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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 statusObjective altered metal stateHistory 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)
OthersCyanosis or mottled/ashen appearanceImpaired immunity (illness or immunosuppression)

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

End organ dysfunction due to sepsis

SystemConditionSignsManagement
Respiratory Acute respiratory distress syndromeImpaired oxygenation, tachypnoea, infiltrates on CXRMechanical ventilation
CardiovascularMyocardial dysfunction/failure, hypovolaemia, septic shockPersistent hypotension (SBP<90)Inotropes/vasopressors
KidneysAcute kidney injuryUrine output <0.5ml/kg/hour or creatinine >50% baselineRenal replacement therapy if required
LiverLiver dysfunctionBilirubin ≥35µmol/L and ALP/ALT >2x normalNo specific treatment
CoagulationCoagulopathy/disseminated intravascular coagulationThrombocytopenia, prolonged PT, low fibrinogen, high D-dimerBlood products (red cells, platelets, FFP, cryoprecipitate)
Nervous systemEncephalopathyNew confusion/↓GCSNo 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?

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Which antibiotics would be appropriate for neutropaenic sepsis and why?

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

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What is the problem with giving excess 0.9% saline?

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And here are some OSCE stations

  1. Sepsis
  2. Neutropenic sepsis prescribing
  3. Find lots more here!

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Managing other emergencies