Sepsis management

Acutely Unwell Patients > Managing other emergencies

Include in assessment

Observations
Sepsis signs (capillary refill, skin temp, pulse etc.)
Look for infection sources (multi-system exam; iatrogenic sources, e.g. surgical wounds, drains, cannulas, lines; exposure e.g. look at skin, joints etc.)
Investigations: to find source (septic screen) and to look for complications/organ dysfunction
- Bloods (especially look at Hb, WCC/neutrophils, platelets, INR, bilirubin)
- VBG (lactate)
- Blood cultures
- Capillary glucose
- Urine dip and culture any other fluids
- CXR
- Other relevant imaging (e.g. CT abdomen if possibility of surgical collection)

Sepsis is an infection with a systemic response.

Identifying a patient with sepsis

Think about it in any patient who has a suspected infection
Use clinical judgement to determine whether a patient has sepsis
They must have a suspected infection (e.g. symptoms, fever) and a systemic response causing life-threatening organ dysfunction
Risk factors = very young, frail/elderly, recent surgery/trauma (<6weeks), impaired immunity (illness or immunosuppression), indwelling catheters/lines, IV drug use, breaks in skin integrity
Lactate correlates with severity (<2mmol/L = mild; 2-4mmol/L = moderate; >4mmol/L = severe)

Parameters suggesting risk of severe illness/death from sepsis

	High risk	Moderate to high risk
Mental status	Objective altered metal state	History of altered mental state/behaviour or deterioration of functional ability
Respiratory rate	≥25 (or new oxygen requirement)	>20
Heart rate	>130	>90
Systolic blood pressure	≤90 (or >40 below normal)	≤100
Urine output	<0.5ml/kg/hour (or no urine in >18 hours)	<1ml/kg/hour (or no urine in >12 hours)
Others	Cyanosis or mottled/ashen appearance	Impaired immunity (illness or immunosuppression)

Reference: NICE ‘NG51 sepsis: recognition, diagnosis and early management’ 2017

End organ dysfunction due to sepsis

System	Condition	Signs	Management
Respiratory	Acute respiratory distress syndrome	Impaired oxygenation, tachypnoea, infiltrates on CXR	Mechanical ventilation
Cardiovascular	Myocardial dysfunction/failure, hypovolaemia, septic shock	Persistent hypotension (SBP<90)	Inotropes/vasopressors
Kidneys	Acute kidney injury	Urine output <0.5ml/kg/hour or creatinine >50% baseline	Renal replacement therapy if required
Liver	Liver dysfunction	Bilirubin ≥35µmol/L and ALP/ALT >2x normal	No specific treatment
Coagulation	Coagulopathy/disseminated intravascular coagulation	Thrombocytopenia, prolonged PT, low fibrinogen, high D-dimer	Blood products (red cells, platelets, FFP, cryoprecipitate)
Nervous system	Encephalopathy	New confusion/↓GCS	No specific treatment

NB: septic shock is sepsis with refractive hypotension despite adequate fluid resuscitation.

Management

Sepsis Six

Should be performed within 1 hour…

3 IN:
- Oxygen
- Fluids (adequate fluid resuscitation is normally 20-30ml/kg quickly)
- Antibiotics
  - Choice depends on hospital protocol
  - Target source of infection if clear
  - Broad-spectrum if source unclear
3 OUT:
- Blood cultures
- Lactate and Hb
- Catheterise (to measure urine output, i.e. renal end-organ dysfunction)

Other aspects to management

Use an ABCDE approach (see ABCDE management)
Some sources may require surgery (abdominal collections, joints, necrosis)
Support organ failure (may require ICU, e.g. for vasopressors, intubation, or renal replacement therapy)
If patient is still hypotensive despite adequate fluid resuscitation (20-30ml/kg) or becoming fluid overloaded, they need vasopressors/inotropes

Test yourself with some questions

Which are the common bacteria to cause sepsis in immunocompetent patients?

Oops! This section is restricted to members. Click here to signup!

Which antibiotics would be appropriate for neutropaenic sepsis and why?

Oops! This section is restricted to members. Click here to signup!

Which types of IV fluid are appropriate for fluid resuscitation for patients with sepsis?

Oops! This section is restricted to members. Click here to signup!

What is the problem with giving excess 0.9% saline?

Oops! This section is restricted to members. Click here to signup!

And here are some OSCE stations

No comments yet

Leave a Reply Cancel reply

You must be logged in to post a comment.

Don't take our word for it

"The stations you provide are strikingly similar to those I came across during my medical school finals (some even verbatim!), and I have tried many other exam platforms. I'm truly grateful for your priceless support throughout my final couple of years at medical school!"

Raza Q

"It has absolutely everything for medical school, so many histories with detailed differential diagnoses, how to approach emergencies, commonly prescribed drugs..every kind go examination you’ll ever need in osces"

John R

"Thank you SO MUCH for the amazing educational resource. I’ve tried lots of platforms and books with mock OSCE stations and yours is by far and away the best I’ve tried"

Ed M

"Get this right away. So helpful for OSCEs but also general clinical learning and understanding. Wish I had brought it sooner"

Emma W

"Without a doubt, your platform outshines all other OSCE resources currently available. In all honesty, I can confidently attribute my success in securing a distinction in my finals to OSCEstop."

Harish K

"OSCEstop distinguishes itself from many other platform banks by offering a wealth of questions that mimic the demanding and complex aspects of our finals. This platform played a crucial role in ensuring I was ready for the level of difficulty that awaited me in my final exams."

Natasha W

Learning notes: 246

Stations available: 207

Qbank questions: 2252

Conditions: 558

More:

More:

Pricing:

Sepsis management

Identifying a patient with sepsis

Parameters suggesting risk of severe illness/death from sepsis

End organ dysfunction due to sepsis

Management

Sepsis Six

Other aspects to management

Test yourself with some questions

And here are some OSCE stations

No comments yet

Leave a Reply Cancel reply

Managing other emergencies