nursing considerations to complement the surviving sepsis

Special Article

Nursing considerations to complement the Surviving SepsisCampaign 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

Sepsis, including severe sepsisand septic shock, continues tobe a major healthcare probleminternationally. Although mor-

tality related to severe sepsis and septic

shock have reduced slightly in the pastdecade, it remains �20% (1, 2). As part ofthe response to optimize care for thisgroup of patients, evidence-based clini-cal practice guidelines have been pub-

lished by the Surviving Sepsis Cam-paign (SSC) to facilitate clinicians toimprove the outcomes of patients withsepsis and septic shock (3, 4).

Although the SSC guidelines (4) pro-vide a comprehensive review of the med-ical management of patients with sepsisand septic shock, they are frequently si-lent on the nursing care that is essentialfor optimal outcome of these patients.Expert nursing knowledge and skill arerequired for both the identification of thedeteriorating patient as a result of newlydeveloped sepsis and the ongoing imple-mentation of competent care for theknown severe sepsis patient. The WorldFederation of Critical Care Nurses, as thepremier organization for critical carenurses worldwide, consequently formedan international group of interested ex-perts in the area to provide guidance fornursing care of severe sepsis patients.

Objectives: To provide a series of recommendations based onthe best available evidence to guide clinicians providing nursingcare to patients with severe sepsis.

Design: Modified Delphi method involving international expertsand key individuals in subgroup work and electronic-based dis-cussion among the entire group to achieve consensus.

Methods: We used the Surviving Sepsis Campaign guidelinesas a framework to inform the structure and content of theseguidelines. We used the Grades of Recommendation, Assessment,Development, and Evaluation (GRADE) system to rate the qualityof evidence from high (A) to very low (D) and to determine thestrength of recommendations, with grade 1 indicating clear ben-efit in the septic population and grade 2 indicating less confidence inthe benefits in the septic population. In areas without completeagreement between all authors, a process of electronic discussion ofall evidence was undertaken until consensus was reached. Thisprocess was conducted independently of any funding.

Results: Sixty-three recommendations relating to the nursingcare of severe sepsis patients are made. Prevention recommenda-tions relate to education, accountability, surveillance of nosocomial

infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infectionmanagement recommendations related to both control of the infec-tion source and transmission-based precautions. Recommendationsrelated to initial resuscitation include improved recognition of thedeteriorating patient, diagnosis of severe sepsis, seeking furtherassistance, and initiating early resuscitation measures. Importantelements of hemodynamic support relate to improving both tissueoxygenation and macrocirculation. Recommendations related to sup-portive nursing care incorporate aspects of nutrition, mouth and eyecare, and pressure ulcer prevention and management. Pediatricrecommendations relate to the use of antibiotics, steroids, vasopres-sors and inotropes, fluid resuscitation, sedation and analgesia, andthe role of therapeutic end points.

Conclusion: Consensus was reached regarding many aspectsof nursing care of the severe sepsis patient. Despite this, there isan urgent need for further evidence to better inform this area ofcritical care. (Crit Care Med 2011; 39:1800–1818)

KEY WORDS: sepsis; severe sepsis; septic shock; nursing care;guidelines; Surviving Sepsis Campaign

From the Research Centre for Clinical and Commu-nity Practice Innovation (LMA), Griffith University, Nathan,Queensland, Australia; Intensive Care Unit (LMA), PrincessAlexandra Hospital, Woolloongabba, Queensland, Austra-lia; Gold Coast Health Services District (GW), Gold Coast,Queensland; Research Centre for Clinical and CommunityPractice Innovation (GW), Griffith University, Gold Coast,Queensland, Australia; Consultants in Critical Care (MH),Glenbrook, NV; General Internal Medicine and InfectiousDiseases (SB), Ghent University Hospital, Ghent, Belgium;Faculty of Medicine and Health Sciences (SB, SL), Uni-versity Ghent, Ghent, Belgium; Faculty of Healthcare (SB,SL), University College Ghent, Ghent, Belgium: Center forClinical Research & Scholarship (RK), Rush UniversityMedical Center, Chicago, IL; Faculty of Nursing and Mid-wifery (AM), University of Sydney, NSW, Australia; NursingPractice Development Unit (GRB), Princess AlexandraHospital, Woolloongabba, Queensland, Australia; Chil-

dren’s Services (PMH), Sinai Hospital of Baltimore, Balti-more, MD; Patient Safety Programme (WR), NottinghamUniversity Hospitals, UK; Advocate BroMenn Medical Cen-ter (APJ), Normal, IL; KK Women’s and Children’s Hospital(PNL), Singapore; and Barnes-Jewish Hospital (TA), St.Louis, MO.

This project was conducted under the auspices of theWorld Federation of Critical Care Nurses (WFCCN), and nosponsorship or funding was received for this project.

Dr. Blot received honoraria/speaking fees fromCovidien and Cook Critical Care. The remaining authorshave not disclosed any potential conflicts of interest.

For information regarding this article, E-mail:[email protected]

Copyright © 2011 by the Society of Critical CareMedicine and Lippincott Williams & Wilkins

DOI: 10.1097/CCM.0b013e31821867cc

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

This care is provided by every regis-tered nurse, as well as many of the ad-vanced practice nurses (e.g., Nurse Prac-titioner, Clinical Nurse Specialist, orConsultant) who practice in the acutehospital setting. Internationally, ad-vanced practice nursing roles vary inscope, education, and authorization. Al-though the scope and requirements forsome of these roles are designated bylegislation, for example, the scope ofpractice of the nurse practitioner, manyof the roles are professional extensions ofthe registered nurse role. Given this vari-ation in nursing roles from one region orcountry to another, we have not at-tempted to limit the recommendationscontained within this document to careprovided only by registered nurses, buthave extended it to cover the practice ofall nurses, regardless of their specificrole.

Most of these recommendations relateto the adult septic patient, with the ma-jority of interventions not tested in thepediatric patient. Despite this, many ofthe recommendations are likely to be ap-plicable to the pediatric setting.Throughout the document, we have iden-tified where specific information con-firming or denying application to patientsin specific age groups exists. Recommen-dations specific to the pediatric septic pa-tient are contained within a section laterin the article.

Although this article is designed toprovide guidance for every nurse whocares for patients with severe sepsis, wealso have provided recommendations re-garding practice in areas of joint respon-sibility with other members of the health-care team. For example, nursesfrequently influence which central ve-nous catheters or endotracheal tubes arepurchased and used, as well as providecare related to the device after insertion.In addition, although most nurses do notorder drugs, they do participate in proto-col development and often advocate forthe timely ordering and administration ofmedications important to patient out-comes in severe sepsis. Consequently, itis essential that nurses are familiar withthe best available evidence.

Of note, this document is not designedto provide information regarding strate-gies for implementation to ensure prac-tice is based on these recommendations.Rigorous and comprehensive implemen-tation and evaluation strategies are es-sential but constitute a separate body ofknowledge and as such are not reviewed

in this document. Clinicians are encour-aged to become familiar with appropriatestrategies before implementing the recom-mendations outlined throughout this doc-ument. Therefore, the aim of this review isto provide a series of recommendations,based on the best available evidence, toguide clinicians providing nursing care topatients with severe sepsis.

METHODS

Sepsis, including severe sepsis and septicshock, has been well-defined in the literatureand inform these guidelines (Table 1). Theseguidelines for nursing care are designed toaugment, not to replicate or replace, the cur-rent SSC guidelines (4) and have been devel-oped using the following methodology: WorldFederation of Critical Care Nurses formed ateam to develop guidelines for the nursingcare of patients with sepsis; the organizationappointed a coordinator (L.M.A.) and an orga-nizational sponsor (G.W.); known experts inthe field of sepsis care were invited to contrib-ute to the guidelines; authors worked in sub-groups of two or three; whenever possible,

these authors represented different geograph-ical regions of the world; the broad structureof the SSC guidelines (4) was used to informthe structure and content of these guidelinesfor nursing care; an additional section relatingto prevention of infection and subsequent sep-sis was added in recognition of the pivotal rolethat nurses provide in this area; each sub-group of authors undertook searches to locateany published literature that informed thenursing care of patients with severe sepsis;authors searched the literature referred to inthe SSC guidelines (4), with searches expand-ing based on the section topics; analogous tothe SSC guidelines (4), the Grades of Recom-mendation, Assessment, Development, andEvaluation (GRADE) system (5) was used torate the quality of the evidence (Table 2); ini-tial discussion of relevance and quality of theevidence was undertaken electronically withinthe subgroups; all recommendations were re-viewed by the coordinator as well as an inde-pendent reviewer (G.R.B.), and queries werediscussed electronically with the subgroupand then with the entire author team whennecessary; the evidence supporting each rec-ommendation, as outlined in the rationale,

Table 1. Definition of sepsis (4, 137)

Term Definition

Sepsis (also referred to assystemic inflammationin response toinfection)

Infection (documented or suspected) and some of the following:General variables: Fever (�38.3°C), hypothermia (�36°C), heart rate

�90/min or �2 SD above normal value for age, tachypnea, alteredmental state, significant edema or positive fluid balance,hyperglycemia

Inflammatory variables: Leukocytosis (WBC �12,000 �L�1),leucopenia (WBC �4000 �L�1), normal WBC with �10%immature forms, plasma C-reactive protein �2 SD above normal,plasma procalcitonin �2 SD above normal

Hemodynamic variables: Arterial hypotension (SBP � 90 mm Hg,mean arterial pressure �70 mm Hg, or SBP decrease �40 mmHg from baseline or in childrena �2 SD below normal for theirage), saturation of oxygen in venous blood �70%, cardiac index�3.5 l/min/m2

Organ dysfunction variables: Arterial hypoxemia (PaO2/FIO2 �300),acute oliguria (urine output �0.5 mL/kg/hr), creatinine increase�0.5 mg/dL, coagulation abnormalities (international normalizedratio �1.5 or activated partial thromboplastin time �60 secs),ileus (absent bowel sounds), thrombocytopenia (platelet count�100,000 �L�1), hyperbilirubinemia (plasma total bilirubin �4mg/dL or 70 mmol/L)

Tissue perfusion variables: Hyperlactatemia (�1 mmol/L), decreasedcapillary refill or mottling

Severe sepsis Sepsis complicated by organ dysfunctionSeptic shock Acute circulatory failure characterized by persistent arterial

hypotension despite adequate volume resuscitation andunexplained by other causes; hypotension is defined as:

SBP �90 mm Hg or, in children,a �2 SD below normal for theirage, mean arterial pressure �60 mm Hg, or reduction in SBP�40 mm Hg from baseline

SBP, systolic blood pressure; SD, standard deviations; WBC, white blood cells.aSee pediatric considerations section for further clarification of diagnosis in children.

1801Crit Care Med 2011 Vol. 39, No. 7

and the associated level of recommendation,was then forwarded to all authors who con-firmed, or not, their support for each recom-mendation based on the rationale and sum-mary of evidence in line with the GRADEsystem (5); and every recommendation thatdid not receive 100% agreement for the gradeof support was subject to e-mail discussionand exploration of additional evidence untilconsensus by all members of the author teamwas achieved.

This project was conducted under the aus-pices of the World Federation of Critical CareNurses, and no sponsorship or funding was re-ceived for this project. All authors report noconflict of interest with respect to the clinicalrecommendations or consensus-based evidenceratings.

I. INFECTION PREVENTION

A. Education

1. We recommend interactive, multi-faceted, longitudinal educationalprograms and educational outreachto enhance guideline implementa-tion. Traditional education ap-proaches, such as incorporated pas-sive education and informationdissemination through conferences,web sites, and didactic lectures, areoften not effective (grade 1A).

2. We recommend educational initia-tives to reduce healthcare-associ-ated infection rates (grade 1C).

Rationale. Education is generally con-sidered as a first step to increase awarenessof a problem and as crucial for processes ofchange. A systematic review found that in-

teractive, multifaceted, longitudinal educa-tional programs and educational outreachenhance guideline implementation (6).More specifically, a systematic review thatinvestigated the effect of education on thereduction in infection rates concluded thatthe implementation of educational inter-ventions may considerably reduce health-care-associated infections (7).

B. Accountability

1. We suggest the promotion of a cul-ture of patient safety and individualaccountability (grade 2D).

Rationale. Recent trends have seen atransition from accepting healthcare-associated infection as an inevitable out-come of admission to the intensive careunit (ICU) (8) toward personal account-ability and a goal of zero tolerance inrelation to hospital-acquired infections(9, 10). A systematic review of 30 reportsof nosocomial infection found that atleast 20% could be preventable (11). Amajor impediment to achieving zero tol-erance toward hospital-acquired infectionhas been a lack of accountability of alllevels of hospital staff (9). This attitude isshifting, with recognition that hospitalmanagement and every healthcareworker are responsible and accountablefor ensuring patient safety, including in-fection prevention and control (9, 10).Educating and empowering nurses to en-sure infection control guidelines are fol-lowed by all staff has the potential topositively impact on hospital-acquired in-fections (12, 13).

C. Surveillance of NosocomialInfections

1. We recommend a continuous sur-veillance program for the detectionof nosocomial infection (grade 1B).

Rationale. Local surveillance systems(eventually integrated in a national sur-veillance program) allow benchmarkingof nosocomial infection data and there-fore are essential to guide and evaluateinterventions to reduce infection rates.Surveillance systems combined with ap-propriate feedback contribute to reducednosocomial infection risk (14–19).

D. Hand Hygiene

1. We recommend hand antisepsis, ir-respective of the use of gloves, be-tween caring for different patients orbetween different care activities forthe same patient, immediately beforeand after each episode of direct patientcontact, and after any activity or con-tact that potentially results in handsbecoming contaminated (grade 1B).

2. We recommend hand antisepsis bymeans of an alcohol-based handrub (grade 1A).

3. We recommend washing handswith soap and water when handsare visibly soiled (grade 1A).

4. We recommend the use of gloveswhen contact with blood or other po-tentially infectious materials, secre-tions, mucous membranes, and non-intact skin could occur (grade 1D).

Rationale. Adequate hand antisepsishas proven to result in reduced infectionrates (20, 21). The use of alcohol-basedhand rub is particularly effective; in con-trast with hand washing, it kills suscep-tible bacteria more rapidly and to agreater extent, is less time-consuming,and skin health is better preserved whenmoisturizers are added. Hand disinfec-tion after glove removal is necessary be-cause gloves may have imperceptible de-fects or may be torn during use, resultingin contamination of hands. Hand wash-ing is necessary when hands are visiblydirty because alcohol-based hand rub isineffective in the presence of organic ma-terial. However, after hand washing, theuse of alcohol-based hand rub remainsmandatory (20, 21).

As a rule of thumb, a first step towardadequate hand hygiene consists of avoid-ing direct contamination of hands. Theuse of nonsterile, well-fitting gloves is

Table 2. Grade criteria (4, 5)

Strength ofEvidence Quality of Evidence

1 � Strong A: High, e.g., well-conducted randomized control trial2 � Weak B: Moderate, e.g., downgraded randomized control trial or

upgraded observational studiesC: Low, e.g., well-done observational studiesD: Very low, e.g., case series or expert opinion

Factors influencing strength of evidenceMethodologic quality: Poor planning and implementation increasing likelihood of bias is likely to

decrease ratingImportance of outcome: Highly desirable outcomes are likely to increase ratingMagnitude of treatment effect: Relative risk �2 with no plausible confounders is likely to

increase ratingPrecision of estimate of treatment effect: Highly precise results are likely to increase ratingInconsistency of results: Multiple studies with inconsistent results are likely to decrease ratingDirectness of evidence: Indirect evidence (e.g., different populations) is likely to decrease ratingRisks associated with therapy: Significant known risks or burden of therapy are likely to decrease

ratingCosts: Significant costs associated with therapy are likely to decrease rating


recommended whenever the risk of con-tamination exists. Gloves must bechanged between separate tasks on onepatient (when going from a dirty/contam-inated to a clean body site) and in be-tween different patients (20–22).

E. Site-Specific Considerations

Most healthcare-associated infections inthe ICU are related to the use of therapeuticdevices. These include ventilator-associatedpneumonia (VAP), catheter-related blood-stream infection (CR-BSI), surgical site in-fection (SSI), and urinary tract infection(UTI) (23, 24). Recommendations for theirprevention are outlined.

E1. Prevention of RespiratoryInfections

The development of pneumonia in pa-tients mechanically ventilated with an artifi-cial airway may affect 10% to 48% of patients(25–27). VAP is associated with a higher mor-tality rate and significantly longer ICU lengthof stay and hospital costs (24, 27). However,VAP is often preventable, and application ofpractices such as education strategies (28, 29)and ventilator bundles (30, 31) have contrib-uted to a reduction in VAP incidence. Strate-gies to prevent VAP should be considered inall patients with severe sepsis (32).

1. We recommend head-of-bed eleva-tion 30 to 45 degrees for all critically illand mechanically ventilated patients(grade 1B). Special attention should begiven to maneuvers in which it is dif-ficult to achieve a 30-degree head-of-bed elevation, such as during bed bathor changing sheets. In such circum-stances, we recommend back-rest ele-vation of at least 10 degrees should bemaintained.

Rationale. Aspiration of upper airwaysecretions is a common event even innormal healthy adults (33). Semirecum-bent position in mechanically ventilatedpatients has been associated with lowerlevels of aspiration into the lower airways(34–36) and lower VAP incidence thanthe supine position (37–39). In patientsreceiving enteral nutrition, head-of-bedelevation is especially effective in reduc-ing the risk of VAP (37). However, thefeasibility of maintaining head-of-bed el-evation in daily practice has been ques-tioned by some authors (40, 41). VanNieuwenhoven et al (41) achieved averagehead-of-bed elevation of only 28 degreesdespite a target of 45 degrees, whereas

Song et al (40) achieved head-of-bed ele-vation �30 degrees in 43.4% of patients.

2. We recommend the use of an en-dotracheal tube with subglottic se-cretion drainage in patients ex-pected to require mechanicalventilation for �72 hrs (grade 1A).

Rationale. Impaired gag reflex leads topooling of secretions in the posterior partof the oropharynx (42), with microaspira-tion of subglottic secretions leading toVAP. Subglottic secretion drainage is ac-complished through use of a specially de-signed endotracheal or tracheotomy tubewith a separate dorsal lumen that opensdirectly above the endotracheal tube cuff.Subglottic secretions drainage appears tobe effective in preventing VAP (relativerisk, 0.51; 95% confidence interval [95%CI], 0.37–0.71) in patients expected to bemechanically ventilated for �72 hrs (43).

3. We suggest the use of a silver-coated endotracheal tube be con-sidered (grade 2A).

Rationale. In multicenter, random-ized, controlled trials, a silver-coated en-dotracheal tube was demonstrated to re-duce bacterial airway colonization as wellas VAP in patients intubated 24 hrs ormore (44, 45). More studies that confirmthe current findings are required.

4. We suggest the use of an endotra-cheal tube with a polyurethane cuff(grade 2B).

Rationale. In a single-center, random-ized, controlled trial, an endotrachealtube with a polyurethane cuff was shownto significantly reduce early-onset post-operative pneumonia in cardiosurgicalpatients (46). More studies that confirmthis result are required.

5. We recommend endotracheal cuffpressure be maintained at least 20cm H2O, but not �30 cm H2O(grade 1C).

Rationale. Inadequate cuff pressure is arisk factor for microaspiration of oropha-ryngeal secretions and subsequent pneu-monia. One observational study among in-tubated patients not receiving antibiotictherapy showed that a persistent intracuffpressure �20 cm H2O was an independentpredictor of VAP (relative risk, 4.2; 95% CI,1.1–15.9) (47). Cuff pressure should bemaintained at the lowest pressure �20 cmH2O that prevents cuff leak.

6. We suggest heat and moisture ex-changers should be changed be-

tween patients, every 5 to 7 days, oras clinically indicated (grade 2C).

Rationale. Humidification of inspiredair to prevent mucosal injury may beachieved by using a heated humidifier, aheated humidifier with a heated wire cir-cuit, or passively using a heat and mois-ture exchangers. There are insufficientdata to demonstrate a benefit in VAP re-duction for any humidification device(48). No benefit in infection rates or func-tionality of ventilator circuits has beendemonstrated when heat and moistureexchangers are changed every day com-pared to every 5 to 7 days (49, 50).

7. We recommend ventilator circuitsshould not be changed routinely,except between patients (grade 1B).

Rationale. There is no evidence thatroutine ventilator circuit changes can re-duce the incidence of VAP (25, 51). Newventilator circuits should be used for eachpatient, and circuit changes should be per-formed only if the circuit becomes visiblysoiled or damaged (32).

8. We recommend the aspiration ofendotracheal secretions in re-sponse to clinical signs, i.e., visibleor audible signs of respiratory se-cretions, respiratory deterioration,or other changes in the patient’scondition that may be attributableto respiratory secretions in intu-bated patients (grade 1C).

Rationale. Critically ill patients me-chanically ventilated via a tracheal tubefrequently require removal of tracheo-bronchial and upper airway secretions be-cause of increased mucus production anda decreased ability to clear secretions (52,53). Secretion removal may reduce infec-tious, respiratory, and tube patency com-plications (54–56).

Suctioning should only be performedwhen necessary, using the lowest possiblesuction pressure, take no longer than 15secs, and use continuous rather than in-termittent suctioning; the suction cathe-ter should occlude less than half the lu-men of the endotracheal tube and beinserted no further than the carina; hy-peroxygenation should be provided beforeand after suctioning; and saline lavageshould be avoided (55, 57).

The optimum frequency of endotra-cheal suctioning has not been clearly de-termined but should be in response toclinical signs (56). There is insufficientevidence to recommend the benefits of


either an open or closed suctioningsystem (57).

9. We recommend regular mouthcare and oral cavity assessment beprovided to all critically ill and in-tubated patients (grade 1C).

Rationale. Colonization of the oro-pharynx by pathogens is a potential riskfactor for the development of VAP (58–60). Critical illness contributes tochanges in the oral flora, and an increasein Gram-negative flora that includesmore virulent organisms may occur (61,62). Providing regular oral care, incorpo-rating oral cavity assessment, is an im-portant part of providing comfort to thecritically ill patient (63) and is also dem-onstrated to contribute to a decrease inVAP (63–67). Assessment should includethe condition of the teeth, gums, tongue,mucus membranes, and lips, and barriersto mouth care delivery (63). The use of adesignated oral care protocol, in associa-tion with an education program for nursesin its importance in preventing VAP, canincrease compliance and assessment ofmouth care (68).

10. We recommend the use of chlorhexi-dine-based antiseptic for oral care inintubated patients (grade 1A).

Rationale. Chlorhexidine is widelyused and investigated in the oral care ofintubated patients (69 –72). Chlorhexi-dine effectively decontaminates the oro-pharynx (73, 74), and its use in oral carehas been proven to decrease dentalplaque (75) and incidence of respiratoryinfections (76), and to substantially de-crease the incidence of VAP (77–79). Theoptimal concentration of chlorhexidinesolution (0.12%, 0.2%, or 2%) remainsundetermined. The optimum frequencyfor oral care with chlorhexidine has notbeen demonstrated. In general, a fre-quency of three to four times daily isproposed (69, 80, 81). The benefit oftooth brushing in critically ill patients asa component of oral care protocols hasdemonstrated efficacy, but additional re-search is indicated (65, 66). Tap water isnot recommended for oral care in thecritically ill (63).

E2. Prevention of CR-BSI

1. We recommend the implementationof a central line care bundle, includ-ing staff education, creation of acatheter insertion cart, implementa-tion of a checklist to ensure adher-

ence to evidence-based guidelines,empowering nurses to stop catheterinsertion procedures when a guide-line violation is observed, and dailyassessment of possible catheter re-moval (grade 1B).

Rationale. A bundle approach to cen-tral venous catheter (CVC) insertion andcare (12, 13, 82, 83) has proven to beeffective in substantially reducing therate of CR-BSI. Nurses play a key role inpreventing CR-BSI through these activi-ties outlined.

2. We recommend the use of maximalsterile barriers during CVC inser-tion (grade 1A).

Rationale. During the CVC insertionprocedure, all healthcare personnel in-volved must wear a mask, cap, sterilegown, and sterile gloves, and the patientis to be covered with a large sterile drape(84–88). Use of maximal sterile barrierprecautions during CVC insertion haveled to reduced infection rates (87, 89, 90).

3. We recommend the use of a chlo-rhexidine-based antiseptic for skinpreparation before insertion and sub-sequent catheter care (grade 1A).

Rationale. Because the risk of CR-BSIincreases with the density of microorgan-isms at and around the insertion site(21), site antisepsis is crucial in the pre-vention of infection. Aqueous chlorhexi-dine (2%) solution consistently has beenfound to be superior to both 10% povi-done iodine and 70% alcohol for prevent-ing CR-BSI (91–93).

4. We suggest the replacement of ad-ministration sets every 96 hrs(grade 2A), except when used forthe administration of blood, bloodproducts, or lipids, in which casesets must be changed within 24 hrs(grade 1A).

Rationale. A Cochrane systematic re-view found no increase in the risk forCR-BSI when the interval for administra-tion set replacement was increased from72 hrs to 96 hrs (94). When a fluid thatenhances microbial growth is infused(lipid emulsions, blood products), morefrequent changes of administration setsare indicated because these products havebeen identified as independent risk fac-tors for CR-BSI in both adults and neo-nates (95–100).

5. We recommend the use of minocy-clin-rifampin impregnated cathe-ters (grade 1B).

Rationale. Studies have repeatedlydemonstrated a significant reduction inCR-BSI with the use of impregnatedCVCs in comparison with standard cath-eters (101–104); this reduction in infec-tion rates has been greatest with mino-cycline-rifampin– coated CVCs whencompared to other impregnated CVCs(105). Minocycline-rifampin impregnatedCVCs are approved for use in the pediatricpopulation by the Food and Drug Admin-istration (United States); however, stud-ies have not been conducted in children.

E3. Prevention of SSI

1. We recommend that antimicrobialprophylaxis be administered within1 hr before incision to maximizetissue concentration. Two hoursare allowed for the administrationof vancomycin and fluoroquinolo-nes (grade 1A).

Rationale. In 2003, the Surgical Infec-tion Prevention Guideline Writers Work-group meeting reviewed the variousguidelines for antimicrobial prophylaxisin surgery (106). On the basis of pub-lished evidence, the workgroup con-cluded that infusion of the first antimi-crobial dose should begin within 60 minsbefore incision, and when a fluoroquino-lone or vancomycin is indicated the infu-sion should begin within 120 mins beforeincision to prevent antibiotic-associatedreactions (106, 107).

2. We recommend that only hair thatwill interfere with the operation beremoved, and that if hair removal isnecessary, then it should be re-moved by using electric clippers(grade 1B).

Rationale. Although several authorshave reported preoperative hair re-moval is associated with increased SSIrates (108 –111), a Cochrane systematicreview compared a variety of hair re-moval methods (depilatory cream, ra-zors, clippers) vs. no hair removal andreported no difference in SSI ratesamong patients who had hair removalbefore surgery and those who did not(112). The same review found that shav-ing led to statistically significantlymore SSIs compared with clipping ordepilatory cream (112). The increasedinfection risk associated with the tech-nique of shaving is attributed to theformation of microscopic cuts in theskin that later act as foci for bacteria(108). Although the use of depilatories


has been associated with a lower SSIrisk than shaving or clipping (113,114), they can produce hypersensitivityreactions (114).

3. We recommend that blood glucose lev-els be controlled during the immediatepostoperative period for patients un-dergoing cardiac surgery: controlledblood glucose level (�200 mg/dL) onpostoperative day 1 and postoperativeday 2, with procedure day being post-operative day 0 (grade 1C).

Rationale. Increased glucose levels(�200 mg/dL) in the immediate post-operative period (�48 hrs) are associ-ated with increased SSI risk (115, 116).One study found that patients with ablood glucose level �300 mg/dL within48 hrs of surgery had more than three-times the likelihood of a wound infection(117). Regular monitoring of glucose levelsand timely administration of insulin andhyperglycemic agents are direct nursing re-sponsibilities; therefore, nursing educationshould stress the importance of glucosecontrol in preventing SSI.

4. We recommend the identificationand treatment of infections remoteto the surgical site before electivesurgery (grade 1B).

Rationale. Concurrent remote siteinfections are considered to increaseSSI risk (118 –120). Therefore, when-ever possible, all infections remote tothe surgical site should be identifiedand treated before elective operation,and elective operations on patientswith remote site infections should bepostponed until the infection has re-solved (108).

E4. Prevention of UTI

1. We recommend that all attemptsshould be made to limit the dura-tion of urinary catheterization(grade 1C).

Rationale. The urinary tract is the mostprevalent source of nosocomial infectionand there are several recommendations toprevent or reduce the incidence of UTI(121). Duration of catheterization is themost important risk factor for developmentof UTI (121). Postoperative urinary cathe-terization �2 days is associated with anincreased likelihood of UTI and 30-daymortality, as well as a decreased likelihoodof discharge to home (122). Nurses shouldadvocate for prompt removal of urinary

catheters (123) and discourage long-termcatheterization, if possible.

2. We recommend that a sterile, contin-uously closed drainage system bemaintained (grade 1A).

Rationale. Closed urinary drainagesystems are pivotal in preventing UTI (21,123). The risk of infection reduces from97% using open systems to 8% to 15%when sterile closed systems are used(124–126). Errors in maintaining sterileclosed drainage and opening the closeddrainage system have been well-docu-mented to predispose patients to infec-tion (124, 126–129).

3. We recommend regular perinealhygiene measures (grade 1C).

Rationale. Most episodes of UTI arecaused by the patient’s own flora (121).Daily cleansing of the urethral meatususing soap and water or perineal cleanseris recommended (123, 130).

4. We suggest the maintenance of un-obstructed urine flow (grade 2C).

Rationale. Reflux of urine is associatedwith infection; therefore, drainage bagsshould be positioned below the level ofthe bladder at all times to prevent urineback-flow and unobstructed urine flowshould be maintained (21, 131, 132).

II. INFECTION MANAGEMENT

A. Infection Source ControlIssues

1. We recommend prompt removal ofintravascular catheters and subse-quent catheter tip culturing in pa-tients with proven bloodstream in-fection associated with severesepsis as well as in hemodynami-cally unstable patients with sus-pected CR-BSI (grade 1C).

Rationale. Prompt removal of contam-inated invasive devices is a cornerstone inthe management of device-related infec-tion. Failure to remove the catheter wasdemonstrated to be an independent pre-dictor of mortality in an epidemiologicstudy on CR-BSI (odds ratio, 0.22; 95%CI, 0.10–0.86) (133). If the catheter isremoved for suspected CR-BSI, thenguide wire exchange is acceptable in cir-cumstances in which catheter insertion isproblematic because this reduces the riskfor mechanical complications (134). If,however, the catheter tip culture appearsto be positive, the newly inserted catheter

should be replaced a second time becausebacterial contamination can be expectedand guide wire exchange on itself wasshown to be an independent risk factorfor the development of CR-BSI in an ob-servational study (odds ratio, 4.59; 95%CI, 2.28–9.3) (133).

B. Transmission-BasedPrecautions

1. We recommend transmission-based precautions for patients whoare known to be or are suspected tobe infected or colonized with infec-tious agents, including certain ep-idemiologically important patho-gens (grade 1A).

Rationale. Standard precautions are re-quired for all patients. In addition, patientscolonized or infected with epidemiologi-cally important pathogens, including me-thicillin-resistant Staphylococcus aureus;vancomycin-resistant enterococci, glyco-peptide-resistant Staphylococcus aureus,extended-spectrum �-lactamase produc-ing Enterobacteriaceae, multidrug-resis-tant nonfermenting Gram-negative bac-teria, and Clostridium difficile may pose apotential threat to patients in their vicin-ity (135) and require additional precau-tions to prevent cross-infection. Thereare three categories of transmission-based precautions: contact, droplet, andairborne precautions (136). For dis-eases with multiple routes of transmis-sion, more than one transmission-based precautions category may berecommended. Transmission-basedprecaution categories and the particu-lar measures they include are describedin detail elsewhere (136).

III. INITIAL RESUSCITATION

Because the SSC guidelines (4) for ini-tial resuscitation (6-hr resuscitation bun-dle) are operational only from the pointthat severe sepsis/septic shock is diag-nosed, the processes that lead to earlydiagnosis are pivotal. Many of the pro-cesses that support compliance with the6-hr resuscitation bundle such as record-ing and interpreting clinical observa-tions, seeking further assistance, and ini-tiating early resuscitation measures areoften the domain of nurses. The role ofthe nurse in initial resuscitation will varyaccording to the clinical area concerned.On a general ward, nurses will be respon-sible for monitoring clinical observationsand administering antibiotics and fluid


challenges, whereas in a critical care areanurses may be also be involved in moni-toring hemodynamic status and adminis-tering vasoactive agents. The nurse’s rolein initial resuscitation does not end whenmedical staff members arrive on thescene. Successful resuscitation dependson collaborative integration of the skillsand expertise of all members of the mul-tidisciplinary team.

A. Recognizing Deteriorationand Diagnosing Severe Sepsis

1. We recommend that all staff with adirect responsibility for patient care(including nursing assistants andhealthcare assistants) be educated torecognize the Systemic Inflamma-tory Response Syndrome (SIRS) cri-teria and signs of severe sepsis orseptic shock (grade 1C).

Rationale. All staff with a direct re-sponsibility for patient care, includingthe taking of vital signs, must be able torecognize the clinical findings of SIRSand sepsis (Table 3). The definitive diag-nosis of sepsis or severe sepsis in hospitalpatients will often be made by a medicalofficer, but the clinical review leading todiagnosis usually will be facilitated by anurse who recognizes signs and symp-toms indicative of the onset of SIRS orsepsis or both (137).

Nurses therefore play a pivotal role inthe early identification of deterioratingpatients and prompt management of sep-sis to enhance recovery (138). Numerousstudies have demonstrated the relation-ship between nursing and failure-to-rescue (139, 140). The effect on patientoutcomes of providing sepsis educationfor all nurses including nursing assis-tants is inconclusive. A national sepsis

education program in Spain for medicaland nursing staff marginally improvedguideline compliance and hospital mor-tality rates (44.0% vs. 39.7%; p � .04) butdid not demonstrate sustained improve-ment after 1 yr (141). However, a morerecent multi-national performance im-provement study demonstrated sustainedimprovement in both compliance and pa-tient mortality at 2 yrs (142).

2. We recommend the use of earlywarning systems (EWS) to assist inthe early recognition of sepsis topromote prompt treatment to en-able best patient outcomes (grade1C).

3. We suggest the use of sepsisscreening tools to assist in the earlyrecognition of sepsis to promoteprompt treatment to enable bestpatient outcomes (grade 2C).

Rationale. Early diagnosis of sepsis islinked to improved outcomes and sur-vival from sepsis. The recognition of pa-tient deterioration and diagnosis of sepsisrelies on the detection of abnormalities inphysiologic data. The collection and doc-umentation of clinical observations is animportant nursing role (143, 144). De-spite this, there is evidence that clinicalobservations sometimes are performedpoorly or not at all, are not documented,are not interpreted correctly, or are notreported when abnormalities are found(145). EWS, also known as track and trig-ger systems, have been promoted to aidin the detection of deterioration by high-lighting abnormalities in clinical obser-vations (146); however, the evidence oftheir effectiveness is inconclusive (147,148). Additional verification of the useful-ness of EWS is needed to recommendconsistent use in clinical care.

The addition of sepsis screening toolshave been recommended in promotingearly recognition of patients at risk fordevelopment of or those who have SIRScriteria, indicating the early onset of se-vere sepsis (146, 149). Sepsis screeningcan be added to observation charts orEWS charts, prompting nurses to use asepsis screening tool if the patient trig-gers one or more of the SIRS criteria oftemperature, heart rate, and respiratoryrate (149). One study reported a decreasein mortality of one-third after the intro-duction of a three-step sepsis screeningtool (150).

B. Seeking Further Assistance

1. We suggest that communicationtools (e.g., Situation, Background,Assessment, Recommendations[SBAR] and Reason, Story, VitalSigns, Plan [RSVP]) be used to im-prove communication and promoteprompt identification and treat-ment of patients with suspected orconfirmed sepsis (grade 2D).

Rationale. Summoning medical assis-tance is crucial in implementing the re-suscitation bundle, and communicationdelays can result in poorer outcomes forpatients with severe sepsis. There is evi-dence that nurses and medical staff donot always communicate effectively witheach other (145, 151). Communicationbetween disciplines can be improved byusing structured communication toolssuch as SBAR (152, 153), RSVP(154), andEWS (155) that incorporate objective,unambiguous language to convey patientinformation. Sepsis screening tools mayalso be incorporated into the assessment(SBAR) or vital signs (RSVP to ensure thenurse cogently relays the message thatthe patient meets the consensus defini-tion for severe sepsis and needs immedi-ate attention to implement the resuscita-tion bundle.

C. Initiating Early ResuscitationMeasures

1. We suggest that the initial resusci-tation of patients with sepsis beprovided through the use of rapidresponse systems (grade 2B).

Rationale. Early recognition of sepsiscan improve patient outcomes if a rapidresponse is initiated (156, 157). Earlygoal-directed therapy (EGDT) and theSSC guidelines have demonstrated effi-

Table 3. Clinical signs of sepsis

Systemic inflammatory response syndrome: two or more of the following conditions can indicatesepsis:

Temperature �38°C or �36°CHeart rate �90 beats/minRespiratory rate �20 breaths/min or PaCO2 �32 mm Hg (�4.3 kPa)White blood cell count �12,000 cells/mm3, �4000 cells/mm3, or �10% immature (band) forms

Additional signs and symptoms:ChillsHypotensionDecreased skin perfusionDecreased urine outputSignificant edema or positive fluid balance (�20 mL/kg over 24 hrs)Decreased capillary refill or mottlingHyperglycemia (plasma glucose �120 mg/dL) in the absence of diabetesUnexplained change in mental status

Adapted from Levy et al (137).


cacy in improving mortality outcomes insevere sepsis (4, 158, 159). Despite this,compliance with the 6-hr resuscitationbundle is poor, ranging from 19% to 52%(160, 161). A number of studies have ex-plored the poor uptake of EGDT and sug-gest barriers to implementation include in-adequate facilities (162) and inadequatenumbers of nurses (163).

Nurses must be able to recognizesigns of severe sepsis and be knowledge-able about the 6-hr bundle componentsto begin prompt implementation of ther-apy. The focus then should be on identi-fying patients eligible for EGDT (thosenot responding to fluid resuscitation orhaving a lactate �4 mmol/L or both) andarranging prompt transfer to a higherlevel of care area such as the high-dependency unit and ICU to ensuretimely treatment for severe sepsis. Table5 outlines additional strategies for inte-grating the SSC guidelines in nursingpractice (138).

2. We suggest the provision of adequateresources to enable prompt identifi-cation of patients with actual or sus-pected sepsis (grade 2D).

Rationale. A recent U.K. survey ofacute medical units found that only 12%appeared to have the minimum facilitiesto comply with the 6-hr resuscitationbundle (162). Performing EGDT can belabor-intensive and may require a mini-

mum of two nurses in the initial phase(164), although some clinical settingscan incorporate EGDT into their regularclinical duties without the allocation ofadditional staff (165). Recommended re-sources include arterial blood gas moni-tors, and laboratory facilities for measur-ing lactate levels such as serum lactatehave been demonstrated to be an inde-pendent predictor of mortality in patientswith severe sepsis (166). Hand-held lac-tate monitors should be available in non-critical care areas to help identify thosewith cryptic shock (raised lactate in theabsence of hypotension) who otherwisemay be overlooked.

3. We recommend that adequate nursestaffing levels be ensured to providequality patient care and improved pa-tient outcomes (grade 1B).

Rationale. The impact of registerednurse staffing levels on patient outcomesis well-documented, with lower nurse-to-patient ratios being associated withhigher rates of pneumonia (167–171),shock, UTI (169), upper gastrointestinalbleeding, deep vein thrombosis, cardiacarrest, and failure to rescue, as well asinfection (172) and sepsis (167, 168, 170,173–176). Nurse-to-patient ratios in ICUsin the United States and some parts ofEurope typically range from 1:1 to 1:3,depending on patient acuity levels,whereas in countries such as Australia, NewZealand, and the United Kingdom, ratiosare 1:1 because of not having personnelsuch as respiratory therapists to assist inthe management of acute and critically illpatients. Nurse-to-patient ratios of onenurse caring for one or two patients (�1:2)vs. one nurse caring for three or more pa-tients (� 1:2) in the ICU have been found tobe associated with increased risk of postop-

erative pulmonary and infectious complica-tions (167).

4. We suggest that nurses be empow-ered to initiate the 6-hr resuscita-tion bundle. All nurses should betrained to take blood, cannulate,and administer intravenous fluidsvia standing orders for hypotensionor increased lactate or both (grade2C).

5. We suggest that the sepsis six ap-proach be promoted in noncriticalcare areas to promote early identifi-cation and treatment of severe sepsis(144) (grade 2D).

Rationale. Although nurses may iden-tify signs of severe sepsis, they may beunable to initiate the resuscitation bun-dle interventions such as administeringantibiotics and fluid boluses without aspecific physician order. Standing ordersets and established protocols have beenutilized to facilitate early implementationof the bundle components (177).

In the United Kingdom, poor uptake ofEGDT in emergency departments (178)led to a change in focus on education toconcentrate on care that could be deliv-ered by staff without specialist skills andequipment in the first hour after diagno-sis. This has been called the sepsis six andincludes six crucial interventions in sep-sis resuscitation, including starting high-flow oxygen, obtaining blood cultures,administering antibiotic therapy, startingintravenous fluid resuscitation, obtaininglaboratory work including hemoglobinand lactate levels, and measuring hourlyintake and output (144, 159, 179) (Table4). Nurses play an important role in eachof these interventions. High-flow oxygentherapy is not currently included in theSSC guidelines (4) but is universally rec-ommended as being an important aspectof resuscitation of the critically ill andshould be initiated by nurses (180, 181).Many nurses perform venipuncture andcan rapidly obtain blood for cultures andvenous lactate assessment, or can ensureequipment is available promptly if theyare unable to perform venipuncture.

Because a medical officer may not bealways readily available, some hospitalshave introduced measures to empowernurses to administer fluid challenges forhypotensive patients via standing ordersor patient group directions to reduce de-lays in patients receiving fluid resuscita-tion (182). Protocol-directed care in theareas of fluid and vasopressor therapy isbecoming more commonplace and has

Table 4. The sepsis six interventions

Administer high-flow oxygenTake blood culturesAdministere intravenous antibioticsStart intravenous fluid resuscitationCheck hemoglobin and lactateMeasure accurate hourly urine output

Adapted from Surviving Sepsis Campaign(144, 159).

Table 5. Strategies for integrating the Surviving Sepsis guidelines in nursing practice

Create a multidisciplinary team and map out a timeline for implementing the strategies.Enlist the participation of nurse champions in leading the initiatives. Many of the

recommendations involve aspects of nursing care, and nurses can play an important role inpromoting implementation of the guidelines.

Integrate the use of the Surviving Sepsis Campaign guidelines as a performance improvementinitiative for the intensive care unit and noncritical care areas.

Target processes to ensure successful adoption of the guidelines.Include discussion of the guidelines in venues such as daily rounds, grand rounds, and critical care

conference. Consider the use of a daily goal sheet to ensure that the components of theSurviving Sepsis Campaign guidelines, including the sepsis bundles, are addressed on a ongoingbasis.

Promote early identification of sepsis. Early identification of sepsis can help to promote prompttreatment.

Adapted from Kleinpell, 2005 (138)


been shown to be safe (177, 183). In theUnited Kingdom and the United States,advanced practice nurses independentlyprescribe medications and can initiate or-ders for sepsis management, thus helpingto facilitate early resuscitation measures (184,185). Including nurses who are able to pre-scribe antibiotics, fluids, and vasopressors oncritical care outreach teams, rapid responsesystem teams may also reduce delays in im-plementing the 6-hr bundle.

EGDT incorporates blood transfusionfor some patients and is recognized as aserious threat to patient safety; nursesplay an important role in ensuring thatpatients who require transfusion receiveblood in a safe manner guided by bestevidence recommendations (186, 187).

6. We recommend that supplies of com-monly used, ready-mixed antibioticsshould be available in all acute wardsand departments (grade 1D).

Rationale. Usually it is nurses whoadminister antibiotics after a medical of-ficer has prescribed them. Unfortunately,antibiotic administration can be delayedup to 6 hrs in some patients with blood-stream infection (188, 189). Reasons forsuch delays include lack of intravenousaccess and the prescribed antibiotic notbeing available (188). Measures such ashaving commonly used antibiotics andready-mixed antibiotics available, as wellas training nurses to cannulate, shouldbe considered (190).

7. We suggest the institution of track-ing systems including the use ofdaily sepsis rounds in critical careareas (grade 2C).

Rationale. Use of check sheets to mon-itor patients for signs of sepsis or auto-mated computer-based sepsis alert pro-grams (191) can enhance identification ofpatients with sepsis.

8. We suggest ER nurses should liaisewith medical colleagues and prehospitalstaff to facilitate diagnosis and initial treat-ment of severe sepsis en route to hospitaland to promote “alerting” of emergencydepartments that a patient with severe sep-sis is expected (grade 2D).

Rationale. This system is already com-mon practice for patients with acute cor-onary syndrome and major trauma, and itmay help to identify those patients eligi-ble for EGDT (192).

9. We suggest further research ontechnology to aid the detection ofsepsis (grade 2D).

Rationale. Technology that alertsnurses performing clinical observationsand calculation of EWS, such as SepsisAlert, Biosign, Vitalpac, and others, iscurrently being developed by many differ-ent biotechnology companies. Evidenceof the benefit of this trend is yet to beconfirmed.

IV. HEMODYNAMIC SUPPORT

Hemodynamic monitoring techniquescontinue to develop and hemodynamictherapies for severe sepsis are essentiallysupportive care, aimed at improving bothmacrocirculation and microcirculation.The current SSC guidelines (4) are pri-marily based on an evidence-based prac-tice guideline published in 2004 (193).Despite these excellent practice guide-lines, questions remain in terms of thenursing care of septic patients with he-modynamic disturbances.

Complicating the care of patients withsevere sepsis is the multimodal nature ofthe hemodynamics of sepsis. For exam-ple, in the early phase of sepsis, patientspresent with a relative hypovolemia thatmay be somewhat managed by restoringblood volume, i.e., restoring macrocircu-lation. However, as sepsis progresses, adisturbance that centers on the microcir-culation is usually detected. At this point,the macrocirculation becomes hyperdy-namic. Further treatment of the macro-circulation does little to address the prob-lem of the microcirculation, e.g.,microcirculatory clotting, cellular dys-oxia, and cell stunning (194). The treat-ment for this latter stage is unclear.

Two key areas are developing in themanagement of the hemodynamics of se-vere sepsis (194). One focus is on improv-ing tissue oxygenation, both in the macro-circulation and microcirculation. Hence,tissue oxygenation end points, such as cen-tral venous oxygen saturation (ScvO2), tis-sue oxygenation (StO2), and lactate are tak-ing on increased importance. The secondfocus on treatment centers on improvingmacrocirculation, moving toward measur-ing flow rather than pressure.

A. Improving TissueOxygenation

1. We suggest continuous measure-ment of tissue oxygenation vs. inter-mittent measurement (grade 2D).

Rationale. Central venous catheteruse is associated with trends in mortalityreduction as long as resuscitation bundle

compliance exists (142). Continuousmeasurement of tissue oxygenation con-tributes to earlier recognition of changesin patient status and treatment efficacy inrelation to periodic central line sampling.Whereas the cost of continuous ScvO2

monitoring technology is higher than thecost of processing intermittent samples,several factors mitigate this disadvantage.These factors include reduced nursingtime with continuous measurement,avoidance of clinician exposure to blood,and improved ability to detect changeswith continuous monitoring. Preliminarydata suggest continuous ScvO2 monitor-ing may be more cost-effective for insti-tutions overall (195).

2. We suggest consideration of noninva-sive monitoring of tissue oxygenation whencentral venous access is less desired or un-available (grade 2D).

Rationale. Newer technology allowsnoninvasive monitoring of tissue (periph-eral vascular) oxygenation, specificallynear-infrared spectroscopy. StO2 is a con-tinuous, transcutaneous measurement oftissue oxygenation via an electrode prox-imal to the thumb. Data suggest thatStO2 may be a better marker than grosshemodynamics at revealing informationregarding the microcirculation. Donati etal (196) showed that StO2 was responsiveto identifying the impact of activated pro-tein C, unlike gross measures of hemo-dynamics. Leone et al (197) indicatedStO2 values �78% were correlated withlower survival rates. However, both ofthese studies were limited in both samplesize and phase of sepsis utilized.

One of the main values of StO2 is itsnoninvasive application. Situations in-volving severe sepsis in which central ve-nous catheter insertion is less desirableor inappropriate should be considered forStO2 monitoring. StO2 measurement canbe obtained via an easy-to-use, transcuta-neous application. Although not defini-tive at this point, some data suggest thatbelow-normal values may identify sepsisearlier (198), predict development of or-gan dysfunction (199), and serve as anScvO2 alternative. However, outcomedata using StO2 are still lacking. Al-though promising, the literature remainsunclear on how best to use StO2 in severesepsis.

3. We suggest consideration of point-of-care lactate values as a quicker alter-native to traditional serum lactate asappropriate (grade 2D).


Rationale. Degree of blood lactate el-evation correlates directly with morbidityand mortality in severe sepsis (200, 201),and high correlation also has been shownbetween central laboratory and point-of-care values. Early detection of elevatedlactate facilitates early recognition andtreatment in addition to being a moreaccurate triage tool than vital signs (201).Howell et al (201) indicated lactate wouldpredict 28-day outcome better than tra-ditional monitoring parameters such asblood pressure. Elevated lactate, specifi-cally type A lactic acidosis, is one of thefew indicators of hypoxia. Lactate can beat dangerous levels while normal moni-toring parameters like vital signs remainwithin normal limits. Using point-of-carelactate as the catalyst to implementationof a sepsis algorithm, an 18% reduction inmortality and 4-day reduction in length ofstay was achieved (202, 203). We suggestthat point-of-care lactate measurement beconsidered to accelerate the clinician’sknowledge of the danger a patient faces ifserum lactate laboratory results exceedturnaround times of approximately 1 hr(200, 201).

B. Improving Macrocirculation

1. We suggest use of stroke volume orstroke volume variation as a key resusci-tation measure, independent of whether acentral line can be placed (grade 2D).

Rationale. Improving blood flow is thekey strategy during resuscitation. Sec-ondary markers such as blood pressure,central venous pressure, and pulmonarycapillary wedge pressure have been usedas surrogates for blood flow (204). How-ever, these parameters have been shownto be inaccurate and slow to change.More direct measures of blood flow, forexample, stroke volume, offer more pre-cise evaluation of the effectiveness oftherapies such as fluids and inotropes(194). Although central venous pressureis recommended as a resuscitation endpoint in the SSC guidelines (4), cliniciansmust be aware of the limitations of treat-ing right atrial pressure. Independent ofsepsis, it is recognized that the usefulnessof central venous pressure is limited inclinical decisions regarding fluid man-agement because of inability to predictblood volume or preload in response tofluid resuscitation (205). Because centralvenous pressure was in both the interven-tion group and the control group in theoriginal early goal-directed therapy arti-cle (158), one could argue that it was the

added advantage of the ScvO2 in the in-tervention group that was associated withimproved outcomes, i.e., not improvingcentral venous pressure. The parameterthat changes before ScvO2 is stroke vol-ume. In the perioperative setting, mea-suring stroke volume has clearly shownto improve patient outcome (183, 206–213). Stroke volume optimization hasbeen shown to be a much better metric ofpreload responsiveness compared to cen-tral venous pressure, blood pressure, andurine output. Even though data from thepulmonary artery catheter enable compu-tation of a stroke volume estimate, moredirect measurements of stroke volumeare made possible by such innovations asthe esophageal Doppler, noninvasiveDoppler, and pulse contour techniques. Agrowing body of literature supports theefficacy of stroke volume optimizationand stroke volume variation in sepsis(214, 215). Although the theoretical prin-ciple is clear, outcome studies usingstroke volume and stroke volume varia-tion for patients with sepsis are ongoing.

2. We suggest insertion of a peripher-ally inserted central catheter(PICC) in the event that subclaviancentral venous access cannot be ob-tained in patients with severe sepsiswho meet the criteria for centralline placement (grade 2D).

Rationale. Enhanced catheter flowrates, hemodynamic monitoring, andpower injection capability are amongsome of the most recent developments inperipherally inserted central catheteruse. Additional advantages include the in-sertion capability of advanced practicenurses or trained registered nurses. Cen-tral venous pressure accuracy has beenfound to be similar when compared witha traditional central venous catheter(216). However, the ability of peripherallyinserted central catheter to allow forScvO2 measurement is perhaps its mostdistinct advantage compared to periph-eral lines.

V. OTHER SUPPORTIVENURSING CARE

All critically ill patients, including thepatient with severe sepsis, should receiveaccepted standards of fundamental nurs-ing care. Whereas no evidence specificallylinks many components of fundamentalnursing care to the outcomes of patientswith severe sepsis, these aspects of carehave been shown to improve outcomes in

all critically ill patients and a brief reviewfollows. Many have been shown to reducethe risk of infection and therefore maydecrease the risk of sepsis.

A. Nutrition Therapy

Critical illness is often associated witha hypermetabolic state and increased nu-tritional requirements. Malnutrition inthe critically ill is not uncommon (217)and is associated with an increase in mor-bidity and mortality (218). Although thetraditional emphasis of nutritional sup-port has been on caloric intake, this hasevolved to nutrition as a therapy in whichthe metabolic response to stress may beattenuated, cellular injury may be pre-vented, and the immune response may befavorably modulated (219). Extensiveguidelines provide recommendations fornutrition therapy for the critically ill(217, 220–222) and have been shown toimprove the provision of enteral nutri-tion (223). Consequently, incorporatingsuch guidelines into the care of patientswith severe sepsis is recommended.

1. We suggest early enteral nutrition(initiated within 24 to 48 hrs of ICUadmission) (grade 2A).

Rationale. Critical illness is associatedwith intestinal mucosal atrophy with lossof barrier function and potential micro-bial translocation. Early initiation of en-teral nutrition may prevent intestinalmucosal atrophy. In addition, enteral nu-trition can reduce the need for parenteralnutrition with substances that enhancebacterial growth (e.g., lipid emulsions)and, as such, reduce the risk of CR-BSI.Enteral nutrition, when compared to par-enteral nutrition, has been shown to re-duce the risk for infectious complicationsby 30% to 40% (224, 225). A similar re-duction has also been found with early,compared to delayed, enteral nutrition(226). Despite the benefits of enteral nu-trition, caution should be exercised inpatients not yet resuscitated from septicshock when gut perfusion may be com-promised. Caution should also be takenin using immune-modulating enteral for-mulations (supplemented with agents,such as arginine, glutamine, nucleic acid,omega-3 fatty acids, and antioxidants) inpatients with severe sepsis (219).

B. Eye Care

1. We suggest daily assessment of theability of the ICU patient to main-tain eyelid closure (grade 2D).


2. We suggest at least weekly assess-ment of ICU patients for iatrogenicophthalmologic complications andprompt referral for suspicion ofthese (grade 2D).

3. We recommend the maintenance ofeyelid closure for intensive care pa-tients (grade 1B).

Rationale. These recommendationsapply to all critically ill patients, includ-ing those with severe sepsis. Many criti-cally ill patients have altered levels ofconsciousness, which may impact on theprotective mechanisms of the eye, result-ing in an increased risk of injury such ascorneal dehydration, abrasion, perfora-tion, and infection (227). The incidenceof corneal abrasion varies widely but mayaffect up to 60% of intensive care patients(228–230). A variety of eye care methodshave been described and tested, with ev-idence that a range of methods reducethe incidence of corneal damage (227,230–232), but there is insufficient evi-dence to recommend any single methodas being superior. Daily assessment of thepatient’s ability to maintain eyelid clo-sure should be undertaken. Nurses couldalso be trained to perform weekly oph-thalmologic examinations using fluores-cein drops and a cobalt blue pen torch(231), because early detection of iatro-genic ophthalmologic complications willfacilitate timely referral to ophthalmol-ogy specialists and potentially improvepatient outcomes.

C. Pressure Ulcer Preventionand Management

1. We recommend the implementa-tion of a pressure ulcer preventionand treatment bundle includingrisk assessment, skin assessment,nutrition, repositioning, and use ofsupport surfaces (grade 1D).

Extensive recommendations for boththe prevention and treatment of pressureulcers have been developed and containspecific recommendations for the criti-cally ill (233, 234).

Critically ill patients are susceptible tothe development of pressure ulcers be-cause of increased risks such as impairedcirculation, use of inotropic drugs, de-creased mobility, disturbed sensory per-ception, and underlying disease processes(235). The patient with severe sepsis of-ten experiences significant hemodynamiccompromise and therefore is particularlyat risk for the development of pressure

ulcers. Although variable, the incidenceof pressure ulcers in the critically ill hasbeen reported to be between 5.2% and20%, with a prevalence rate of 14.4%(236). Whereas not all pressure ulcerscan be avoided, strategies can be used toreduce the incidence. Assessment of riskfactors is one such strategy, but the pre-dictive validity of risk assessment scales isproblematic and there is little evidencefor a valid risk assessment tool in thecritically ill (237–239).

Special considerations related to pre-vention include: use of special supportsurfaces for patients who cannot beturned regularly; slow, gradual turns,while assessing patient tolerance for theprocedure, may reduce the effect on he-modynamic and oxygenation compro-mise; more frequent small shifts in posi-tion will allow some reperfusion inpatients who cannot tolerate major shiftsin body position; lateral rotation therapymay be considered. Patients receiving lat-eral rotation therapy will continue to re-quire regular turns and skin assessment(233). Shear injury is a potential conse-quence of lateral rotation therapy. Bol-ster pads may prevent sacral shearing inthese patients (233).

Special considerations related to man-agement of pressure areas in severe sepsispatients include: positioning to minimizepressure on affected area; inspectingpressure ulcer and surrounding area withevery dressing change; and, if there isevidence of shear injury, changing lateralrotation support to a support system withimproved pressure redistribution, shearreduction, microclimate control, andwithout rotation (234). Documentationof pressure ulcer staging and treatmentare essential for continuity of care; how-ever, two recent systematic reviews re-vealed that a multitude of pressure ulcergrading scales currently exist, with insuf-ficient evidence to recommend a specificclassification system (240, 241). The roleof ICU mobilization of critically ill pa-tients also has been advocated for thepromotion of skin integrity as well asprevention of complications of bed rest(242).

VI. PEDIATRICS

Sepsis remains an urgent issue amongpediatric patients. Worldwide, it affects alarge pediatric population and is the mostcommon cause of death in infants andchildren (243). Severe sepsis accounts for�4300 deaths annually (244).

Sepsis tends to peak at two primarytimes in the child’s life and corresponds tosignificant times in the maturity of theimmune system (245). The first peak is inthe neonate stage, with an incidence of 4.3per 1000 neonates. Sixty percent of casesoccur in the first 5 days, with an overallmortality of approximately 20%. The sec-ond peak is at approximately age 2 yrs.

In 2002, the International PediatricSepsis Consensus Conference partici-pants modified the adult SIRS criteriaand associated definitions for children(246). SIRS is defined as the presence ofat least two of the following conditions,one of which must be abnormal temper-ature or leukocyte count. The conditionsinclude: core temperature of �38.5°C or�36°C; tachycardia, defined as a meanheart rate �2 standard deviations abovenormal for age in the absence of externalstimulus, chronic drugs, or painful stim-uli or otherwise unexplained persistentelevation over a 30-min to 4-hr time pe-riod, or for children older than 1 yr ofage, or bradycardia, defined as a meanheart rate below the tenth percentile forage in the absence of external vagal stim-ulus, �-blocker drugs, or congenitalheart disease, or otherwise unexplainedpersistent depression over a 30-min timeperiod; mean respiratory rate �2 stan-dard deviations above normal for age ormechanical ventilation for an acute pro-cess not related to underlying neuromus-cular disease or general anesthesia; andleukocyte count elevated or decreased forage (not secondary to chemotherapy-induced leukopenia) or the presence of�10% immature neutrophils (246).

An infection is defined as a suspectedor proven (by positive culture, tissuestain, or polymerase chain reaction test)infection caused by any pathogen or aclinical syndrome associated with a highprobability of infection. Evidence of in-fection includes positive findings on clin-ical examination, imaging, or laboratorytests (e.g., white blood cells in a normallysterile body fluid, perforated viscus, chestradiograph consistent with pneumonia,petechial or purpural rash, or purpurafulminans) (246).

Sepsis is defined as SIRS in the pres-ence of or as a result of a suspected orproven infection (246). Severe sepsis isdefined as sepsis plus one of the follow-ing: cardiovascular organ dysfunction;acute respiratory distress syndrome; andtwo or more other organ dysfunctions(respiratory, renal, neurologic, hemato-logic, hepatic) (246).


There are developmental differencesin the hemodynamic response to sepsis inchildren when compared to adults. A de-crease in cardiac output is associatedwith mortality in children with septicshock (247). Based on this developmentaldifference, reaching a therapeutic endpoint of a cardiac index of 3.3– 6.0L/min/m2 may result in better survival(247). In addition, oxygen delivery is themajor determinant of oxygen consump-tion in children as opposed to oxygenextraction, so the therapeutic end pointof an oxygen consumption of �200 mL/min/m2 also may be associated with abetter outcome (247).

A. Fluid Resuscitation

1. We suggest intravascular volumeexpansion is achieved with fluid bo-luses of 20 mL/kg of isotonic salineor colloids, as identified in the SSCguidelines (4) (grade 2C).

Rationale. As much as 200 mL/kg maybe administered in the first hour of re-suscitation, although the average is 40 to60 mL/kg. Fluid replacement should bedirected toward perfusion, central venouspressure, echocardiographic determina-tion of end-diastolic volume, pulmonarycapillary wedge pressure/end-diastolicvolume, and cardiac output (247).

B. Vasopressors/Inotropes

1. We suggest vasopressors/inotropesare implemented if clinical signs ofshock continue despite adequatevolume replacement, as identifiedin the SSC guidelines (4) (grade2C).

Rationale. An important point to re-member about these medications is thatbecause septic shock is a dynamic pro-cess, the medication used and the infu-sion dose may require adjustment overtime, based on the need to maintain or-gan perfusion as well as the pharmacoki-netics and the pharmacodynamics of thechild’s response to the drug. Perfusionand function of the liver and kidney areoften changed in the child with severesepsis, causing changes in the medicationpharmacokinetics with higher concentra-tions observed. Therefore, standard infu-sion doses may need to be adjusted.

For ongoing therapy, the use of ino-tropes, vasopressors, and vasodilators willdiffer. Dobutamine may be useful for pe-diatric patients with low cardiac outputstates (248). Vasopressin can increasemean arterial pressure, systemic vascularresistance, and urine output in childrenwith vasodilatory septic shock and lack ofresponse to catecholamines. However,the safety and effectiveness of vasopressin

in children with septic shock have notbeen well-demonstrated (249). Occasion-ally, children alter their hemodynamicrequirements from vasopressor to ino-trope or vice versa (247). Table 6 presentsa summary of the pharmacologic therapyused in the treatment of pediatric septicshock (250).

C. Steroids

1. We suggest hydrocortisone therapymay be generally reserved for thechild with catecholamine-resistantshock and suspected or proven ad-renal insufficiency, as identified inthe SSC guidelines (4) (grade 2C).

Rationale. Hydrocortisone therapymay be life-saving in the child with sep-sis, but its use is generally reserved forthe child with catecholamine-resistantshock and suspected or proven adrenalinsufficiency. A recent study examinedthe issue of neuroendocrine dysfunctionin children, including adrenal insuffi-ciency, and found a markedly higher in-cidence of multiple neurohormonal dys-functions in children with sepsis (249).These findings suggest both that neu-roendocrine deficiency is common in pe-diatric sepsis and that many neurohor-monal responses may be affected (249).Generally, adrenal insufficiency in the

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 DysrhythmiaDopaminergic and �1 2–10 Inotropy

ChronotropyIncrease renal perfusion

� 10–20 VasoconstrictionNorepinephrine � � � 2–10 Vasoconstriction 1Myocardial oxygen consumption

Inotropy Dysrhythmias2Renal blood flow

Epinephrine � and � 0.05–1.5 Vasoconstriction 1Myocardial oxygen consumptionInotropy DysrhythmiasChronotropy 2Renal blood flow

Dobutamine �1 5–20 Inotropy TachycardiaDysrhythmiaVasodilatationHypotension

Sodium nitroprusside NA 0.5–10 (light sensitive) Vasodilatation (balanced) 2Pulmonary vascular resistance1Ventilation/perfusion mismatchCyanide toxicity

Nitroglycerin NA 0.2–20 Vasodilatation (venous) 2Pulmonary vascular resistance1Intracranial pressure

Amrinone NA 5–10 (load with up to3 mg/kg over 20 min)

InotropyVasodilatation

Dysrhythmias2Pulmonary vascular resistanceThrombocytopenia

Milrinone NA 0.75–1.0 (load with75 �g/kg over 20 min)

aDifficult to predict the dose-response effect. Management requires individual titration at the bedside.


case of catecholamine-resistant shock isassumed at a random total cortisol levelof �18 �g/dL (496 nmol/L). Dose recom-mendations for treatment of shock are 50mg/kg, followed by the same dose as a24-hr infusion (248, 251). Although notresponsible for ordering steroids, it is es-sential that nurses work collaborativelyto recognize the presence of refractoryshock and initiate both timely measure-ment of cortisol levels and administrationof hydrocortisone therapy when appropriate.

D. Sedation/Analgesia

1. We suggest that critically ill pedi-atric patients receive goal-directedtherapy for sedation and analgesia(grade 2D).

Rationale. Pain causes energy expen-diture and increases oxygen demand.Nurses play a key role in addressing thisissue. Sedation and analgesia are com-monly used in pediatric patients with se-vere sepsis to relieve pain, support me-chanical ventilation, and reduce oxygendemand (252). The first step to initiatingsedation and analgesia is to rule out phys-iologic causes of agitation, including hy-poxemia, pain, hypercapnea, and cerebralhypoperfusion. Addressing the child’scomfort by providing analgesia and seda-tion and decreasing restlessness helps topreserve oxygen for use by major organs(253). There are no data supporting anyspecific medications; therefore, drugs anddosages are based on the child’s response.Therapy should be goal-directed using avalidated scale to determine the child’slevel of comfort (254). In addition, com-fort measures including appropriate po-sitioning, gentle touch, and managingthe environment to decrease or eliminatenoxious stimuli are essential.

E. Therapeutic End Points

1. We recommend the use of thera-peutic end points to guide inter-ventions for the pediatric patientwith severe sepsis and septic shock(grade 1D).

Rationale. Therapeutic end pointshave been established for both initial re-suscitation and ongoing treatment. Thegoals for the first hour of resuscitationremain focused on airway, breathing, andcirculation. The therapeutic end pointsinclude a capillary refill time �2 secs,normal pulses, no differential betweenperipheral and central pulses, warm ex-

tremities, urine output �1 mL/kg/hr,normal mental status and normal glu-cose, ionized calcium, and blood pressurefor age (247).

Once the initial resuscitation hastaken place, attention is required to verifythe effects of hypovolemia and cardiacand vascular dysfunction. The goals ofstabilization are: normal perfusion; a per-fusion pressure normal for age; superiorvena cava or mixed venous oxygen satu-ration of �70%; and cardiac index �3.3L/min/m2 and �6.0 L/min/m2 (255). Thetherapeutic end points are a capillaryrefill time �2 secs, normal pulses withno difference between peripheral andcentral pulses, warm extremities, urineoutput �1 mL/kg/hr, normal mentalstatus, cardiac index �3.3 L/min/m2

and �6.0 L/min/m2, and superior venacava or mixed venous oxygen saturation�70%. Cardiac index is augmented byincreasing preload (247). Monitoringincludes heart rate, oxygen saturation,blood pressure, temperature, urine out-put, central venous pressure, pulmo-nary artery pressure, cardiac output,glucose, and calcium (247).

CONCLUSION

This document provides a summary ofthe evidence that currently exists to un-derpin the nursing care of the patientwith severe sepsis. Several limitations re-late to the document, including the timeand resources available to develop theserecommendations and the lack of evi-dence that exists in many areas of care.Whereas a concerted effort was made tosummarize the evidence from existing re-search and guidelines and reach consen-sus as to the level of support for nursingcare considerations, much of the workwas undertaken by small groups of two tothree authors, with discussion and con-sensus by the entire author group thenachieved through e-mail discussion. Al-though this provided an opportunity forall authors to raise concerns regardinggrading of recommendations, the depthof discussion was confined to that possi-ble by e-mail.

As outlined, multiple areas of nursingcare have either no evidence to informpractice or the level of evidence is con-fined to expert opinion. Research to iden-tify the most appropriate nursing inter-ventions for severe sepsis patients isurgently required. Areas that are partic-ularly needed include recognition of de-terioration and diagnosis of sepsis, type

and effect of early resuscitative measures,effective methods of hemodynamic as-sessment and support, type and effect ofsupportive care such as nutrition ther-apy, pressure ulcer prevention and man-agement, mouth and eye care, and appli-cation of these interventions to thepediatric patient with severe sepsis. Iden-tification of new evidence should informthe ongoing care of the severely septicpatient and, as such, this document rep-resents an ongoing process.

ACKNOWLEDGMENTS

We acknowledge and appreciate the in-put of R. Phillip Dellinger, MD, during theinception of this project, particularly as itrelated to his experience with the develop-ment of the Surviving Sepsis CampaignGuidelines for the Management of SevereSepsis and Septic Shock. We thank GordonSpeed for his review of the document inrelation to comprehensiveness, logicalflow, and use of terminology.

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nursing considerations to complement the surviving sepsis

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