SEPSIS

Recognition

Definition

• “Life-threatening organ dysfunction caused by a dysregulated host response to infection”(The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA Feb 23, 2016 Volume 315 Number 8)

Risk Factors

• NICE guidance highlights (NICE guidance NG51)
  • Children under 1 year of age
  • Adults over 75 years old
  • People who are very frail
  • People who are immunocompromised
  • Patients post-surgery
  • People with any damage to the skin such as burns, blisters, wounds
  • Intravenous (IV) drug users
  • People with lines or catheters

History

• If possible, ascertain:
  • How the patient is feeling
  • What symptoms they have
  • Do they have any allergies

General symptoms

• Cough
• Shortness of breath (dyspnoea)
• Cyanosis
• Pale
• Clammy
• Sweating
• Cool peripheries
• Fever
• Rigors
• Dysuria

General Signs

• Tachypnoeic
• Low oxygen saturations
• Delayed capillary refill time
• Reduced skin turgor
• Dry mucous membranes
• Hypotensive
• Tachycardic
• Decreased urine output

Severity

NICE Risk stratification tool for adults, children and young people aged 12 years and over with suspected sepsis

Initial Assessment and Investigations

• ABCDE assessment
• Assess patient’s airway
• Monitor oxygen saturations and respiratory rate
  • If patient is hypoxic give Oxygen (O₂) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
• Target saturations:
  • 94 - 98% for patients not at risk of hypercapnic respiratory failure
  • 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Examine patient’s chest
  • Listen for:
    • Asymmetric breath sounds,
    • Crepitations
    • Increased resonance
    • Pleural rub
• Arterial blood gas (ABG) if concerned about patient’s ventilation
• Chest X-ray if concerned about the patient’s ventilation. If the patient is unwell request a portable X-ray
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es), Liver Function Tests (LFTS), Venous Blood Gas (VBG), Blood Cultures, C-Reactive Protein (CRP) and Clotting
• Check Capillary Refill Time (CRT) - hold for five seconds and refilling should occur in 3 seconds
• Assess pulse rate, rhythm and character
• Monitor heart rate and blood pressure
• Intravenous (IV) fluid bolus of 0.9% sodium chloride 250-500 ml over 10-15 mins as required by clinical picture and balanced with patients’ risk of fluid overload.
  • See more details in the “Circulation” Chapter in the “Response” Section under “Fluid Challenge”
• Listen to patient’s heart sounds
• Check urine output and consider catheterisation
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Check patient’s temperature and blood sugar
• If suspicion of sepsis ensure Sepsis 6 care bundle is completed (a useful neumonic for this is BUFALO)
  • B - take Blood Cultures
  • U - start Urine output monitoring/check U+E/Urinalysis and urine cultures if positive
  • F – Start Intravenous Fluids if not already done so
    •  0.9% Sodium Chloride 500 ml over 10-15 minutes. See more details in the “Circulation” Chapter in the “Response” Section under “Fluid Challenge”
  • A – Start Broad Spectrum Antibiotics
  • L – Check the Lactate (venous gas)
  • O – Apply Oxygen if not already done
• Examine patient’s abdomen and legs
• Consider venous thromboembolism prophylaxis
• Call for senior help if not done already

Response

Management

• Immediate pharmacological management
  • Start antibiotics as per trust guidance

Referrals

• Discuss with senior member of the team
• Contact critical care outreach team
• Consider referral to Intensive Care Unit (ICU) if:
  • Failure to respond to medical management
  • Patient requires ventilator support
  • Patient requires blood pressure support
  • Deterioration of blood gas despite full medical management