Reviewed and updated by Megan Doble, DNP, CRNP, FNP-C, AGACNP-C: April 22, 2024

Sepsis is a life-threatening, medical emergency affecting approximately one million persons annually in the United States (NIH, 2023). Patients hospitalized with sepsis are eight times more likely to die during hospitalization (Hall et al., 2011). Early identification and treatment are the cornerstones of sepsis management. As nurses, we are in a position to directly impact sepsis-related morbidity and mortality. We are on the frontline in the care of the hospitalized patient. Being cognizant of the subtle clinical changes indicative of impending clinical decline is critical for timely interventions and avoidance of poor clinical outcomes. 

In 2016, “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” was published (Singer et al., 2016). As nurses, there are several key points from this publication that we should be familiar with. First, the terminology related to sepsis has changed, but the basis of the definition of sepsis has not. Sepsis is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection;” the term severe sepsis has been eliminated; and septic shock is defined as a “subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities are profound enough to substantially increase mortality” (Singer et al., 2016). Clinically, those in septic shock have been given the standard fluid resuscitation (30 mL/kg) with refractory hypotension/hypoperfusion requiring vasoactive medications to maintain a mean arterial pressure (MAP) greater than 65 mmHg. Furthermore, Systemic Inflammatory Response Syndrome (SIRS) is no longer part of “sepsis” terminology. Previously, sepsis was considered SIRS with an infectious etiology.

As with many medical conditions that we see on a regular basis, there are continual advances in the understanding of the disease, both from a medical and scientific perspective. With these advances come changes to best practice recommendations. It is essential that nurses stay well-informed of these developments. The latest update to the Surviving Sepsis Campaign’s International Guidelines for Management of Sepsis and Septic Shock was released in 2021 (Evans et al., 2021). Below is a summary of recommendations based on the most recent literature on sepsis with a focus on what is most pertinent to our practice as nurses.

Tips for nurses taking care of patients with sepsis (Evans et al., 2021; SSC, 2019)

Recommendation: Sepsis and septic shock are medical emergencies, treatment and resuscitation should begin immediately.

Recommendation: For patients with sepsis-induced hypoperfusion or septic shock administer at least 30 mL/kg of intravenous (IV) crystalloid fluid within the first 3 hours of resuscitation.

• Tip: Crystalloids refer to IV fluids with a balanced electrolyte composition, such as normal saline or lactated ringers solution (as opposed to colloids, such as albumin or hetastarch).
• Tip: This initial fluid bolus is often referred to as a fluid challenge.
• Tip: In those patients diagnosed with sepsis, the nurse plays a critical role in monitoring appropriate administration of fluids as the patient transitions between levels of care (i.e., emergency department [ED] to floor; floor to intensive care unit [ICU]).

Recommendation: Measure lactate level; if elevated (greater than 2 mmol/L), ensure that a repeat level is obtained within 2-4 hours. In patients with sepsis or septic shock, resuscitation should be guided to decrease serum lactate in patients with elevated lactate levels.

• Tip: Lactate (or lactic acid) is a byproduct of glycolysis in anaerobic metabolism.
• Tip: In the septic patient, think of elevated lactate as a sign of tissue hypoperfusion.

Recommendation: Obtain two or more sets of blood cultures prior to the administration of antibiotics; at least one set should be peripheral, the other from a vascular access device, if present.

• Tip: Bacteremia is common in patients with sepsis; collecting cultures prior to administration of antibiotics gives us the best chance of identifying the correct organism before antibiotics have a chance to affect the growth of pathogens.
• Tip: A “set” of blood cultures is collected in 2 separate bottles, one anaerobic culture bottle and one aerobic culture bottle.

Recommendation: Administer broad-spectrum antibiotics (covering gram-positive and gram-negative organisms) within one hour of diagnosis or in those with high clinical suspicion for sepsis or septic shock.

• Tip: Controlling the source of infection, either with antibiotics or intervention for those infections amenable (wound drainage, debridement, removal of potentially infected device, cholecystectomy), is the foundation of treating patients with sepsis or septic shock.
• Tip: Failure to control the source of infection could lead to persisting or worsening sepsis or septic shock and the inability to stabilize your patient.
• Tip: If a patient is not getting better, think “Do we have adequate source control?”

Recommendation: Administer vasoactive medications if a patient remains hypotensive or if lactate remains elevated following initial fluid resuscitation. Vasoactive medications should be titrated to a mean arterial pressure (MAP) greater than 65 mmHg.

• Tip: Norepinephrine (Levophed) is typically the first vasopressor that is initiated. This is typically started at 2-5 mcg/min and titrated to a MAP greater than 65 mmHg.
• Tip: The second vasoactive medication added is typically vasopressin at 0.03 U/min or 0.04 U/min. This medication does NOT get titrated and can be added in an attempt to decrease the dose of norepinephrine.

Recommendation: In taking care of a patient with sepsis, it is imperative to reassess hemodynamics, volume status and tissue perfusion regularly.

• Tip: Frequently reassess blood pressure, heart rate, respiratory rate, temperature, urine output, and oxygen saturation.
• Tip: Dynamic measurements such as passive leg raising (PLR) are recommended to assess for fluid responsiveness. PLR mimics endogenous volume expansion (equivalent to a 300 mL fluid bolus) and can be thought of as a preload challenge. It is used to predict if a patient will respond to additional fluid boluses. ​Follow these steps to perform PLR (Mikkelsen et al., 2023):
  • Position the patient in the semi-recumbent position with the head and torso elevated at 45 degrees.
  • Obtain a baseline cardiac output (CO) measurement.
  • Lower the patient's upper body and head to the horizontal position and raise and hold the legs at 45 degrees for one minute.
  • Obtain subsequent CO measurement.
  • The expected response to this maneuver in those that are fluid responsive is a 10% or greater increase in CO. Although not considered a validated measure, blood pressure is often used as a surrogate marker of CO in evaluating response to the PLR.

New Recommendation: The quick Sequential Organ Failure Assessment (qSOFA) score should not be used as a single screening tool for sepsis or septic shock.

• What is the qSOFA?
  • If your patient has 2 of the following criteria, be concerned for sepsis.
    • Respiratory rate greater than 22 breaths/min
    • Altered mental status
    • Systolic blood pressure of 100 mmHg or less
• What’s new?
  • qSOFA was a recommended tool in the 2016 guidelines.
  • Found to be poorly sensitive; may not capture sick patients
  • The Surviving sepsis campaign guideline (Evans et al., 2021):
    • Although the presence of a positive qSOFA should alert the clinician to the possibility of sepsis in all resource settings, given the poor sensitivity of the qSOFA, the panel issued a strong recommendation against its use as a single screening tool.
    • Studies suggest that only 24% of infected patients had a qSOFA score of 2 or 3, but these patients accounted for 70% of poor outcomes (Seymour et al., 2016).
    • The panel concluded that the qSOFA could be used to alert clinicians of the possilbity of sepsis but shouldn’t be used as a single screening tool.

References:
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181–1247. https://doi.org/10.1007/s00134-021-06506-y
 
Hall, M. J., Williams, S. N., DeFrances, C. J., & Golosinskiy, A. (2011). Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS data brief, (62), 1–8.
 
Jones, A. E., Trzeciak, S., & Kline, J. A. (2009). The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Critical care medicine, 37(5), 1649–1654. https://doi.org/10.1097/CCM.0b013e31819def97
 
Mikkelsen, M.E., Gajeski, D.F., & Johnson, N.J. (2023, December 8). Novel tools for hemodynamic monitoring in critically ill patients with shock. UpToDate. https://www.uptodate.com/contents/novel-tools-for-hemodynamic-monitoring-in-critically-ill-patients-with-shock  
 
National Institutes of Health (NIH): National Institute of General Medical Sciences. (2023). Sepsis Fact Sheet. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx.
 
Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., Rubenfeld, G., Kahn, J. M., Shankar-Hari, M., Singer, M., Deutschman, C. S., Escobar, G. J., & Angus, D. C. (2016). Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 762–774. https://doi.org/10.1001/jama.2016.0288

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J. D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C., Martin, G. S., Opal, S. M., Rubenfeld, G. D., van der Poll, T., Vincent, J. L., & Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801–810. https://doi.org/10.1001/jama.2016.0287
 
Surviving Sepsis Campaign (SSC) (2019). SSC Hour-1 Bundle Updated. http://survivingsepsis.org/News/Pages/SCCM-and-ACEP-Release-Joint-Statement-About-the-Surviving-Sepsis-Campaign-Hour-1-Bundle.aspx.

More Resources
Collection	Pocket Card	Guideline Summary
Sepsis Guidelines and Protocols: Providing Care to Patients	Recognizing and Managing Sepsis	Management of Sepsis and Septic Shock in Adults