Identification and management of sepsis

Sepsis is defined as life threatening organ dysfunction caused by a dysregulated host response to infection.

Could This Be Sepsis?

Need to suspect infection but patients may have a non-specific, non-localised presentation, e.g. feeling very unwell, and may not have a high temperature.

Consider:

Possible source of infection
Patient factors that increase risk of sepsis (see below)
Any new-onset abnormalities of behavior, circulation or respiration
Symptoms and signs of infection (see below)

People most vulnerable to sepsis

Extremes of age (<1 year or > 75 years) and frailty
Impaired immunity due to illness e.g. diabetes, splenectomy, sickle-cell disease
Impaired immunity due to drugs e.g. cancer chemotherapy/neutropaenia, long-term steroids, immunosuppressants
Surgery, or other invasive procedures, in the past 6 weeks
Any breach of skin integrity (e.g. cuts, burns, blisters or skin infections)
Misuse of intravenous drugs
Indwelling lines or catheters
Pregnant, have given birth or had a termination of pregnancy or miscarriage in the past 6 week

History

Symptoms consistent with infection, fever (not always present), rigors, factors that increase risk of sepsis, frequency of urination in past 18 hours, travel.

Examination

Localising signs of infection, mottled/ashen appearance, cyanosis, non-blanching petechial or purpuric rash, any breach of skin integrity, other rash indicating potential infection.

Evaluating Risk (NEWS2)

Use NEWS2 scoring as a way of identifying illness severity/clinical deterioration, urgency of review/investigation/antibiotic initiation and ongoing evaluation. Failing to recognise clinical deterioration promptly can be potentially life threatening.

NEWS2 Score	Risk of severe illness or death from sepsis	Urgency of review	Urgency of investigations and antibiotics	Recalculate NEWS2 score and re-evaluate
≥7	High	<30 mins (FY2+ doctor)	<1 hour	Every 30 mins
5-6	Moderate	<1 hour (FY2+ doctor)	<3 hours	Every hour
1-4	Low	<1 hour (nurse or doctor)	<6 hours	Every 4-6 hours if stable
0	Very low	-	-	Standard obs

Interpret NEWS2 scores in the context of the person’s underlying physiology and comorbidities.

Risk may be higher than suggested by NEWS2 alone if:

a score of 3 in any single NEWS2 parameter
deterioration/lack of improvement since previous NEWS2 score or an intervention
presence of mottling, non-blanching rash, cyanosis
lactate >2mmol/l
neutropenia
AKI

NEWS2 is for adults (16+). It should not be used for children or during pregnancy.

Initial Management

Urgency of assessment guided by NEWS2 score. Moderate-high risk patients should be assessed by a doctor FY2 or above. Assessment and management can include:

Blood investigations

blood gas (including glucose & lactate)
blood cultures (2 sets, adequately fillede. 10ml per bottle)
FBC, CRP, U&Es, LFTs, Coag

Antibiotics

Blood cultures should be taken before antibiotics given
Antibiotic choice guided by antimicrobial guidelines based on likely source of infection or microbiology results if already available
Urgency of antibiotic delivery guided by risk level/NEWS2 score (as per table above)

IV fluids

Fluid bolus within 1hr if high risk, lactate >2mmol/l or systolic BP <90mmHg
Fluid bolus: 500ml crystalloid over <15minutes
Repeat if no improvement

Oxygen

Give to achieve target saturation of 94-98% (88-92% if risk of hypercapnia)

Ongoing monitoring

Recalculate NEWS2 score with frequency guided by risk level (as per table above)
If high risk patient does not improve within 1 hour of any interventions
- Senior clinician review
- Referral to ICU if no improvement
- Inform the responsible consultant

Investigating And Controlling Source of Infection

It is important to investigate and control the source of infection. In moderate-high risk patients, source of infection should be identified within 3 hours and source control initiated within 6 hours.

Blood cultures x2 (before initiation of antibiotics)
Tailor other investigations (cultures/imaging) to symptoms/signs of infection e.g. urine for culture, viral and bacterial throat swabs, sputum for culture, CXR
CT imaging if no likely source identified after initial investigations
Involve surgeons/interventional radiology early if suitable for source control