Brenda Shelton, DNP, RN, APRN-CNS, CCRN, AOCN
Identifying early signs of sepsis can help save lives. However, this comes with many challenges as sepsis can present with atypical signs and symptoms in patients with cancer.
Brenda Shelton, DNP, RN, APRN-CNS, CCRN, AOCN, an oncology nurse at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins in Baltimore, discussed the intervention she and her colleagues implemented at their center, and how fellow oncology nurses can follow their lead during a presentation at the 42nd Annual ONS Congress held May 4-7 in Denver.
Sepsis is the third leading cause of death in the world, and is among the most common causes of nonmalignant deaths in oncology patients—occurring in 14% of patients with cancer. Mortality can be as high as 30% to 40% in those patients.
“While they may die of infection, what we really know in our hearts is that they died of the cancer-related effects that caused the infection,” said Shelton.
She went on to explain how nurses are often seeing patients more frequently than physicians, and therefore can assist in noticing the subtle changes a patient may be experiencing.
The stages of sepsis include: systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock.
According to Shelton’s presentation, the least accurate SIRS criterion in patients with cancer is heart rate, with the strongest indicator being respiratory rate above 20.
Recommendations for surviving sepsis in the first 3 hours is to begin by screening a patient at the first encounter—be it triage or outpatient—and, if there is a positive screening, have a blood culture and lactate done. A nurse should also assess organ function and give the first antimicrobial within the first hour of the decision that the patient is in fact infected.
In addition, oxygen should be given if saturation is not above 90%, and give a fluid bolus if the patient is hypotensive or has a lactate above 2.
In the next 3 hours, there should be assessment of the source, mean arterial pressure should be above 65 mm, and if the patient has remained hypotensive despite fluids, vasopressors should be initiated.
A landmark study—the Rivers trial, published in the New England Journal of Medicine
in 2001—found a 7% mortality reduction if the bundle elements were completed 37% of the time.
The team from Hopkins revised current Core Measure Sepsis screening criteria in order to better identify sepsis among patients with cancer, and help lower its number of false positives. Its criteria now include: temperature less than 35.5⁰C and more than 38.0⁰C; heart rate greater than 100; neutropenia; added elevated glucose in the absence of diabetes; altered mental status; and mottling.
Since modifying the criteria, Hopkins has not missed any cases of sepsis; it has reduced hypotension from 50% to 30%, and significantly lowered cases of severe sepsis to 12%.
Shelton stressed the importance of fast action when it comes to assessing a patient for sepsis. “I am a strong believer that timely antibiotics are the key intervention. For every hour that you delay beyond the first 60 minutes, mortality increases to about 7.6%. You don’t really know who is the person who is going to become sicker at hour 2.”
She added that screening should be done in a more methodical way. “We need to improve this process so it is more specific and not so sensitive.”