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Course: Oncology Nursing

Topic: Nursing Management of

Oncological Emergency - Septic Shock

The Nurses International Community

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Module Goals

Learners will be able to:

Explain the underlying pathophysiology of septic shock.
Describe the scope of the problem including the incidence, etiology and risk factors for this oncologic emergency.
List the clinical manifestations that are associated with this emergency situation.
Explain the nursing assessment for septic shock including relevant diagnostic tests.
Characterize the nursing interventions and supportive care important to address this problem in a timely and effective manner.

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Sepsis

Kochanek et al, (2019)
Canadian Cancer Society, n.d., Septic Shock
McClelland & Moxon (2014)

Widespread infection in the blood causes sepsis².
Leading cause of death in neutropenic cancer patients¹.
It is a medical emergency that needs immediate management^1,2,3.
Life-threatening organ dysfunction can occur and is caused by a poor response to infection¹.
Nurses play a vital role in identifying patients with sepsis and starting essential treatment³.

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Sepsis:

Some of the causes¹:

Leukemia
Prior Antibiotic/Chemotherapy
Prolonged hospital stay
Prior surgery
Advanced disease
Delay of ICU admission

Sign/symptoms²:

Fever
Rapid heart beat
Hypotension (Low BP)
Hyperventilation (High RR)
Confusion or delirium
Redness/soreness
Shaking
Skin rash
Decreased urine output
Diarrhea /vomiting

Kochanek et al, (2019)
John Hopkins Medicine, n.d., Sepsis

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Sepsis: Early Identification is Key

Sequential Organ Failure Assessment (SOFA):

Assess severity of organ dysfunction
Scores used to clinically characterize septic patient
Score of ≥2 points indicates organ dysfunction consequent to infection

Suspected or documented infection and an acute increase of ≥2 SOFA points is clinical criteria for sepsis (International Classification of Diseases Coding clinical criteria 2015 as cited in Singer et al 2016)

Singer et al (2016)

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SOFA Criteria

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Sepsis: Early Identification is Key

The Third International Consensus Definitions Task Force recommend using Quick SOFA (qSOFA) criteria as a prompt to consider possible sepsis ¹

qSOFA Criteria:

Respiratory rate ≥22/min (1 point)

Glasgow Coma Scale <15 (1 point)

Systolic blood pressure ≥100 mm Hg (1 point)

Score ≥2 should prompt:

Further investigation for organ dysfunction (SOFA)
Initiate or escalate therapy as appropriate
Referral to critical care or increase the frequency of monitoring

Singer et al. (2016)

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Singer et al (2016)

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Septic Shock

Singer et al. (2016)

Defined as subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality
A life- threatening condition that needs immediate medical intervention
Criteria:

Sepsis
AND, vasopressor therapy needed to elevate MAP ≥65 mmHg and Lactate >2 mmol/L (18 mg/dL) despite adequate fluid resuscitation

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Sepsis: Diagnostics

Physical exam includes:

Head to toe assessment
Heart rate
Blood Pressure
Respiratory rate
Temperature
Urine output
Glasgow coma scale

Lab tests:

Complete blood count
Blood cultures
Arterial oxygen saturation
Lactate and other blood chemistry tests
Urinalysis and urine culture (for patient with urinary catheter)
Chest x-ray
Electrocardiogram (ECG)

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Sepsis: Initial Management

According to Surviving Sepsis Campaign- Hour-1 Bundle, within first hour of identifying sepsis/septic shock¹:

1st: Quickly measure lactate level in first hour

2nd: Take blood cultures^1,2

3rd: Administer broad-spectrum antibiotics^1,2

4th: Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L^1,2

5th: Apply vasopressors if hypotensive during or after fluid resuscitation to maintain mean arterial pressure ≥ 65 mmHg^1,2

Levy et al (2018)
Rhodes et al. (2017)

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What is the rationale behind taking blood sample before starting the antibiotic therapy in a patient with sepsis/septic shock?

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Sepsis/Septic Shock: Further Management

Peake & Maiden (2016)

Antimicrobial Therapy:

Should be started within 1 hour of identifying sepsis/septic shock
Blood cultures from two sites (vascular access device, catheter etc, if clinically indicated) must be sent before starting antimicrobial therapy
Empirical broad spectrum agents through IV route while waiting for the report

As soon as the causative agent is identified, switch antibiotic regimen to which the causative microorganism is sensitive to

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Sepsis/Septic Shock: Further Management

Hemodynamic Resuscitation:

Sepsis can cause inadequate cellular oxygen delivery and/or impaired utilization.
Circulatory disturbance involves decreased preload, myocardial depression, arteriolar dilatation, and peripheral shunting.
Resuscitation should occur where continuous physiological monitoring and close medical/nursing attention is possible.
Principles of resuscitation:

Optimizing preload and afterload
Contractility, heart rate
Hemoglobin concentration and oxygen saturation

Peake & Maiden (2016)

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Sepsis/Septic Shock: Further Management

Cardiovascular Insufficiency

Treated by volume substitution using crystalloid fluids or colloids
Goal is:

Mean arterial pressure (MAP) ≥ 65 mmHg,
Central venous pressure 8–12 mmHg
Pulmonary wedge pressure 12–15 mmHg
Urinary output ≥ 0.5 ml/kg/h
Central venous or mixed venous oxygen saturation ≥ 70%

Volume substitution done under hemodynamic monitoring

Central venous pressure, blood pressure, heart rate, cardiac output, pulmonary wedge pressure and lactate levels

Penack et al. (2011)

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Sepsis/Septic Shock: Further Management

Vasopressors

If blood pressure is not restored after initial fluid resuscitation then vasopressor should be commenced within first hour.
Nor-epinephrine recommended as first-choice vasopressor.
Dopamine as an alternative vasopressor in highly selected patients eg. patients with low risk of tachyarrhythmias.
Low-dose dopamine not recommended for renal protection.
Dobutamine might be given to patients who show evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents.

Rhodes et al. (2017)

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Sepsis/Septic Shock: Further Management

Corticosteroids

Use suggested only if fluid resuscitation and vasopressor are not able to restore hemodynamic stability.

Recommended Hydrocortisone at dose of 200 mg/day.

Blood Products

RBC transfusion suggested only when hemoglobin concentration decreases to <7 g/dL in the absence of extenuating circumstances like myocardial ischemia, severe hypoxemia, or acute hemorrhage^1,2.
Erythropoietin should not be used for treatment of anemia associated with sepsis.

Rhodes et al. (2017)
Kochanek et al (2019)

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Sepsis/Septic Shock: Further Management

Rhodes et al. (2017)

Mechanical Ventilation recommendations

Tidal volume of 6 mL/kg predicted body weight (PBW)
For sepsis-induced acute respiratory syndrome (ARDS)

Tidal volume of 12 mL/kg
Upper limit goal for plateau pressures of 30 cm H₂O over higher plateau pressures
Conservative fluid strategy for patients without evidence of tissue hypoperfusion

Supine position is recommended for patient with sepsis-induced ARDS and a Pao₂/Fio₂ratio < 150

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Sepsis/Septic Shock: Further Management

Rhodes et al. (2017)

Head of bed elevated between 30 and 45 degrees reduce risk for aspiration and VAP development.
Spontaneous breathing trials who are ready for weaning.
Weaning protocol for sepsis-induced respiratory failures who can tolerate weaning.
Continuous or intermittent sedation to be minimized, targeting specific titration end points.

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Sepsis/Septic Shock: Further Management

Glucose Control recommendations:

Protocolized approach to blood glucose management in ICU

Commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL.
Target upper blood glucose level ≤ 180 mg/dL rather than upper upper target level ≤ 110 mg/dL.
Monitor blood glucose values every 1 to 2 hours until glucose values and insulin infusion are stable, then every 4 hours thereafter.

Glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution.

Rhodes et al. (2017)

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Sepsis/Septic Shock: Further Management

Venous Thromboembolism Prophylaxis recommendations:

Vasopressor are risk factor for ICU-acquired Deep Venous Thrombosis (DVT) even more so in sepsis/septic shock patients.
Use Unfractionated heparin (UFH) or low-molecular weight heparin (LMWH) against venous thromboembolism (VTE) in the absence of contraindications to use of these agents.
LMWH preferred to UFH if LMWH not contraindicated.
Mechanical prophylaxis like intermittent pneumatic compression or graduated compression stockings may be used where possible.

Rhodes et al. (2017)

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Sepsis/Septic Shock: Further Management

Rhodes et al. (2017)

Stress Ulcer Prophylaxis recommendations:

Stress ulcer prophylaxis to be given for patients with risk factors of gastrointestinal bleeding (GI).
Use of proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H₂RAs).
Avoid stress ulcer prophylaxis in patients without risk factors of GI bleeding.

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Sepsis/Septic Shock: Further Management

Nutrition recommendations:

Early enteral nutrition feeding in patient who can be fed enterally.

Trophic/hypocaloric or full enteral feeding advanced according to patient tolerance.
Avoid early parenteral nutrition alone or in combination with enteral feeding.

Avoid parenteral nutrition over the first 7 days in whom early enteral feeding is not feasible.

Rather IV glucose recommended.

Avoid omega-3 fatty acids as an immune supplement.
Avoid IV selenium and glutamine to treat sepsis/septic shock.

Rhodes et al. (2017)

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Sepsis/Septic Shock: Further Management

Setting Goals of Care:

Goals of care and prognosis must be discussed with patient as early as possible but no later than 72 hours of ICU admission.

Proactive family care conference to identify advance directives and treatment goals that promote:

Communication and understanding between care team and family.
Family satisfaction, decrease stress/anxiety/depression.
Facilitate end-of-life decision making.
Shorten ICU length of stay for patients who die in ICU.

Rhodes et al. (2017)

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Sepsis/Septic Shock: Further Management

Rhodes et al. (2017)

Continued….

ICU treatment goals must be realistic
Non-beneficial ICU advanced life-prolonging treatment is not consistent with setting goals of care
Provide palliative care in ICU
Provide patient and family centered care:

Early and repeated family conferences reduce family stress and improve consistency in communication
Open flexible visitation
Family presence during clinical rounds, resuscitation,invasive procedures
Attention to cultural and spiritual support

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Take a moment and think……

What is the nurse’s role in care of patient with sepsis/septic shock?

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Nurse’s Role in Sepsis/Septic Shock Management

Nurse are critical in early identification and management of sepsis/septic shock.
Consider implementation of sepsis screening as part of routine nursing care for patient assessments and patient care rounds.
Prompt identification of sepsis.

Monitoring vital signs for elevated heart rate, reduced blood pressure, increased respiratory rate or elevated temperature.
Detecting abnormal vital signs is the first step in early sepsis recognition.

Activate sepsis team/sepsis care protocol including transfer to higher level of care as indicated.

Kleinpell et al (2019)

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Nurse’s Role in Sepsis/Septic Shock Management

Provide sepsis treatment measures

Maintain asepsis while performing invasive procedure like IV access, medication administration.
Obtain blood cultures prior to administering antibiotics whenever possible.

Two sets of blood cultures: aerobic and anaerobic, if doing so results in no substantial delay to start antibiotic therapy.

Provide antibiotics as ordered.
Provide fluid resuscitation as outlined in the guidelines and directed by institutional protocol.

Kleinpell et al (2019)

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Nurse’s Role in Sepsis/Septic Shock Management

Fluid resuscitation of up to 30 mL/kg of IV crystalloids within the first 3 hours,
In septic shock requiring vasopressors target MAP of 65 mmHg
Monitor lactate levels that guide fluid resuscitation

Manage altered perfusion and shock

Monitor and report alterations in perfusion including decreasing urine output, altered skin perfusion, mental status changes, and changes in other perfusion metrics
Monitor lactate levels as directed by institutional protocols and as ordered
Assess and report response to sepsis care treatment

Kleinpell et al (2019)

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Nurse’s Role in Sepsis/Septic Shock Management

Be aware of and promote awareness/implementation of international sepsis guidelines

Disseminate information on international guidelines
Include discussion of international guideline during clinical care meetings/clinical rounds

Take quality improvement initiatives

Support and champion quality improvement initiatives aimed at improving sepsis care
Using international guidelines, identify gaps in care and specific areas for improvement

Kleinpell et al (2019)

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Nurse’s Role in Sepsis/Septic Shock Management

Advocate for patient- and family-centered care to improve sepsis care outcomes

Promote patient and family awareness of sepsis
Address needs for families

Holding family care conferences to discuss goals of care
Timely communication of patients treatments and condition
Spiritual and cultural needs

Adhere to recommendations regarding healthcare-associated infection prevention

Kleinpell et al (2019)

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References:

Canadian Cancer Society, n.d., Septic shock. Retrieved from https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/septic-shock/?region=on

John Hopkins Medicine, n.d., Sepsis.. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/sepsis

Kleinpell R., Blot S., Boulanger C., Fulbrook P., & Blackwood B. (2019). International critical care nursing considerations and quality indicators for the 2017 surviving sepsis campaign guidelines. Intensive care medicine, 45(11), 1663–1666. Retrieved from https://doi.org/10.1007/s00134-019-05780-1

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References:

Kochanek, M., Schalk, E., von Bergwelt-Baildon, M., Buetel, G., Buchheidt, D., Hentrich, M., Henze, L., Kiehl, M., Liebregts, T., von Lilienfeld-Toal, M., Classen, A., Mellinghoff, S., Penack, Ol, Piepel, C., & Boll, B. (2019). Management of sepsis in neutropenic cancer patients : 2018 guidelines from the Infectious Diseases Working Party (AGIHO) and Intensive Care Working Party (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO). Annals of Hematology, 98 (5): 1051 -1069. Retrieved from https://link.springer.com/article/10.1007/s00277-019-03622-0

Levy, M.M., Evans, L.E. & Rhodes, A. (2018). The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med, 44, 925–928. Retrieved from https://doi.org/10.1007/s00134-018-5085-0

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References:

Peake S.L. & Maiden M.J. (2016). Management of septic shock in the critically ill. Webb A., Angus D., Finfer S., Gattinoni L., & Singer M. (Eds.) Oxford Textbook of Critical Care (2nd ed., pp.1420-1424). Oxford University Press. Retrieved from: https://oxfordmedicine.com/view/10.1093/med/9780199600830.001.0001/med-9780199600830-chapter-298

Penack O., Buchheit D., Christopeit M., von Lilienfeld-Toel M., Massenkeil G., Salwender H., Hentrich M., Wolf H.H., & Ostermann H. (2011). Management of sepsis in neutropenic patients: guidelines from the infectious diseases working party of the German Society of Hematology and Oncology. Annals of Oncology, 22 (5): 1019-1029. Retrieved from: https://www.annalsofoncology.org/article/S0923-7534(19)38507-2/fulltext#articleInformation

Contact info: info@nursesinternational.org

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References:

Rhodes A., Evans L., Alhazzani W., Levy M., Antonelli M. et al (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45 (3): 486-552. Retrieved from: https://journals.lww.com/ccmjournal/Fulltext/2017/03000/Surviving_Sepsis_Campaign___International.15.aspx

Singer M, Deutschman CS, Seymour CW, et al. (2016).The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8):801–810. Retrieved from: https://jamanetwork.com/journals/jama/fullarticle/2492881

Contact info: info@nursesinternational.org

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References:

Zhang M, Yin F, Chen B, Li YP, Yan LN, Wen TF, et al. (2012) Pretransplant Prediction of Posttransplant Survival for Liver Recipients with Benign End-Stage Liver Diseases: A Nonlinear Model. PLoS ONE, 7(3): e31256. Retrieved from: https://doi.org/10.1371/journal.pone.0031256

Contact info: info@nursesinternational.org

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