. which may impact on the Special considerations related to pre. white blood cells in a normally ulcers have been developed and contain tients also has been advocated for the sterile body fluid. but the pre. Sepsis is defined as SIRS in the pres- cause of increased risks such as impaired VI. may reduce the effect on he. infection caused by any pathogen or a risk assessment. and evidence of shear injury. and underlying disease processes pediatric patients. Pressure Ulcer Prevention improved pressure redistribution. Bol. tissue tion of a pressure ulcer prevention are essential for continuity of care. or purpura Critically ill patients are susceptible to (242). repositioning. agement of pressure areas in severe sepsis period. with an overall tients (grade 1B). heart rate below the tenth percentile for sure should be undertaken. or laboratory the prevention and treatment of pressure of ICU mobilization of critically ill pa. Nurses could quence of lateral rotation therapy. pressure on affected area. factors is one such strategy. A variety of eye care methods mise. more frequent small shifts in posi. every dressing change. 7 . with an incidence of 4. and use of grading scales currently exist. The first peak is in these (grade 2D). perforated viscus. and. We suggest at least weekly assess. for a valid risk assessment tool in the Sepsis Consensus Conference partici- cally ill patients have altered levels of critically ill (237–239). and ten experiences significant hemodynamic common cause of death in infants and two or more other organ dysfunctions compromise and therefore is particularly children (243). microclimate control. Sepsis remains an urgent issue among defined as sepsis plus one of the follow- ception. one of which must be abnormal temper- tion. ⬍36°C. persistent depression over a 30-min time (231). The conditions of corneal abrasion varies widely but may procedure. shear induced leukopenia) or the presence of and Management reduction.

standard infu. as identified a summary of the pharmacologic therapy difference.5 Vasoconstriction 1Myocardial oxygen consumption Inotropy Dysrhythmias Chronotropy 2Renal blood flow Dobutamine ␤1 5–20 Inotropy Tachycardia Dysrhythmia Vasodilatation Hypotension Sodium nitroprusside NA 0. Steroids major determinant of oxygen consump. the child with catecholamine-resistant luses of 20 mL/kg of isotonic saline tions observed.3– 6. as identified in netics and the pharmacodynamics of the child’s response to the drug. We suggest hydrocortisone therapy extraction. Fluid Resuscitation and function of the liver and kidney are Rationale. There are developmental differences B. resistance. because septic shock is a dynamic pro- tion in children as opposed to oxygen cess. We suggest intravascular volume sepsis. adrenal insufficiency in the Crit Care Med 2011 Vol. 1. As much as 200 mL/kg may tropes.2–20 Vasodilatation (venous) 2Pulmonary vascular resistance 1Intracranial pressure Amrinone NA 5–10 (load with up to Inotropy Dysrhythmias 3 mg/kg over 20 min) Vasodilatation 2Pulmonary vascular resistance Thrombocytopenia Milrinone NA 0. Therefore. Fluid replacement should be states (248). directed toward perfusion. Dobutamine may be useful for pe. systemic vascular These findings suggest both that neu- pressure. Management requires individual titration at the bedside. For ongoing therapy. 1. and urine output in children roendocrine deficiency is common in pe- tion of end-diastolic volume. central venous mean arterial pressure. No. Occasion- children when compared to adults.0 (load with 75 ␮g/kg over 20 min) a Difficult to predict the dose-response effect. pulmonary with vasodilatory septic shock and lack of diatric sepsis and that many neurohor- capillary wedge pressure/end-diastolic response to catecholamines. including adrenal insuffi- be administered in the first hour of re. shock (250). A. but its use is generally reserved for expansion is achieved with fluid bo. In addition. renal insufficiency.0 2C). A recent study examined guidelines (4) (grade 2C).75–1. so the therapeutic end point sion dose may require adjustment over may be generally reserved for the of an oxygen consumption of ⬎200 mL/ time. and found a markedly higher in- suscitation. as identified in the SSC sion doses may need to be adjusted. shock and suspected or proven adrenal or colloids. monal responses may be affected (249). the use of ino. differ. reaching a therapeutic end in the SSC guidelines (4) (grade used in the treatment of pediatric septic point of a cardiac index of 3. causing changes in the medication sis. the safety and effectiveness of vasopressin Generally. vasopressors. However. and vasodilators will in children. Table 6 presents shock (247). the issue of neuroendocrine dysfunction Rationale. We suggest vasopressors/inotropes ally. and cardiac output (247). Vasopressors/Inotropes in children with septic shock have not in the hemodynamic response to sepsis in been well-demonstrated (249).Table 6 Pharmacologic Therapies Used in Septic Shock (250) Drug Site of action Dose (␮g/kg/min) Primary Effecta Secondary Effect Dopamine Dopaminergic 2–5 Increase renal perfusion Dysrhythmia Dopaminergic and ␤1 2–10 Inotropy Chronotropy Increase renal perfusion ␣ 10–20 Vasoconstriction Norepinephrine ␣⬎␤ 2–10 Vasoconstriction 1Myocardial oxygen consumption Inotropy Dysrhythmias 2Renal blood flow Epinephrine ␣ and ␤ 0. Perfusion the SSC guidelines (4) (grade 2C). children alter their hemodynamic crease in cardiac output is associated are implemented if clinical signs of requirements from vasopressor to ino- with mortality in children with septic shock continue despite adequate trope or vice versa (247). Based on this developmental volume replacement. 39. insufficiency. child with catecholamine-resistant min/m2 also may be associated with a shock and suspected or proven ad- gan perfusion as well as the pharmacoki- better outcome (247). Hydrocortisone therapy often changed in the child with severe may be life-saving in the child with sep- 1. An important point to re- (247). volume.05–1. although the average is 40 to diatric patients with low cardiac output cidence of multiple neurohormonal dys- 60 mL/kg. based on the need to maintain or. L/min/m2 may result in better survival Rationale. the medication used and the infu. pharmacokinetics with higher concentra. oxygen delivery is the member about these medications is that C. 7 1811 .5–10 (light sensitive) Vasodilatation (balanced) 2Pulmonary vascular resistance 1Ventilation/perfusion mismatch Cyanide toxicity Nitroglycerin NA 0. ciency. echocardiographic determina. A de. Vasopressin can increase functions in children with sepsis (249).

et three authors. the effects of hypovolemia and cardiac cation of these interventions to the sential that nurses work collaboratively and vascular dysfunction. Crit Care Med remain focused on airway. and blood pressure sessment and support. and use of terminology. and tify the most appropriate nursing inter. including the time specific medications. Cardiac index is augmented by Speed for his review of the document in issue. type and effect of mendations for treatment of shock are 50 for age (247). 1.0 L/min/m2 (255). blood pressure. Phillip Dellinger. Al. 29:1303–1310 comfort by providing analgesia and seda- the evidence that currently exists to un.case of catecholamine-resistant shock is tremities. no differential between ularly needed include recognition of de. type United States approach to strategies in the 1812 Crit Care Med 2011 Vol. com- summarize the evidence from existing re. 32:858 – 873 level of comfort (254). L/min/m2 and ⬍6. and calcium (247). et al: recommendations and the lack of evi. Addressing the child’s This document provides a summary of Care Med 2001. Guerin M. No. There are no data supporting any partments in Australia and New Zealand. 14:888 – 897 suscitation and ongoing treatment. et al: fort measures including appropriate po- search and guidelines and reach consen. and managing sus as to the level of support for nursing guidelines for management of severe sepsis the environment to decrease or eliminate and septic shock: 2008. Monitoring relation to comprehensiveness. Sedation and analgesia are com. oxygen saturation. ANZICS APD Management Commit- tion and decreasing restlessness helps to tee: The outcome of patients with sepsis and derpin the nursing care of the patient preserve oxygen for use by major organs septic shock presenting to emergency de- with severe sepsis. Surviving Sepsis Campaign guidelines for Therapy should be goal-directed using a dence that exists in many areas of care. gentle touch. Therapeutic End Points sensus by the entire author group then and quality of evidence in clinical guide- achieved through e-mail discussion. The goals of pediatric patient with severe sepsis. The first step to initiating nary artery pressure. Research to iden- fection: A systematic review. particularly as it therapy for sedation and analgesia output ⬎1 mL/kg/hr. all authors to raise concerns regarding 129:174 –181 ventions for the pediatric patient grading of recommendations. superior the ongoing care of the severely septic ment of cortisol levels and administration vena cava or mixed venous oxygen satu. a per. includes heart rate. Dellinger RP. Dose recom. much of the work noxious stimuli are essential. care considerations. and reduce oxygen put. The effectiveness of clinical guideline im- (grade 1D). Carlet JM. Abad C: Educational interventions practice or the level of evidence is con- for prevention of healthcare-associated in- goals for the first hour of resuscitation fined to expert opinion. Safdar N. the ICU. multiple areas of nursing tematic review findings. management of severe sepsis and septic validated scale to determine the child’s Whereas a concerted effort was made to shock. and ⬍6. assumed at a random total cortisol level normal mental status and normal glu. it is es. Surviving Sepsis Campaign: International sitioning. cava or mixed venous oxygen saturation Sepsis and Septic Shock. We thank Gordon Nurses play a key role in addressing this ⬎70%. warm ex. 2008. cardiac index ⬎3. tification of new evidence should inform shock and initiate both timely measure. urine output ⬎1 mL/kg/hr. In addition. glucose. supportive care such as nutrition ther- mg/kg. with discussion and con- al: Grading strength of recommendations E. The D.3 resents an ongoing process. Guyatt G. support me. Pittet D: Infection control in include a capillary refill time ⬍2 secs. ARISE. Prior M. Levy MM. including hy. J Eval Clin Pract have been established for both initial re. Dellinger RP. drugs and Crit Care Resusc 2007. increasing preload (247). terioration and diagnosis of sepsis. out- come. Jarvis WR: The Lowbury Lecture. late to the document. Baumann MH. as such. plementation strategies—A synthesis of sys- Rationale. 9. flow. 9:8 –18 and resources available to develop these dosages are based on the child’s response. urgently required. The 7. cardiac output. Sedation/Analgesia therapeutic end points are a capillary ACKNOWLEDGMENTS refill time ⬍2 secs. Crit Care Med 2004. et iologic causes of agitation. pressure ulcer prevention and man- 24-hr infusion (248. though this provided an opportunity for Chest Physicians task force. ration of ⬎70%. Linde-Zwirble WT.3 L/min/m2 ment of the Surviving Sepsis Campaign Rationale. during the central pulses. Pain causes energy expen. Carlet JM. warm extremities. mouth and eye care. 36:296 –327 was undertaken by small groups of two to 5. and effect of early resuscitative measures. cose.0 L/min/m2. and cerebral CONCLUSION United States: Analysis of incidence. Crit Care Med 2008. MD. ble by e-mail. ionized calcium. Masur H. fusion pressure normal for age. Iden- to recognize the presence of refractory stabilization are: normal perfusion. central venous pressure. 251). patient and. Chest 2006. Gutterman D. and cardiac index ⬎3. urine inception of this project. normal mental related to his experience with the develop- (grade 2D). 3. Areas that are partic. 120:2059 –2093 normal pulses. attention is required to verify agement. Angus DC. and superior vena Guidelines for the Management of Severe diture and increases oxygen demand. followed by the same dose as a Once the initial resuscitation has apy. 36:933–940 circulation. the depth 6. 7 . Chest 2001. and associated costs of care. pulmo- REFERENCES demand (252). pain. 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