Sepsis management

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

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

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