Table of Contents
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
(any criteria) Produced using NICE ‘NG51 sepsis: recognition, diagnosis and early management’ 2016
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) |
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 – within 1 hour!
- 3 IN:
- Oxygen
- Fluids (adequate fluid resuscitation is normally 20-30ml/kg quickly – use 0.9% saline/Hartmann’s solution)
- 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