Because of weakened immune systems and prolonged treatment courses, patients with cancer have a higher chance of developing sepsis. Once acquired, sepsis puts patients at risk for hospitalization and increased morbidity and mortality. Prevention and prompt management are essential to improve outcomes.
In their article in the February 2020 issue of the Clinical Journal of Oncology Nursing, Boucher and Carpenter outlined the nursing considerations required to prevent, recognize, assess, and manage sepsis in patients with cancer. Their recommendations are based on the Surviving Sepsis Campaign Hour-1 bundle, which is considered best practice for sepsis management.
Sepsis and Its Complications in Cancer
In 2016, the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) released new criteria to define and identify sepsis. It’s based on an assessment that assigns points for each of the following symptoms, and a score of at least 2 indicates sepsis, Boucher and Carpenter explained:
- Systolic blood pressure less than or equal to 100 mmHg (1 point)
- Respiratory rate greater than or equal to 22 breaths per minute (1 point)
- Altered mental status with a Glasgow coma scale less than 15 (1 point)
Immunosuppression from cancer treatments increases patients’ risk of developing infections from medical devices (e.g., stents or catheters, venous access devices) or clinical syndromes (e.g., enterocolitis), and respiratory infections are the primary cause of sepsis, Boucher and Carpenter wrote. Other contributing infections include intrabdominal, bloodstream, and urinary. Pathogens such as gram-positive (e.g., S. aureus, S. pneumoniae) and gram-negative (e.g., E. coli) organisms, fungi (e.g., Candida, Aspergillus), or viruses (e.g., herpes simplex, influenza A or B) are implicated.
The Centers for Disease Control and Prevention defined sepsis as previous symptoms of infection plus shivering, fever or feeling cold, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, shortness of breath, or high heart rate, Boucher and Carpenter wrote. Symptoms of general infection include fever, chills, or sweats; redness, soreness, or swelling in any area, such as surgical wounds and ports; diarrhea or vomiting; sore throat, cough, or nasal congestion; new mouth sores; shortness of breath; stiff neck; unusual vaginal discharge or irritation; new pain onset; or changes in skin, urination, or mental status. Boucher and Carpenter cautioned that older adults and immunocompromised patients may not exhibit typical signs and symptoms of sepsis, however.
National Comprehensive Cancer Network (NCCN) guidelines for assessing and diagnosing sepsis recommend taking a thorough medical history, including:
- Cancer diagnosis
- Comorbidities (e.g., autoimmune, kidney, liver, or respiratory disease; diabetes)
- Surgery or other cancer treatments
- Recent illnesses (e.g, influenza, infection)
- Recent travel (risk for communicable diseases)
- Recent hospitalizations (risk for nosocomial infection)
- Antibiotic regimens (potential for multidrug resistance)
Take a complete set of vital signs, including blood pressure, heart rate, respiratory rate, pulse oximetry, electrocardiogram, and arterial blood gases. Physically examine the head, eyes, ears, nose, and throat and the cardiac, pulmonary, gastrointestinal, genitourinary, integumentary, musculoskeletal, and neurologic body systems. Order a complete blood count with differential; NCCN recommends including two sets of peripheral blood cultures and wound, urine, and stool cultures.
Take swabs for influenza and strep and complete a respiratory viral panel; order a chest x-ray for suspected infection and computed tomography scans or magnetic resonance imaging if necessary. Clinical presentation, assessment, and diagnostic findings may suggest a need for lumbar puncture as well.
Managing Sepsis With the Hour-1 Bundle
SCCM and ESICM’s 2016 guideline was updated in 2019 into the Surviving Sepsis Campaign Hour-1 bundle. It recommends recognizing symptoms early, acting quickly to measure lactate levels in the first hour, taking blood cultures, and administering broad-spectrum antibiotics. For hypotension or lactate levels of 4 mmol/l or higher, provide supportive care with fluid resuscitation with 30 ml/kg crystalloid from hour 1 to hour 3 and vassopressors.
According to both Hour-1 and NCCN, treatment of the underlying sepsis depends on the type of infection and may include antibacterial agents and antibiotics for gram-negative and gram-positive organisms, metronidazole for anerobic organisms, antifungals for yeast infections, or antivirals for viruses. Treatment should begin promptly, even if all Hour-1 measures are not completed in the first hour (e.g., blood cultures).
What This Means for Oncology Nurses
Nurses are critical to recognizing sepsis symptoms early and implementing Hour-1 interventions quickly. They’re also acutely aware of the system barriers that may affect successfully completing Hour-1 measures and can advocate for change to improve patient outcomes.
Preventing infection is essential to stopping sepsis before it starts. Oncology nurses should ensure that patients are up to date on vaccinations and that prophylactic agents are used if indicated. Educate patients and family members on neutropenic diets (e.g., cooking foods thoroughly) and practices (e.g., handwashing, avoiding crowds or people who are sick).
For more information about recognizing sepsis and treating it with the Hour-1 bundle, refer to the full article by Bouchon and Carpenter.