Sepsis involves life-threatening organ dysfunction owing to a dysregulated inflammatory response to infection, and septic shock is a subset of sepsis with its own criteria involving blood pressure and serum lactate. Early recognition and intervention are linked to better outcomes, explained Laura J. Zitella, MS, RN, ACNP-BC, AOCN, of the University of California San Francisco, in an oral presentation at the 46th Annual Oncology Nursing Society (ONS) Congress.
Patients with sepsis often do not look well, and systemic inflammatory response syndrome criteria will be met in most cases. “Anytime you’re seeing effects on the organs, that’s much more serious than a garden-variety infection,” Ms Zitella explained. Sepsis in the presence of suspected or known infection is identified by a Quick Sequential Organ Failure Assessment score of 2 or higher, which is calculated based on mental status, systolic blood pressure, and respiration rate.
Sepsis management centers on recognition of the condition, maintenance of adequate perfusion, and source control. Vital signs, blood pressure, and serum lactate are important measurements for assessing sepsis during fluid resuscitation. Normalized blood pressure and lactate suggest progress toward restored perfusion. Lactate is a sign of inadequate oxygenation to cells. However, lactic acidosis can have multiple possible causes, and capillary refill time can be another indicator of the level of peripheral perfusion.
If perfusion is not restored, treatment in an intensive care unit with vasopressors are often required. Research findings suggest hydrocortisone with oral fludrocortisone may improve outcomes for severely ill patients with septic shock being treated with vasopressors and mechanical ventilation.
Prior to antibiotic therapy the following tests and imaging studies should be obtained: 2 sets of blood cultures (a minimum of 40 mL is needed for adequate cultures), CBC with differential, comprehensive metabolic panel, chest radiograph, pulse oximetry, urinalysis, lactate, and COVID-19 testing. Additional tests that may be needed based on patient symptoms include: for diarrhea, Clostridoides difficile essay, GI PCR panel; for skin lesions, biopsy, aspirate, viral DFA, or HSV/VZV PCR of skin lesions; for erythema or tenderness at venous catheter site, site culture; for respiratory symptoms, respiratory PCR for respiratory viruses; for abnormal urinalysis or urinary symptoms, urine culture.
Patients with septic shock should receive vancomycin and a broad-spectrum antibiotic such as piperacillin-tazobactam. This combination is not recommended for neutropenic sepsis, but pseudomonal coverage is. If the patient is not getting better, reevaluate the infection source and the antibiotic choice.
A poorer prognosis occurs with an infection that is associated with hypotension or respiratory failure. Ms Zitella also indicated that infections related to Gram-negative organisms show a higher risk of septic shock, compared with Gram-positive organisms, and the most fatal source of sepsis generally arises from an abdominal source.
The longer the illness, hospitalization, or immunocompromised state, the greater the likelihood a patient will develop significant sepsis, Ms Zitella explained. “Every hour counts.”
Zitella LJ. It’s a matter of time: sepsis in oncology practice. Oral presentation at: 46th Annual ONS Congress; April 20-29, 2021. Accessed April 27, 2021.