Early recognition and intervention are improving short-term survival of sepsis, however there are many who suffer complications, long after resolution of the primary infection and discharge from the hospital. Post-sepsis syndrome (PSS) occurs in about one-sixth of sepsis survivors and includes both physical and psychological long-term effects (Prescott & Costa, 2018).

What are the Signs and Symptoms of Post-Sepsis Syndrome?

Sepsis survivors have higher readmission rates and an increased risk of myocardial infarction, stroke, and fatal coronary heart disease (Shankar-Hari & Rubenfeld, 2016). The Sepsis Alliance (2021) identifies the following physical and psychological effects of PSS lasting months to years:

Physical Effects

• Difficulty sleeping; fatigue; lethargy 
• Shortness of breath; dyspnea
• Muscle or joint pain; swelling in the limbs
• Repeat infections
• Poor appetite
• Organ dysfunction
• Hair loss; rash

Psychological Effects

• Hallucinations
• Panic attacks
• Flashbacks
• Nightmares
• Decreased cognitive functioning
• Depression; loss of self-esteem
• Mood swings
• Difficulty concentrating; memory loss
• Post-traumatic stress disorder (PTSD)

Who’s at Risk for Post-Sepsis Syndrome?

All patients diagnosed with sepsis are at risk for PSS and the incidence increases with sepsis severity. Older adults and patients with preexisting medical conditions are also at increased risk for PSS. Other conditions associated with poor long-term outcomes include immobility, vision or hearing impairment, frailty, residing in a nursing home, single marital status, and development of delirium during hospitalization (Prescott & Costa, 2018).

How Can the Occurrence of Post-Sepsis Syndrome Be Minimized?

While the most effective method to treat PSS is to prevent sepsis (using primary prevention techniques such as handwashing, vaccinations, and nutrition), managing chronic conditions is also key to decreasing sepsis and PSS risk (Leviner, 2021).

When a patient develops sepsis, treatment with antibiotics is indicated. Stewardship programs are recommended to improve antibiotic use and decrease the risk of future infections. Procalcitonin levels can be used to help providers make decisions on titrating or stopping antibiotics (Prescott & Costa, 2018).

When stress ulcer prevention is indicated, H2-receptor agonists are preferred over proton pump inhibitors (PPI) to minimize the risk of subsequent infections, as PPI have been associated with increased risk for clostridium difficile infection and pneumonia (Prescott & Costa, 2018).

Other recommendations, especially for the highest risk patients in the ICU, include using medications for pain and agitation at the lowest possible doses for the shortest durations. Strategies such as treating pain first in conjunction with routine pain assessments using a validated pain assessment scale; using intermittent rather than continuous medications; using a sedation scale (i.e., Richmond Agitation Sedation Scale, or RASS) to target light levels of continuous sedation; and performing daily awakening trials are suggested. Also, benzodiazepines have been associated with increased risk for delirium, which is associated with worse long-term outcomes. Propofol and dexmedetomidine, both short-acting continuous sedative medications, are preferred over benzodiazepines when continuous sedation is required. (Prescott & Costa, 2018).

Nonpharmacological strategies mirror those that prevent delirium and include:

• Promoting progressive activity and early mobility, including while the patient is in the ICU
• Vision and hearing aids if the patient normally uses them
• Use of adaptive equipment to facilitate independence
• Promote sleep at night and activity during the day

Rehabilitation is associated with decreased 10-year mortality, as well as improved physical functioning and quality of life (Leviner, 2021), so physical and occupational therapy referral and follow-up are key.

These recommendations make it clear that clinicians in most settings play a role in lessening the effects of PSS. In outpatient settings, educating patients on infection prevention and chronic disease management, and recognizing signs and symptoms of PSS, are critical. In the acute care setting, working collaboratively to optimize treatment while minimizing risks and complications is vital as well. PSS awareness and strategies for PSS prevention are key to optimize long-term outcomes after sepsis.

References:

Annane, D., & Sharshar, T. (2015). Cognitive decline after sepsis. The Lancet. Respiratory medicine, 3(1), 61–69. https://doi.org/10.1016/S2213-2600(14)70246-2

Leviner S. (2021). Post-Sepsis Syndrome. Critical care nursing quarterly, 44(2), 182–186. https://doi.org/10.1097/CNQ.0000000000000352

Prescott, H. C., & Costa, D. K. (2018). Improving Long-Term Outcomes After Sepsis. Critical care clinics, 34(1), 175–188. https://doi.org/10.1016/j.ccc.2017.08.013

Sepsis Alliance (2021, January 21). Post-Sepsis Syndrome. https://www.sepsis.org/sepsis-basics/post-sepsis-syndrome/

Shankar-Hari, M., & Rubenfeld, G. D. (2016). Understanding Long-Term Outcomes Following Sepsis: Implications and Challenges. Current infectious disease reports, 18(11), 37. https://doi.org/10.1007/s11908-016-0544-7