Post-Sepsis Syndrome: Critical Care Nursing Quarterly

Post–Sepsis Syndrome : Critical Care Nursing Quarterly 05/09/23, 10:08
Post–Sepsis Syndrome : Critical Care Nursing

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April/June 2021 - Volume 44 - Issue 2
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Original Articles
Post–Sepsis Syndrome
Leviner, Sherry PhD, RN, CEN, FNP-C
Author Information
Fayetteville State University, Fayetteville, North Carolina.
Correspondence: Sherry Leviner, PhD, RN, CEN, FNP-C, Fayetteville State University, 1200 Murchison Rd,
Fayetteville, NC 28301 (sleviner@uncfsu.edu).
The author has disclosed that she has no significant relationships with, or financial interest in, any commercial
companies pertaining to this article.
Critical Care Nursing Quarterly 44(2):p 182-186, April/June 2021. | DOI: 10.1097/CNQ.0000000000000352
Metrics
Abstract
Sepsis is both common and costly. Successful implementation of guidelines in the acute care setting has decreased
mortality and increased the number of sepsis survivors. However, patients returning to the community continue to
experience complications related to sepsis and many are poorly prepared to manage these long-term complications.
These long-term complications are collectively referred to as post–sepsis syndrome. The purpose of this review is to
increase knowledge about post–sepsis syndrome and to compare post–sepsis syndrome with post–intensive care unit
syndrome.
BACTERIAL, VIRAL, and fungal pathogens are common causes of infections requiring health care intervention. A
subset of patients with these infections will progress to sepsis. Risk factors for sepsis include the following:
advanced age 65 years and more, African American race, male gender, immunosuppression, and cancer.1,2 Sepsis is
a syndrome marked by a “dysregulated host response...” and “...organ dysfunction” precipitated by infection.3 It is
the body's uncontrolled response to pathogens that distinguishes sepsis from infection.3 According to the 2015
National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP),4 Agency for Healthcare Research
and Quality, sepsis is the most common diagnosis for inpatient hospital admission, excluding maternal/neonatal
stays.
The incidence of sepsis is increasing and this can be attributed to the aging population, immunosuppression,
multidrug-resistant infections, and improved detection.2,3,5–7 While the incidence of sepsis has increased, in-hospital
mortality has decreased.1,3,8 This decrease in mortality can be ascribed to better detection7 and the implementation
of evidence-based guidelines established by the Surviving Sepsis Campaign.9,10 These guidelines provide clinicians
with a clear understanding of what steps need to be taken within a particular time frame to provide the best outcomes
for the hospitalized patient with sepsis.11
Sepsis is costly to treat; $24 billion was spent on the inpatient treatment of sepsis in 2013.7 However, inpatient care
for the index admission accounts for only 30% of the total cost associated with treatment.12 Most charges occur after
discharge and are associated with ongoing treatment and readmission.12 In the Medicare population, sepsis has the
second highest 30-day readmission rates.5 Approximately 40% of older sepsis survivors are readmitted within 90
days following the index admission13 and 60% are readmitted within a year.14 The risk of readmission is
independent of sepsis severity.15 The most common reason for readmission is infection.13,15 Heart failure
exacerbation, acute renal failure, chronic obstructive pulmonary disease exacerbation, and aspiration pneumonia are
additional reasons for readmission.13,14 Patients who require readmission after treatment of sepsis experience worse
outcomes as evidenced by higher mortality, skilled care facility placement, and hospice placement compared with
nonsepsis readmissions.15
The pathophysiology associated with sepsis increases the risk for cognitive impairment and functional disabilities,
particularly in older patients,13 and increases the likelihood that sepsis survivors will require assistance following
discharge.16 Not only is sepsis survivorship associated with an increased risk for cognitive and functional
impairments but it is also associated with a faster rate of acquiring future impairments.17 Approximately 25% of
older sepsis survivors are discharged to a post–acute care facility.13
Implementation of the Surviving Sepsis Campaign guidelines has improved the short-term survival of patients
diagnosed with bacterial sepsis.8 Despite these improved acute care outcomes, many survivors of sepsis experience
poor long-term outcomes,8,18 and there are no guidelines directing care in the posthospital period. Post–sepsis
syndrome (PSS) is terminology that has been used with increasing frequency to describe the long-term effects of
sepsis. The purpose of this article is to provide a review of PSS, identify patients at greatest risk for developing PSS,
and identify interventions to mitigate PSS. Finally, post–intensive care unit (ICU) syndrome is reviewed and
compared with PSS.
POST–SEPSIS SYNDROME DEFINED

Patients are discharged when their infection has resolved; however, survivors of sepsis continue to experience effects
related to their sepsis diagnosis long after discharge. PSS refers to the collection of physical and psychological long-
term effects patients experience following diagnosis and treatment of sepsis.5,12,16,19 Approximately one-sixth of
sepsis survivors will experience the long-term effects of sepsis.13 Symptoms may include “insomnia, hallucinations,
disabling muscle and joint pains, extreme fatigue, poor concentration, decreased cognitive functioning, and loss of
self-esteem.”12(p932) Sexual dysfunction, while less commonly discussed, is also experienced by sepsis survivors.16
Mental health is also affected after sepsis; survivors have higher rates of “anxiety, depression, and posttraumatic
stress disorder.”13(p2) These physical and psychological long-term effects of sepsis last up to 8 years in some
survivors and impact the ability to perform normal activities of daily living.5,17
Sepsis survivors have poor long-term outcomes. As mentioned earlier, most sepsis survivors are readmitted;
readmission rates among sepsis survivors are higher than readmission rates in other groups.14,15 Sepsis survivors
have an increased risk of cardiovascular disease such as myocardial infarction, stroke, and fatal coronary heart
disease.14 They also experience higher mortality up to 10 years posthospitalization.14 While quality of life (QOL) in
sepsis survivors is decreased compared with the general population, it is comparable with QOL experienced by other
survivors of critical illness.14
Risk factors for PSS

Nurses should be aware of the poor long-term outcomes associated with sepsis and realize that all patients diagnosed
with sepsis are at risk for PSS. However, certain patients are at increased risk. The incidence of PSS increases with
sepsis severity; patients diagnosed with severe sepsis have a higher incidence of PSS.5(p8) Elderly patients and
patients with preexisting medical conditions are also at increased risk for PSS.13,20 Vision and hearing impairments,
because of their association with delirium, are associated with increased disability following an episode of
sepsis.13,21 Other conditions that are associated with poor long-term outcomes and increased risk of PSS include the
following: immobility, frailty, residing in a nursing home, single marital status, and development of delirium during
hospitalization.13
Interventions
The long-term effects of sepsis persist up to 8 years17 and are associated with significant personal and financial costs.
The most effective method for the treatment of PSS is the prevention of sepsis. Primary prevention techniques
include handwashing and vaccinations. Managing chronic conditions such as diabetes, immunodeficiency, chronic
lung disease, obesity, and chronic edema (associated with venous insufficiency, congestive heart failure, hepatic
disease, and nephrotic syndrome)22 decrease the risk of developing sepsis and PSS.23 Patients have an important role
in chronic disease management, a role that nurses must prepare them for by serving as a coach, clinician, gatekeeper,
and educator.24 When sepsis does occur, it is important to implement treatment quickly to prevent the development
of PSS. Pharmacological and nonpharmacological strategies aimed at preventing the development of PSS are
discussed as follows.
Pharmacological strategies
Patients with sepsis are at an increased risk for future episodes of infection.14 Antibiotics are essential in the
management of sepsis and prevention of PSS. While antibiotics are necessary for the elimination of infection, they
can also disrupt the microbiome and lead to an increased risk of sepsis in the future. Antibiotic stewardship programs
improve the use of antibiotics and decrease the risk of future infections.10,13,25 Nurses have an important role in
medication review and initiating discussion with providers pertaining to the use of antibiotics.25 Procalcitonin levels
are a relatively new tool used to assist clinicians in making the decision to de-escalate and stop antibiotics.13
Proton pump inhibitors (PPIs) are another class of medications that are known to disrupt the microbiome13 by
altering pH in the stomach. They are frequently administered in the acute care setting to prevent stress ulcers. When
it is deemed clinically necessary to prevent stress ulcers, H2-receptor agonists are preferred over PPIs.13
Functional and cognitive decline is commonly experienced by sepsis survivors. Prevention of these conditions
should begin while patients are in the ICU. Focusing on early mobility and using medications for the shortest
duration and at the lowest dose possible are associated with decreased incidence of PSS.13 Avoiding hypoglycemia
and preventing rapid alterations in blood glucose levels are important to prevent long-term cognitive impairment.23
Nonpharmacological strategies
Education of nurses, who are the frontline care providers, on evidence-based practice and their role in patient
outcomes related to the treatment of sepsis is needed on a continual basis. Patients and their families also need
education on sepsis survivorship, what to expect after discharge, and where to go for help.13 A survey of sepsis
survivors revealed that a great number of survivors are dissatisfied with support services and education following a
sepsis diagnosis.16
Vision and hearing aids, when needed, reduce the incidence of delirium.21 All patients should be screened for these
impairments in the ICU and vision aids, such as glasses and magnifying glasses, should be kept on the unit. Adaptive
equipment, such as large-print materials and fluorescent tape on call bells, can also assist vision-impaired patients.21
More than half of patients with severe sepsis experience disability.20 Rehabilitation is associated with decreased 10-
year mortality risk,26 improved physical functioning,13 and improved QOL.16 However, many sepsis survivors do
not receive referral to rehabilitation. Nurses have a key role in discussing this option with providers and discharge
planners to determine whether patients are appropriate for rehabilitation.
POST–SEPSIS SYNDROME VERSUS POST–INTENSIVE CARE

UNIT SYNDROME
Post-intensive care unit (PICS) is defined as “new or worsening impairment in physical, cognitive, or mental health
status” arising and persisting after hospitalization for critical illness.27(p90) Patients who have experienced critical
illness, including sepsis, are at risk for PICS. The presentation of PICS and PSS is similar; however, PSS is used to
describe the long-term complications associated with sepsis and PICS refers to long-term complications in any
patient with critical illness.28
Approximately one- to three-fourths of ICU survivors will exhibit some form of physical, cognitive, or mental health
impairment.27 These symptoms can persist for several years following the initial critical illness.27 The risk factors
and interventions for PSS and PICS overlap, and the ABCDE bundle is an important tool to prevent and manage
impairments in both syndromes.27
All patients experiencing critical illness need to be screened for impairments in cognitive, physical, and mental
health functioning prior to discharge. Solverson et al29 conducted a study to examine muscle strength and physical
functioning using handheld dynamometry and the 6-minute walk test. They discovered that performance on the 6-
minute walk test was associated with physical functioning, health-related QOL, and mental health.29 It is possible
that the 6-minute walk test may be a low-cost screening tool to identify patients who would benefit from additional
services following discharge.
CONCLUSION
Advances in the identification and treatment of sepsis have decreased mortality in the acute phase of sepsis, resulting
in an increased number of sepsis survivors. These sepsis survivors are often unprepared to deal with the long-term
complications of sepsis, which are collectively known as PSS. Nurses are an important link in improving long-term
outcomes among sepsis survivors. Prevention, education, and screening are 3 approaches that nurses can use to
improve long-term outcomes in sepsis survivors.
Preventing sepsis is the most effective method for decreasing the risk for PSS. Educating patients on proper
handwashing techniques and encouraging them to receive preventative vaccines are key to preventing infection and
sepsis. Patients with chronic conditions also need education on how to self-manage their condition, and nurses
should take the lead in providing this education.
When sepsis does occur, nurses must provide anticipatory guidance to patients and their caregivers, so they know
what to expect during the acute phase of their treatment. Nurses need to also provide information about sepsis
survivorship, what to expect after discharge, and where to go for help following discharge. Sepsis survivors and their
caregivers need to know which resources are available and how to access those resources after discharge.
Screening for impairments in cognitive, physical, and mental health functioning prior to discharge will help identify
which patients should be referred to rehabilitation. Nurses can be advocates for rehabilitation referral of sepsis
survivors, which has been proven to decrease 10-year mortality risk, improve physical functioning, and improve
QOL.
The incidence of long-term complications associated with sepsis is predicted to increase due to the increased
incidence of sepsis and decreased acute-phase mortality. Sepsis and its long-term complications are costly to treat,
and they have an impact on QOL for both the sepsis survivor and their caregivers. Nurses are in a unique position to
have a positive impact on health care cost and patient outcomes.
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Keywords:
complications; post–sepsis syndrome; sepsis; survivors
© 2021 Wolters Kluwer Health, Inc. All rights reserved.

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Post–Sepsis Syndrome : Critical Care Nursing Quarterly 05/09/23, 10:08

Post–Sepsis Syndrome : Critical Care Nursing

Articles & Issues

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Fayetteville State University, Fayetteville, North Carolina.

POST–SEPSIS SYNDROME DEFINED

Risk factors for PSS

POST–SEPSIS SYNDROME VERSUS POST–INTENSIVE CARE

complications; post–sepsis syndrome; sepsis; survivors

© 2021 Wolters Kluwer Health, Inc. All rights reserved.

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