SEPSIS: Does My Patient Look Sick? - NurseCe4Less.com · 20-03-2014 · serves as a Subject Matter...

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SEPSIS: Does My

Patient Look Sick?

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital

Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

Abstract

The human body has an amazing ability to respond to bacteria and viruses,

but occasionally the level of response outmatches the threat. When the

body’s immune system goes into overdrive, sepsis can result, which can be

life-threatening. Since many illnesses have symptoms that are similar to

sepsis, it is important for nurses to be able to recognize those symptoms

and understand the process for making an accurate sepsis diagnosis. Nurses

should also understand the appropriate treatment in order to halt the effects

of this potentially fatal illness.


Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

The national Surviving Sepsis Campaign highlights recommendations and

guidelines related to sepsis prevention in healthcare. All members of the

health team are encouraged to improve knowledge in the prevention and

early identification of sepsis.

Course Purpose

To provide nursing professionals with knowledge of the early signs of sepsis,

complications, prognosis and treatment, including prevention.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 5/15/2018

Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned

will be provided at the end of the course.


1. Sepsis is:

a. A condition that starts on its own

b. A condition that is linked to another medical condition, such as

infection

c. A condition that only the elderly or very young children develop

d. A condition seen only in people with diseases like cancer or AIDS

2. Older adults who develop sepsis

a. Do so because their immune systems are less efficient

b. Do so because they often have chronic health problems

c. Do so because they may have an infection that lingered for some

time or was difficult to spot and developed into sepsis without a

practitioner noticing

d. All of the above

3. Some things that increase the risk of developing sepsis are

a. Age; i.e., being very young or being elderly

b. The presence of infection

c. Chronic health conditions

d. All of the above

4. Which of the following is NOT a type of white blood cell?

a. Neutrophils

b. Monocytes

c. Basophils

d. Erythrocytes

5. Normal results for neutrophils on a blood differential are in what

range?

a. 20% - 40%

b. 40% - 60%

c. 60% - 80%

d. 80% - 100%


Introduction

Sepsis is a serious and expensive medical condition worldwide. Over

fourteen billion dollars is spent annually on hospitalization for sepsis in the

United States alone, and hospitalizations for the condition have more than

doubled in the past ten years.1 The precise definition of sepsis has been

debated upon for years. Sepsis can simply be termed as blood poisoning and

is the body’s reaction to infection, a reaction that is quite frequently deadly.

The Merinoff Symposium on Sepsis issued a global definition on sepsis and

declared sepsis a medical emergency. The Symposium’s definition is as

follows: “Sepsis is a life threatening condition that arises when the body's

response to an infection injures its own tissues and organs. Sepsis leads to

shock, multiple organ failure and death especially if not recognized early and

treated promptly. Sepsis remains the primary cause of death from infection

despite advances in modern medicine, including vaccines, antibiotics and

acute care. Millions of people die of sepsis every year worldwide.”2 The origin

of the word sepsis may be found in the Greek word for “decay,” and can be

defined as “the presence of pathogenic organisms or their toxins in the blood

and tissues” or “the poisoned condition resulting from the presence of

pathogens or their toxins as in septicemia.”3

A diagnosis of sepsis is not given based on where the infection is located;

rather, a patient receives a sepsis diagnosis if they develop the clinical signs

of an infection or systemic inflammation. Practitioners must pull from a list

of certain signs and symptoms so that they may make the sepsis diagnosis.

These signs and symptoms include: confusion, difficulty breathing, rash,


chills, bruising, bleeding, fever, warm skin, an elevated heart rate, abnormal

white blood cell count, and low blood pressure.

Sepsis may be diagnosed in patients with a wider range of illnesses; for

example, an elderly gentleman suffering from pneumonia, a fever, and an

elevated white blood cell count, may be diagnosed with sepsis. An infant

with appendicitis, a reduced body temperature, and a reduced white blood

cell count could also be diagnosed with sepsis. Sepsis is considered severe

when findings occur in concert along with signs of organ dysfunction. Nearly

everyone with severe sepsis must be treated in intensive care for a period

ranging from several days to several weeks. Many of those with severe

sepsis do not survive; approximately 40% will die. Across the world, one-

third of those with sepsis will die.3 While the majority of cases of sepsis are

linked to disease or injury, there are many cases of sepsis that follow routine

or elective surgery. Sepsis may even occur as a result of injuries that seem

remarkably minor, such as scrapes and cuts, or torn cuticles.

Sepsis is potentially disabling and deadly, but early detection as well as

rapid treatment increases the chances of survival. Even so, nearly 50% of

sepsis survivors suffer from post-sepsis syndrome, a syndrome that leaves

the sufferer with long-term difficulties that include insomnia, vivid

nightmares and hallucinations, panic attacks, fatigue, decreased ability to

concentrate as well as decreased cognitive function, and reduced self-

esteem.3 Other survivors may still suffer from organ dysfunction or other

difficulties stemming from sepsis related events, such as resulting

amputations.


Sepsis Along The Age Spectrum

Anyone can get sepsis at any time; however, some groups of people tend to

get it more often.

Sepsis in Children

Children are one of these groups. In particular, babies born prematurely and

infants may be more likely to develop sepsis. More than 42,000 youngsters

develop severe sepsis every year in the United States. Around 4,400 of them

die.3 This number is greater than the number of children who die from

pediatric cancer.

Sepsis is a greater issue in developing countries, where an even greater

number of children develop sepsis and die. Sepsis in developing countries

may occur as a result of unsanitary conditions present at birth, from

infections passed from mother to child, or from preventable infection. It is

important to note that sepsis in children may be the result of any sort of

infection, just as it may be in adults.

Sepsis in the Older Adult

Another group that sepsis may affect more often is older adults. This is

because older people frequently have developed chronic health issues or

may have immune systems that have become compromised. People, age 65

and older, are particularly at risk for developing sepsis.


Causes Of Sepsis

Sepsis is not something that just starts on its own accord. It is a condition

that is linked to another medical condition; for example, infections of the

lungs, skin, abdomen, urinary tract, or some other part of the body can lead

to sepsis.6 Additionally, some invasive medical procedures – such as

vascular catheterization - may lead to sepsis. This is because this procedure

may cause bacteria to enter the blood stream, which in turn prompts sepsis.

A variety of microbes may cause sepsis. These include bacteria, a number of

fungi, and viruses but bacteria are the most common cause.6 Severe cases

of sepsis frequently result from a widespread infection that spreads through

the entire bloodstream; however, sepsis may also arise from localized

infections. Anyone is susceptible to getting sepsis, but those individuals who

have compromised immune systems, children, babies, and elderly

individuals are the most susceptible. Additionally, individuals who have

chronic illness, including those individuals who have illnesses such as

diabetes, cancer, kidney disease, liver disease, and autoimmune deficiency

syndrome (AIDS) are more susceptible to getting sepsis. So too are those

individuals who have sustained a serious physical trauma, such as a severe

burn.

Pediatric Patients

Neonatal Sepsis3

Children who develop sepsis within 90 days of being born are diagnosed with

neonatal sepsis. Additionally, children who develop sepsis within 24 hours of

being born are diagnosed with early onset sepsis, and the child would have

contracted the infection during delivery. There are some things that increase


the risk of early onset sepsis. These include a mother who has a group B

streptococcus infection during pregnancy, premature birth, and, if the water

breaks sooner than 24 hours prior to delivery of the baby.

Sepsis that occurs post-delivery is termed late onset neonatal sepsis.

Children may develop sepsis following birth if they get a bacterial, viral, or

fungal infection, although fungal infections are very rare. There are certain

things that increase the chances of children getting these infections, which

include hospital treatment visits and exposure to individuals who have these

types of infections. The most common types of infections that cause sepsis

in children and infants include: respiratory syncytial virus (RSV),

cytomegalovirus (CMV), E. Coli, Candida, Herpes simplex virus, and, listeria

monocytogenes.

Very young children and infants as well as those children who have serious

medical issues may not have the ability to receive required vaccinations at

recommended times. This then makes these individuals vulnerable to

catching preventable diseases, which in turn can lead to developing

complications that include sepsis. The most common preventable diseases in

this grouping are rubella (German measles), haemophilus influenzae Type B

(Hib), and varicella (chicken pox).

Sepsis in Children3

As children age, they may experience increased illness as they start

attending daycare, school, and activities such as sports or other

extracurriculars.


Children may get infected wounds such as scrapes or cuts, which may then

lead to the development of sepsis. Scrapes or cuts must be cleaned out

properly and then kept clean. Bacteria are a normal occurrence on the skin,

but when it gets inside a wound it may then cause an infection. One

common wound infection develops from staphylococcus aureus (s. aureus)

bacteria. Bacteria may also enter the body through surgical incisions.

Additionally, children may also develop illnesses such as ear infections,

meningitis, urinary tract infections, or pneumonia. If these illnesses are not

treated properly, they may lead to the development of sepsis.

Older Adult

Researchers think that as people age, their immune system starts to become

less efficient at fighting off infections. This means that older people will

contract more infections, and these infections will be more severe. With

every infection a person gets they are at risk for developing sepsis.

Additionally, as people age, they are at risk for developing chronic health

problems such as diabetes, heart failure, or kidney disease. Quite frequently,

older individuals have two or more chronic ailments. Research has indicated

that chronic health conditions, along with other conditions such as cancer,

hypertension, chronic obstructive pulmonary disease (COPD), human

immunodeficiency virus (HIV), and liver cirrhosis, are common in people who

develop sepsis.3 Any kind of infection may cause sepsis to develop;

infections from the flu to infected bug bites may lead to sepsis. However, the

most common infections that lead to the development of sepsis in older

individuals are respiratory illnesses, for example, pneumonia. Also common

is urinary tract infections (UTI) or infections that occur through infected


teeth or infected sores present in the skin from either dry skin or skin that

has become sore from sitting for prolonged periods in a wheelchair or lying

in bed. Regardless, there are many ways that infection may occur in older

people, just as there are many ways that infection may occur in other

populations.

It is sometimes very difficult to spot infections in older individuals. For

instance, the symptoms that are present with a UTI include the urge to

urinate frequently and urgently, burning and pain while urinating, cloudy or

foul smelling urine, and a feeling as though the bladder has not been

completely emptied. However, for many older individuals, one of the first

signs of a urinary tract infection is actually confusion or disorientation. If this

sign is overlooked, the infection could be in the individual’s system for quite

some time before it is detected. The same thing could occur with other

infections, for example, with pneumonia, which is often mistaken for a time

as being a bad cold.

Overlooking infections can be disastrous for older individuals, as this can

then lead to the development of sepsis. Therefore, since infections may not

be obvious in an older person, if an older person becomes confused or

behaves in a way that is not usual, they should receive a medical provider’s

examination as soon as possible.

Cause of Symptoms

Sepsis is triggered by and subsequently progresses due to a number of

factors that are related to both the individual and the infection that the


individual suffers. Some of the factors related to the individual include things

such as natural predisposition to illness, their genetics and immune system.8

Factors Related to Blood Coagulation

Normally, the blood is liquid and flows freely in the vessels but still clots in

an appropriate way such that bleeding is controlled. Sepsis, however, is an

inflammatory event. During this inflammatory event, alterations may occur

within the body’s coagulatory system as well as the cells that regulate the

coagulatory system. Patients who have sepsis may present with

disseminated intravascular coagulation (DIC), where there is a consumption

of platelets and clotting time is prolonged. Additionally, hemostasis may be

altered, which will allow blood to clot when it should not, which leads to

clogged blood vessels and a reduction in blood flow.10

Factors Related To Inflammation

Hyperinflammation

It has been argued that individuals with sepsis suffer from a hyperimmune

response known as immunostimulation. This simply means that

inflammation is excessive. The idea is that the excessive inflammation leads

to tissue damage and toxicity, which in turn leads to death.10

Blunted Inflammation

Blunted inflammation is also known as immunosuppression. It has been

argued that some individuals with sepsis do not control the bacterial


infection and die as a result of the suppressed immune system instead of the

inflammatory response.10

Factors related to cellular dysfunction

When a patient becomes septic, cells begin to lose their function, becoming

either excessively active or depressive in function. Excessively active cells

respond very vigorously to stimuli; depressed cells become less responsive

to stimuli. One example of cells that are excessively active would be

neutrophils that are generating toxic products in such a way that they are

causing damage to the cells nearby. An example of cells that are depressed

would be neutrophils that are failing to phagocytize and clear the invading

pathogens.10

One area that is of particular interest where cellular dysfunction is concerned

is cell apoptosis or necrosis, in particular apoptosis of lymphocytes, which

are crucial cells in response to sepsis. Studies have indicated that individuals

who have sepsis have marked apoptosis of lymphocytes in nearly all

lymphoid organs, including the spleen, thymus, gastric tissue, and other

areas where lymphocytes exist.11 There are other cells in the body that do

not function normally in patients with sepsis. It has been shown that there is

increased apoptosis of macrophages or monocytes, mucosal epithelial cells,

dendritic cells, and others, in patients with sepsis.12

Factors Related to Individual Health

Bacteremia, viremia, and fungemia may pose risks to individuals who are

higher risk patients or who are in high-risk groups, such as the very young

or the elderly. Bacteremia means that there are viable bacteria present in

the blood. Viremia means that there is viable, viral material present in the


blood. Fungemia means that there is viable fungal material present in the

blood. Normally, these things do not pose a problem for most individuals.

For instance, bacteria can be introduced into an individual’s bloodstream

through as simple a task as brushing one’s teeth. However, bacteria can also

be introduced into an individual’s bloodstream through some surgical dental

procedures that can then cause an infection of the valves of the heart that is

known as endocarditis. This more frequently occurs in those individuals who

are considered high risk. Not only does the incidence of an infection increase

the risk for the development of sepsis, but the subsequent development of

chronic medical conditions such as heart disease increase the likelihood that

the individual may develop or die from sepsis. Research has shown that

chronic health conditions are common in those individuals who develop

sepsis.3

Symptoms Of Sepsis

Delirium

Delirium associated with sepsis is considered one of the most prevalent

causes of delirium in the intensive care unit (ICU).13 In this particular

context, delirium affects between 9% and 71% of all sepsis patients.14

Delirium that is linked to sepsis is not simply unpleasant confusion, but

rather is linked to serious organ dysfunction that is marked by increased

mortality.15 Further, in these patients, there is often seen an increase in

impaired cognitive function.16 However the precise mechanisms that are

associated with delirium that is linked to sepsis remain unknown, although

they are probably multifactorial.


It is important to note that there are likely precipitating factors that

practitioners should look out for, such as reduced cerebral blood flow, a

disruption of the blood-brain barrier, cerebral edema, impaired astrocyte

function, and neuronal degeneration.17 It is frequently difficult to diagnose

delirium in patients who have developed sepsis since sedation as well as

other treatments may obscure the full neurological picture. Additionally,

there is a difference in diagnostic criteria. This is why there is such variability

in reported instances of delirium in those who have developed sepsis.

Post-ICU Syndrome (ICU Delirium)

Post-ICU Syndrome (PICS) is a serious problem that may affect individuals

who have spent a period of time in intensive care. It especially affects those

who have been placed on sedation or on ventilation. Post-ICU Syndrome is

marked by delirium and is also called ICU delirium. The longer a patient is in

the ICU unit, the more likely they are to develop ICU delirium, or PICS. One

study discovered that some individuals continue to have cognitive issues for

up to a year after discharge from the unit.3 There are differences between

PICS and a condition such as PSS, or post-sepsis syndrome. Those with PSS

may experience a change in cognitive function and a decrease in the ability

to concentrate, but those who experience PSS also have additional issues

(such as insomnia, nightmares, hallucinations, panic attacks, and fatigue),

whereas PICS is marked by delirium and cognitive decline.

Difficulty Breathing

Sepsis is a severe systemic infection that leads to an increase in oxygen

demands on the body. When this happens, there is often an increase in the

difficulty to breathe. Breathing will become rapid and shallow, a condition

called tachypnea. Adults normally breathe between 12 to 20 breaths per


minute while at rest. An adult with sepsis breathes at greater than 20

breaths per minute while at rest, and the breaths will frequently be shallow,

with the individual not receiving adequate blood oxygen.18

Often, when sepsis progresses to acute respiratory distress or acute lung

injury, individuals must be placed on ventilation to assist with breathing.

However, should these conditions develop in patients with sepsis, current

protocol for ventilator management now utilizes lowered tidal volume

ventilation, with tidal volumes of 6 mL/kg of predicted body weight in an

effort to keep plateau air pressures at <30 cm H2O.18 Additionally, recent

decisions that a modest fluid balance leads to a reduction in the length of

time that mechanical ventilation will be utilized for patients with acute

respiratory distress or acute lung injury has meant that the standard has

come to limit fluid and promote diuresis, if at all possible, if conditions such

as acute lung injury develops in patients who have sepsis.

Rash

Rash is a common symptom of sepsis, but does not always occur. An

individual may have sepsis without rash.19 A common rash is reddish or

purplish in appearance. The rash may develop in tiny spots and may occur in

groupings in any area on the body. The rash may progress to become

blotchy and bruise-like in appearance. The rash can range from one or two

groupings to develop into many groupings.

The rash that develops with sepsis is marked by a lack of fading when

pressed. Most rashes will fade when pressed; this kind of rash will not. The


individual or practitioner can check for fading by doing a test known as the

“glass test.”19 The individual or practitioner simply presses a glass firmly

against the spotted area. If the area does not fade, he or she should seek

medical treatment immediately.

Chills

Individuals who have developed sepsis often experience chills, sometimes

also termed rigors. These are episodes of exaggerated shivering or shaking,

which may also occur in concert with a high fever (greater than 101.3 F or

38.5 C).21 Chills are a reflex which may occur for a number of reasons, but

they should never be ignored because they are often present because the

individual has some sort of infection, which will most frequently be bacterial

if chills are present. Chills are an incredibly good predictor of bacterial

infection and bacteremia in both children and in elderly individuals, although

they present more commonly in children and less commonly in elderly

patients.

Chills alone do not indicate sepsis. Practitioners should examine the patient

for other symptoms, including fever as well as rash. Chills involve a

particular sign of meningococcal septicemia, which is sepsis that results from

an infection of meningococcal bacteria. However, a number of other things

may cause chills as well, including pericarditis, respiratory and urinary tract

infections, pneumonia, recent surgery, medications or drug interactions, and

allergies.

Bruising

Individuals who develop sepsis may often develop strange patterns of

bruises. These develop for more than one reason. One reason this may


happen is as a result of problems with the body’s coagulatory system,

making the patient more prone to unusual internal bleeding.10 Another

reason strange bruising patterns may show up on a patient who has sepsis

could be as a result of the hemorrhagic rash that frequently develops with

sepsis. This rash starts as a small cluster of tiny spots of blood that look like

simply pin pricks on the surface of the skin. If left untreated, the

hemorrhaged area grows until it takes on the appearance of a fresh bruise.

The bruised areas then in turn join together and form large areas of

discoloration and dark skin damage.23

Bleeding

The blood is ordinarily liquid and free flowing throughout the body while still

clotting in appropriate ways. However, when sepsis develops, the

coagulatory system of the body is altered, as are the cells that regulate the

coagulatory system.10 Patients who develop sepsis often present with

disseminated intravascular coagulation (DIC). In this case, there is

generalized bleeding as well as microvascular thrombosis, which occur as a

result of the consumption of platelets. This prolongs clotting time.

Additionally, there may be damage to the walls of the blood vessels, which

can happen in meningococcal septicemia.24 Hemostasis can also be affected,

which can lead to blood clotting when it should not. This can result in

clogged blood vessels, which reduces blood flow.

Other Symptoms

Fever

Fever is one of the initial indicators that a person has sepsis, although fever

may be an indicator of a number of common infections, and on its own is not


an indication of sepsis. In order to be diagnosed with sepsis, an individual

must have a fever of greater than 101.3 F (38.5 C) or a body temperature of

below 95 F (35 C) [25] and another symptom including:

A heart rate that is greater than 90 beats per minute

A respiratory rate that is greater than 20 breaths per minute, or

A likely or confirmed infection

Warm Skin

Warm skin is common in sepsis when the blood pressure drops and the

patient experiences shock. Blood flow becomes very poor as a result of the

drop in blood pressure, and vasodilation occurs.26 This leads to the skin

becoming warm and flushed in appearance.

Rapid Heartbeat

A rapid heart rate is one of the basic symptoms of sepsis, although it should

not on its own be used to diagnose sepsis because there are a variety of

conditions during which a rapid heart rate can occur, including anemia, heart

failure, pregnancy, hyperthyroidism, and even heavy exercise or anxiety.

Rapid heart rate is also sometimes called tachycardia or bounding pulse.27

Septic patients have a heart rate that is greater than 90 beats per minute

along with at least one other symptom, such as a rapid respiratory rate

(greater than 20 breaths per minute), a body temperature that is greater

than 101.3 F (38.5 C) or less than 95 F (35 C), or a likely or confirmed

infection.25


Abnormal WBC

Individuals who develop sepsis frequently have abnormal white blood cell

counts. White blood cell count may be tested through the Blood Differential

Test or a WBC Count. There are five different types of white blood cells, also

called leukocytes. These are neutrophils, lymphocytes, monocytes,

eosinophils, and basophils.

Abnormal white blood cell count on a blood differential can mean a variety of

different things, including anything from anxiety and stress to cancer. Even

the slightest stressors can increase white blood cells in the blood. However,

when an individual develops sepsis, there are generally certain types of

white blood cells that become unbalanced.

One type of white blood cell that commonly decreases abnormally in septic

patients is neutrophils. These cells are often markers of a viral or bacterial

infection that may then lead to the development of sepsis. Septic patients

may also experience an increase or decrease in lymphocytes, or an increase

in monocytes. The imbalance of WBC is very much dependent upon the type

of infection or trauma that leads to the development of sepsis. Different

infections affect the body in different ways even if the end result is still the

development of sepsis.

Low Blood Pressure

Blood pressure measures the pressure in the arteries during the resting and

active phases of every heartbeat. Blood pressure is measured utilizing two

rates of pressure; systolic pressure, which is the amount of pressure that


the heart generates when it is pumping blood throughout the arteries into

the rest of the body, and, diastolic pressure, which is the amount of pressure

within the arteries when the heart is resting between each beat.

General guidelines indicate that normal blood pressure is 120/80 or lower.28

Blood pressure is generally at its lowest rate in the evening and increases in

the morning upon waking. Blood pressure varies depending upon time of day

and optimal blood pressure varies from person to person. A blood pressure

that is considered too low for one person may be a normal blood pressure

for another person. A blood pressure is generally considered too low if it is

causing noticeable symptoms. A person with sepsis, who has gone into

septic shock, experiences a sharp drop in blood pressure. The drop in blood

pressure is what causes the shock.29 When this occurs, vital organs are

unable to receive adequate amounts of oxygenated blood. This can lead to

organ dysfunction or organ failure.

Diagnostic Testing

An individual who has sepsis will look extremely ill. There are several

diagnostic tests that may be done to confirm a diagnosis of sepsis. These

includes the following tests.26

Blood Tests

The infection is frequently confirmed through drawing and testing blood.

However, there are occasions where a blood test may not indicate infection.

This can happen when the individual has been given antibiotics. Also, there


are some infections that lead to sepsis that are not diagnosable through

blood tests.

There are few to no risks involved to having blood drawn, although the veins

and arteries will vary from patient to patient. This variation means that

drawing blood may be more difficult in some patients. The risks that are

associated with drawing blood include excessive bleeding, dizziness or

fainting, hematoma, or infection. It is important to note that there is a risk

of infection any time anything breaks the skin’s surface. It is important for

practitioners to be aware of the medications their patients are taking prior to

any type of blood draw. Medications, particularly those that thin the blood,

may affect blood draws.

Important advances are being made in the area of blood testing and sepsis

diagnostics. Researchers searching for a test that will predict if someone had

sepsis discovered through their research that they may be able to predict

with a high degree of accuracy who will die from sepsis.30 Researchers led by

Dr. Stephen Kingsmore of the National Center for Genome Resources in

Santa Fe, New Mexico, discovered a blood test that could accurately pick out

patients who would develop severe sepsis that would lead to death as

opposed to patients who simply had severe infections but would live. The

researchers would like to develop the test into a tool designed to assist

practitioners in deciding which patients need hospitalization urgently as well

as treatment in an ICU as opposed to those patients who can “tough it

out.”30 Eventually, the hope is that the test may be utilized to predict

susceptibility to all sorts of infections; “the test is looking for a signature

that will guide a physician – is this patient going to have a catastrophic


illness or is he going to have a mild infection?”30 Specifically, researchers

from the National Center for Genome Resources, have developed a test that

can identify molecular signatures designed to indicate if an individual will die

from sepsis.

Kingsmore’s team took an approach to the problem of sepsis that was as

unique as the condition itself: they ran tests for nearly every metabolite and

protein that exists in human blood. The study examined 1,152 people with

sepsis from 2005-2009 in Henry Ford Hospital in the Detroit area and Duke

University Hospital and Durham Veteran Affairs Medical Center in North

Carolina. Study participants had blood drawn when they first arrived and

then later in the study as well. Kingsmore said that study findings were

“really surprising,” and went on to elaborate: “The study was designed to

identify a signature that would just tell us if it was sepsis or not…much to

our surprise, as we got into the study and identified the results, we found

that we have these really big differences between these patients.”30

The differences consisted of differing levels of blood chemicals in the

patients who eventually developed severe sepsis or died. The researchers

reported their finding in Science Translational Medicine, and stated that

while it did not matter what the infectious agent was, the signature pattern

of how the patient’s body utilized energy was clear. One group of patients

had a very robust response to infection, where they generated a high

amount of energy and developed a fever. This response contributed to

survival. However, patients who did not have this response or who had a

partial response tended to have bad outcomes.


Kingsmore does note that a great deal more testing is required in this area,

but the discovery shows promise: “The signature is going to be good for a

broad spectrum of infectious diseases. That would include the flu and other

severe viral infections as well as the common bacterial infections with fungi.”

Kingsmore even adds that this discovery could aid in discerning who could

die following severe trauma.

Blood Differential

This type of test is done to measure what percentage of every type of white

blood cell the individual has present in the blood. The test will also reveal if

there are any immature or abnormal cells present. The blood differential is

typically performed through drawing blood, although in younger children and

infants it is taken by pricking the heel or fingertip and collecting the blood on

a test strip or slide. The blood is then stained with dye, which helps a lab

technician differentiate between the different types of white blood cells,

hence the name of the test.

There are five types of white blood cells or leukocytes that appear in the

blood. These are: neutrophils, lymphocytes, monocytes, eosinophils, and

basophils. Normal results in a blood differential are:

For neutrophils: 40% - 60%

For lymphocytes: 20% - 40%

For monocytes: 2% - 8%

For eosinophils: 1% - 4%

For basophils: 0.5% - 1% and

For young neutrophils: 0% to 3%


Abnormal results may indicate a number of problems, from stress to cancer.

Any sort of infection or stress on the body can increase the number of white

cells in the blood. One important thing to note is that if one type of white

blood cell increases abnormally, another type of white blood cell may

decrease abnormally, causing a dangerous imbalance.

Decreases in neutrophils are commonly seen in patients who eventually

develop sepsis, as they are markers of viral and bacterial infection that can

eventually lead to the development of sepsis. However, imbalances in other

white blood cells may also be seen in patients who eventually develop

sepsis. For example, an increase in lymphocytes is often seen in patients

who experience chronic bacterial infections. Decreased lymphocytes are seen

in patients who have HIV, and HIV infection is a risk factor for developing a

condition such as sepsis. Also an increase in monocytes or an increase in

basophils may be indicative of preventable infections such as mumps,

measles, or varicella, which can then lead to sepsis if not properly

controlled.

White Blood Cell Count

A white blood cell count count measures how many white blood cells are in

the blood. WBCs assist in fighting infections, and are also known as

leukocytes. The five types of WBCs are: basophils, eosinophils, lymphocytes,

monocytes, and neutrophils.36 This test is performed by drawing blood from

the inner elbow or from a vein on the hand, although with small children and

infants, a prick test may be utilized instead.

The white blood cell count may be abnormal for a number of reasons,

including stress. A normal result for a WBC Count test is 4,500 – 10,000


WBC/mcL although this range can vary depending on the laboratory

interpreting the test.36 Medication may interfere with test results, decreasing

or increasing WBC. Some medications that interfere with test results include:

antibiotics, antithyroid medication, certain chemotherapy medication,

anticonvulsants, albuterol and other beta adrenergic agonists, epinephrine,

heparin, corticosteroids, and lithium. Its important to realized that

individuals without a spleen will have a higher WBC count.

Arterial Blood Gas

A blood gas test measures how much oxygen and carbon dioxide is in the

blood. Additionally, it determines the acidity, or pH, of the blood.31 The test

is performed by taking blood from an artery. The test can be performed

through collecting blood from the radial artery (in the wrist), the brachial

artery (in the arm), or the femoral artery (in the groin).

Blood gas tests are most frequently utilized to evaluate conditions that affect

the lungs because the test evaluates the effectiveness of therapies that

involve oxygen. However, the blood gas test also evaluates blood pH, so it

can reveal important information about the way the lungs and kidneys are

functioning. Since the kidneys are quite frequently impacted severely when

an individual develops sepsis, this is an important test. Normal results in a

blood gas test are:31

Partial oxygen pressure (PaO2) – 75 – 100 mmHg

Partial carbon dioxide pressure (PaCO2) – 38 – 42 mmHg

Arterial blood pH of 7.38 – 7.42

Saturation of oxygen (SaO2) – 94 – 100%

Bicarbonate – (HCO3) – 22 – 28 mEq/L (mEq/L equals milliequivalents

per liter; mmHg equals millimeters of mercury)


Blood gas values are depicted at sea level. At high altitude (3,000 feet and

higher), O2 values are lower.

Risks associated with this test are much the same as the minimal risks

associated with any other blood draw, although there is a slightly higher risk

for bruising since the blood is drawn from an artery instead of a vein in most

cases. Additionally, as always, it is important to note that there is a slight

risk of infection as a result of the test. Infection is always a possibility when

there is a break in the skin.

Kidney Function

Kidney function tests are utilized to determine how well the kidneys are

functioning. Common kidney function tests include the following.

Blood Urea Nitrogen (BUN):

The urea nitrogen is what is left over after protein breaks down. This is the

test that is done to measure how much urea nitrogen there is in the blood.32

This test is done by blood draw. Blood is drawn from the inner elbow on

from a vein located on the hand.

Medication may interfere with test results. This test is designed to check how

well the kidneys are or are not functioning. A normal BUN result is 6 – 20

mg/dL, although this result may vary depending on what measurement the

laboratory uses.32 If the result is abnormal it can mean different things. In

people with sepsis, a high level generally means that they are dehydrated,

are in kidney failure, have experienced extreme trauma, or are in shock. A


low level in patients with sepsis can mean that the kidneys are fine but that

they are experiencing liver failure or are having nutritional deficits.

Creatinine:

This is a blood draw that measures how much creatinine – the chemical

waste result of creatine – is in the blood.33 This is a test designed to

determine how well the kidneys are or are not working. Should the kidneys

not be functioning the way they should, the creatinine level will be

abnormally high. Medication may interfere with test results, and certain

medications may need to be stopped temporarily. These medications include

certain chemotherapy drugs, some drugs that damage the kidneys, NSAIDS,

Cimetidine, and Trimethoprim.

A normal Creatinine Blood Test result is 0.7 – 1.3 mg/dL in men and 0.6 –

1.1 mg/dL in women.33 If their creatinine levels are off, individuals with

sepsis will generally have higher than normal creatinine levels, indicating

damage or infection in the kidneys or kidney failure. This is a common

problem in individuals who have developed sepsis.

Urine Creatinine:

This test measures how much creatinine is in the urine.34 The patient simply

provides a urine sample, which is then tested in a laboratory. Medication

may interfere with test results, and certain medication may need to be

stopped temporarily. These medications include Cimetidine, certain

antibiotics (including trimethoprim and cefoxitin), and Cisplatin.


A normal Creatinine Urine Test result is 500 – 2000 mg/day (24 hour

period). The result may vary depending on what measurement the

laboratory uses.34

Creatinine Clearance:

This test offers information regarding how well the kidneys are or are not

functioning by comparing the creatinine level in the blood as well as the

creatinine level in the urine.35 Both a blood draw and a urine sample are

required for the test. Medication may interfere with test results. This test is

generally performed in order to estimate glomerular filtration rate (GFR),

which provides information on how well the kidneys’ glomeruli are filtering.

A normal Creatinine Clearance Test result is 97 – 137 ml/min for men and

88 – 128 ml/min for women. Results may vary depending on what

measurement the laboratory uses.35 Patients with sepsis frequently present

with creatinine clearance levels that are lower than normal. This can mean

that their kidneys are damaged or infected, or are failing.

Prognosis

Prognosis is linked to how severe or what stage the sepsis has progressed. It

is also linked to the health of the patient. For instance, a patient who has no

sign of ongoing organ failure when they are diagnosed with sepsis only has

about a 15% to 30% chance of dying.37 However, Sepsis can be and often is

life-threatening, particularly for those individuals who have weakened

immune systems as well as for those with chronic illnesses. Many individuals

who develop sepsis do not survive.38 If there is a delay in prompt and swift


treatment, there is approximately a 40% mortality rate, which rises to

approximately 60% should the patient experience septic shock.33 Infants and

children who have developed sepsis have approximately a 9% to 36%

mortality rate.37 The elderly population has the highest mortality rates.39

Researchers have developed the Mortality in Emergency Department Sepsis

(MEDS) scoring system, which is based on a patient’s symptoms to

determine the patient’s prognosis.40

The MEDS scoring system utilizes 7 historical exam and laboratory findings

in a simple point system. The scale is designed to identify those patients

who are at a high risk for death.41 Patients who have scores in the highest

category on the MEDS system have a predicted mortality rate of 50%. The

scale is also useful in terms of predicting mortality at 1 year.42 Additionally,

the scoring system assists practitioners in identifying those individuals who

require care in an intensive care unit as well as require other more extreme

interventions, such as sedation or ventilation. Sepsis may also cause

considerable long-term damage that can take some time to improve as well

as lead to permanent, life altering consequences, such as amputations.

Damages created as a result of reduced blood flow to vital organs such as

the kidneys, brain, or heart may take a long time to improve; there may

also be reduced function in these organs.

Additionally approximately 50% of sepsis survivors suffer from post-sepsis

syndrome,3 which leaves sufferers with long-term mental and physical

difficulties, including insomnia, nightmares and hallucinations, extreme

fatigue, panic attacks, problems concentrating, and a decrease in cognitive

function. Sepsis survivors, who have spent time in the ICU, especially if they

have been sedated or on ventilation, may experience post-ICU syndrome


(PICS), a prolonged period of delirium in which cognitive function is

reduced.3

Prevention

Preventing sepsis starts by preventing the infection from occurring. If any

infection does occur then that infection should be treated very quickly and

effectively in order to prevent sepsis. An infection is always what causes

sepsis. Usually a bacterial infection is the cause of sepsis, but sometimes

viruses or fungi can cause sepsis as well. Therefore, preventing the infection

is the number one way to prevent sepsis.1 For hundreds of years, the human

immune system has been the way to protect from infection; although

modern medicine does a good job at saving lives, it also increases a person’s

risk at developing sepsis because many advances in medicine also weaken

the human immune system. Some of these advances include such things as

chemotherapy, medication utilized to treat rheumatoid arthritis or

gastrointestinal illness, or medication utilized to help with organ rejection

following organ transplant.

Those individuals who have had certain chronic diseases such as kidney or

liver disease also often have weakened immune systems, as are those

individuals who are older or who have had a major operation or injury. Also,

the very young or elderly individuals are more likely to get infections such as

pneumonia, ear infections, or sinusitis, which may in turn lead to sepsis.

There are a number of vaccinations for young children that can assist with

immunity to pneumococcus pathogens. It is important to vaccinate young

children.


Individuals who are without a spleen must have vaccinations as well as be

educated regarding their heightened risk of infection. It is important for

those without a spleen or for those who do not have a fully functional spleen

to be vaccinated against pneumococcus, meningococcus, and haemophilus,

as these individuals have a much greater risk of sepsis. This risk remains life

long and many people without a spleen, or who have reduced spleen

function, have not been educated on this risk. Additionally, these individuals

must be treated with antibiotics prior to surgery.

Another important preventative measure to reduce sepsis death is to reduce

the use of antibiotics. This will reduce the growing bacterial resistance to

antibiotics. Practitioners have utilized antibiotics excessively in recent years,

which has led to an increase in bacterial resistance to antibiotics. Steps can

be made in this area by utilizing antibiotics prudently and for appropriately

lengths of time. Another area that must be addressed is improved hygiene

conditions in areas that have reduced resources. In certain areas of the

world, hygiene for treating wounds and giving birth is tremendously

unsanitary. These conditions may start infection that can in turn lead to

sepsis. A starting point in these areas is to promote effective hand hygiene

as well as improvements in nutrition and sanitation, as well as clean water

delivery.

Personal Hygiene

The best way to prevent sepsis is to prevent the infection from setting in to

begin. Infections may be reduced by properly caring for all wounds, even

down to the tiniest cut or scrape. This can be accomplished through proper


hygiene. Thoroughly cleaning the wound with soap and water can assist in

removing bacteria that may have entered the opening of the wound.

The risk of infection drops dramatically by following proper hand washing

procedures.43 Proper hand hygiene is the number one way to decrease the

amount of pathogens that may enter the human body, and it is essential to

understand why and how proper and frequent hand hygiene is so beneficial

to infection prevention. Hand washing is essentially a “do it yourself

vaccine.”44 There are five simple, effective steps to hand washing. These

include: Wet, Lather, Scrub, Rinse, and Dry. These steps help reduce the

spread of many illnesses and help people stay healthy. Regular hand

washing before and after activity is a great way to help remove germs and

avoid infection as well as avoid spreading germs to other people.

A number of infections are spread simply through poor hand hygiene. Feces

from people and animals are a major source of germs such as salmonella, E.

coli, and norovirus. These may spread certain respiratory infections such as

adenovirus.45 These germs can get onto the hands after individuals change a

baby’s diaper or use the toilet, although there are other ways individuals

may acquire these germs, for instance, handling raw meat. Even a tiny

amount of human feces – an amount as small as a single gram – can contain

up to 1 trillion germs.45 Germs can also be transferred onto the hands if an

individual touches an object that already has germs on it as a result of

another individual coughing, sneezing, or even touching it. If these germs

get on the hands and are not washed off, then they have the potential of

being passed to another person and potentially infecting that person and

making him or her sick.


Washing hands with soap helps remove the germs and prevent infection. In

a number of ways, hand washing helps by:

Washing away germs that may get into the body by way of the eyes,

nose, and mouth; People often touch their eyes, nose, or mouth

without realizing it and transfer germs into their bodies, making

themselves sick.

Washing away germs that may transfer to food or drink that people

then consume; there is a risk that germs transferred to food or drink

may multiply and then make an individual ill.

Washing away germs that may transfer to other objects, such as toys,

countertops, or handrails; these items may then be touched by others

and the germs spread, causing infection and illness.

Overall, teaching individuals about hand washing assists in keeping

individuals and their communities healthy. Communities who are educated

on hand washing see:45

A reduction in the number of people who are sick with diarrhea by

approximately 31%;

A reduction in diarrheal illness in those individuals who have weakened

immune systems by approximately 58%; and,

A reduction in respiratory illnesses such as colds by approximately

21%.

Hand washing education has come a long way, but it still has a way to go

worldwide. Approximately 2.2 million children ages 5 and younger die every

year from pneumonia and diarrheal disease, and although many people


worldwide wash their hands using water, many do not wash with both soap

and water. Utilizing soap and water together has been proven much more

effective at removing germs. Washing with soap and water may help protect

approximately 1/3 of children who get diarrheal disease and 1/6 of children

who get pneumonia from life-threatening infection.45

How to Wash The Hands – Basic Technique

While hand hygiene itself is an important first step, knowing how to properly

wash your hands is of equal importance.46 First, use either warm or cold

clean running water to wet your hands, turn off the water, and apply soap.

Never place hands in a sink full of standing wander, as they may become

contaminated by whatever germs are present in the water from previous

use.47 The temperature of the water is not of great importance, although

warmer water may cause greater skin irritation. It is also more costly to the

environment.48-50 Utilizing soap is more effective than simply using water on

its own. Also, people scrub their hands more when they use soap, which

removes germs more effectively.51-54

When to Use Hand Sanitizer

Washing hands utilizing soap and water is ideal; however, if soap and water

is not available, hand sanitizer may be useful in some cases. The best hand

sanitizer is one that is alcohol based and contains a minimum of 60%

alcohol.56 This concentration of alcohol is important because studies have

indicated that hand sanitizers that have alcohol concentrations between 60%

and 95% are more effective when it comes to killing germs than sanitizers

that have a lower concentration.57-58 Additionally, hand sanitizers that are

not alcohol based may not work as well for all germs and they may lead to


some germs developing a resistance to the sanitizer. Also, hand sanitizers

that are not alcohol based are sometimes more likely to cause skin irritation

than are alcohol based hand sanitizers.57,58

One important thing to note about hand sanitizers is that they can reduce

the amount of germs on hands quickly, but they are not effective at

eliminating all types of germs. This is because many people often do not use

enough sanitizer or they wipe the sanitizer off before it has had a chance to

dry.59 Further, soap and water are still more effective than are hand

sanitizers when it comes to removing or inactivating many kinds of germs,

for example, Cryptosporidium, Clostridium difficile, and norovirus.60, 61

Intravenous Infusions and Catheters

Short Peripheral Intravenous Catheters (PIVC) are essential tools in modern

healthcare settings. They are most commonly utilized for vascular access,

and they are utilized more than 300 million times in the United States in

hospitals alone. However, their usage comes with risks, specifically the risk

of infection. Infection may occur around the infection site, or the individual

may develop sepsis when infection enters the bloodstream after catheter

insertion. These infections were previously thought to be relatively low in

number, but statistics show that they are on the rise and cause around

90,000 deaths annually. These infections cost approximately $4.5 billion

annually in the United States alone.63 One study by Rhode Island Hospital

indicated that greater than one in every ten catheter related bloodstream

infections were caused by short peripheral intravenous catheters that had

become infected.63 Some of the risk factors for infected intravenous site are

an extended catheterization, concurrent infection, the intravenous catheter


having been poorly inserted, and the catheter not having been taken care of

properly.

Intravenous catheters can cause infection because they penetrate the skin,

which creates an opening for bacteria, viruses, and fungi to enter the

bloodstream. Antiseptics can’t eliminate every organism that has entered the

opening, although proper catheter care can help reduce the likelihood that

an infection will occur. During insertion of the catheter, the needle and the

catheter pass through the skin and come into contact with the bacteria,

viruses, and fungi. The needle is removed; however, the catheter remains in

place and is accessed repeatedly in order to administer medication to the

patient, flush the line, and change things such as tubing or caps. Each of

these actions may potentially introduce new microorganisms into the

individual’s system. One study found that catheters that have been removed

as a result of complications such as leakage, phlebitis, or infiltration had

higher rates of culture-positivity. It is possible that the practice of

maneuvering leaking or occluded catheters offers an opportunity for

contaminants, thereby perpetuating infections of intravenous devices. The

affected devices include peripheral venous catheters, which are

contaminated by microorganisms that have colonized the skin surrounding

the insertion site.

The majority of patients who have phlebitis do not have systemic infection;

however, those with phlebitis have an 18 times greater risk of developing

sepsis than do those who do not have phlebitis. Further, approximately 50%

of those with catheter related sepsis also have phlebitis.63 Should an

individual have phlebitis, it is often suggestive that sepsis infection is of an


intravenous related origin. There are ways to minimize the chances of an

intravenous catheter infection. One way to do this is to make certain that

the PIVC is placed and held securely. Even if the catheter moves a small bit,

the patient is at a higher risk for complications, and these complications are

linked to a greater likelihood of sepsis.

Once the PIVC has been inserted, the catheter should be firmly placed and

held in such a way as to prevent any movement that may cause trauma to

the cannulated vein that would then facilitate entry of bacteria, viruses, or

fungi into the catheter insertion site. Tape has not been shown to be

adequate when it comes to securing catheters; it may still contribute to

movement, which can then lead to infections. However, tape is still

commonly utilized in securing intravenous catheters, either on its own or in

tandem with other dressings. Studies have shown that non-sterile tape,

when it is placed close to the intravenous insertion site for long periods of

time, may lead to infection, which in turn may lead to sepsis.64 Additionally,

it is important to note that tape can injure fragile skin. The skin is a patient’s

first level of defense when it comes to infection, so it is important to keep

the skin barrier as intact as possible. Additionally, it’s important to recognize

the amount of time that a patient has an intravenous catheter in place. The

longer an intravenous catheter is in a patient, the more likely an infection

will develop. Additionally, patients who are administered intravenous “just in

case” – also known as “idle IVs,” which are administered in the event an

intravenous may be needed – frequently develop infections.

To help in reducing the likelihood that a patient with an intravenous catheter

will develop sepsis, the practitioner should use aseptic technique when


caring for intravenous catheter lines. Lines should also be removed as soon

as possible, or once the individual has been stabilized. Also, the patient

should be mobilized early and often in order to improve circulation and to

assist in the prevention of atelectasis and pneumonia. If mobilization is not

possible, then the individual’s lung function should be optimized through

deep breathing exercises and coughing as well as chest physiotherapy and

frequent position changes. Finally, patients should be monitored to make

certain that they are receiving adequate nutrition and appropriate hydration;

this will assist in decreasing the risk of infection.64

Summary

Sepsis is one of the most serious and expensive medical conditions that

practitioners face in their practices today, with more than $14 billion spent

every year on hospitalizations in the U.S. alone.1 Blood poisoning results

from infections that are often preventable if quick measures are taken to

prevent infection from occurring in the first place; however, should infection

occur and lead to sepsis, shock, multiple organ failure, and even death may

occur, as sepsis is very deadly for many people. Most cases of sepsis result

from disease or injury, and sepsis can result from injuries that seem

remarkably minor, such as small scrapes or cuts. Sometimes sepsis can

develop following routine or elective surgery as well. Sepsis remains a

primary cause of death from infection even though there have been huge

advances in modern medicine. Many people who develop severe sepsis do

not survive, with 40% of these people dying. Worldwide, 30% of people who

develop sepsis die.3


Of the individuals who survive sepsis, almost 50% develop post-sepsis

syndrome (PSS), a syndrome that leaves the individual with long-term and

often disabling difficulties.3 Other survivors may suffer difficulties that

include organ dysfunction or difficulties stemming from sepsis related

events, such as amputation. Some populations are more likely to develop

sepsis and more likely to develop complications. These groups include very

young children and infants, the elderly, as well as those in developing

countries. Sepsis remains a pervasive problem, but with ongoing patient

education and early intervention, sepsis is an issue that the health care

community can continue to confront and contain.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment

of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course

requirement.


1. Sepsis is:

a. A condition that starts on its own

b. A condition that is linked to another medical condition, such as

infection

c. A condition that only the elderly or very young children develop

d. A condition seen only in people with diseases such as cancer or

AIDS

2. Older adults who develop sepsis

a. Do so because their immune systems are less efficient

b. Do so because they often have chronic health problems

c. Do so because they may have an infection that lingered for some

time or was difficult to spot and developed into sepsis without a

practitioner noticing

d. All of the above

3. Some things that increase the risk of developing sepsis are

a. Age; i.e., being very young or being elderly

b. The presence of infection

c. Chronic health conditions

d. All of the above

4. Fever indicates

a. That a person has sepsis

b. That a person is delirious

c. Nothing on its own; it must be accompanied by another

symptom, such as a heart rate greater than 90 beats per

minute, to lead to a diagnosis of sepsis

d. That a person is going to die


5. Which of the following is NOT a type of white blood cell?

a. Neutrophils

b. Monocytes

c. Basophils

d. Erythrocytes

6. Normal results for neutrophils on a blood differential are in what

range?

a. 20% - 40%

b. 40% - 60%

c. 60% - 80%

d. 80% - 100%

7. In a WBC Count test, why do some medications, such as

antibiotics, need to be stopped temporarily prior to having the

test done?

a. Medication may interfere with the test results, decreasing or

increasing WBC

b. Medication may make the patient feel lightheaded when they go

to have their blood drawn

c. Medications such as antibiotics just aren’t a good idea

d. Taking medication prior to a WBC Count test is illegal

8. What is the best way to prevent sepsis from occurring?

a. Treat sepsis early and very quickly

b. Hit sepsis hard with antibiotics

c. Quarantine individuals who have sepsis immediately so they

don’t spread it to others

d. Prevent the infection from occurring


9. What extra precautions must individuals without a spleen take

where sepsis is concerned?

a. They must be educated regarding their higher risk for infection

b. They should be vaccinated against pneumococcus,

meningococcus, and haemophilus

c. They must be treated with antibiotics prior to surgery

d. All of the above

10. What is the minimum concentration of alcohol that is

recommended for hand sanitizer to be effective at killing germs?

a. 40%

b. 50%

c. 60%

d. 75%

Correct Answers:

1. b

2. d

3. d

4. c

5. d

6. b

7. a

8. d

9. d

10. c


References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

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http://www.world-sepsis-

day.org/?MET=SHOWCONTAINER&vCONTAINERID=11

2. Merinoff Symposia. Merinoff Symposia 2010: sepsis. Obtained March 20,

2014 from http://www.merinoffsymposia.org/sepsis-2010.html

3. Sepsis Alliance. Definition of sepsis. Obtained March 20, 2014 from

http://www.sepsisalliance.org/sepsis/definition/

4. Rory Staunton Foundation. Sepsis kills. Image obtained March 26, 2014

from http://rorystaunton.com/

5. Kunz A. Underrated disease keeps killing – world sepsis day 2012. Image

obtained March 26, 2014 from http://nbhap.com/articles/world-sepsis-

day/

6. National Institute of General Medical Sciences. Sepsis Fact Sheet.

Obtained March 20, 2014 from

http://www.nigms.nih.gov/Education/pages/factsheet_sepsis.aspx

7. Causes of Neonatal Sepsis. Image obtained March 26, 2014 from

https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcTWmel-

0ODLzIrwa_R0qa0662CwIs_

8FBvMeali786TrlMWKfFS-A


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9. Remick D. Pathophysiology of Sepsis. Am J Pathol. 2007;171(3):1078.

10. Hotchkiss RS, Dunne WM, Swanson PE, et al. Role of apoptosis in

Pseudomonas aeruginosa pneumonia. Science. 2001;294:1783.

11. Wesche DE, Lomas-Neira JL, Perl M, et al. Leukocyte apoptosis and its

significance in sepsis and shock. J Leukoc Biol. 2005;78:325–337.

12. Pfister D, Siegemund M, Dell-Kuster S, et al. Cerebral perfusion in

sepsis-associated delirium. Crit Care. 2008;12:R63

13. Cerejeira J, Mukaetova-Ladinska EB. A Clinical update on delirium: from

early recognition to effective management. Nursing Res and Practice.

2011. doi.org/10.1155/2011/875196

14. Ebersoldt M, Sharshar T, Annane D. Sepsis-associated delirium. Intensive

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http://www.patient.co.uk/


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