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ALL / Infectious Diseases
Sepsis
Sepsis
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. It is an important cause of morbidity and mortality and can be difficult to distinguish from uncomplicated infection early in the illness.The old term severe sepsis is no longer used. Septic shock is a more severe form of sepsis associated with circulatory, cellular and metabolic abnormalities and a higher risk of mortality.
NICE guidance now separates suspected sepsis guidance for:
- adults aged 16 years and over
- children and young people
- pregnant or recently pregnant people
Risk assessment
In acute hospital, ambulance and acute mental health settings, NICE recommends using NEWS2 to assess risk of severe illness or death from sepsis in adults.
| NEWS2 score | Risk category |
|---|---|
| 7 or more | High risk |
| 5-6 | Moderate risk |
| 1-4 | Low risk |
| 0 | Very low risk |
Clinical judgement should also be used. Concerning features include:
- mottled or ashen appearance
- cyanosis
- non-blanching rash
- acute deterioration in functional ability
- new confusion or altered mental state
- failure to improve despite treatment
In the community, NICE recommends assessing suspected sepsis using history, examination and clinical judgement.
| High-risk features | Moderate- to high-risk features |
|---|---|
|
Risk factors for sepsis or delayed recognition include:
- age >=75 years
- frailty
- impaired immune function
- severe chronic disease or multimorbidity
- indwelling vascular lines or urinary catheters
- breach of skin integrity
- recent surgery or invasive procedure
- communication difficulties, including learning disability, cognitive impairment or language barrier
Management
Management depends on the risk category, clinical setting and likely source of infection. The underlying infection should be identified and treated, with appropriate source control where required.
For adults at high risk of severe illness or death from sepsis:
- arrange urgent assessment by a clinician competent in acute illness
- take bloods, including FBC, U&E, CRP, blood gas with glucose and lactate, and blood cultures
- give broad-spectrum intravenous antibiotics within 1 hour of calculating the NEWS2 score
- give oxygen if needed to achieve target saturations
- give intravenous fluids if there is shock or evidence of hypoperfusion
- monitor urine output
- escalate to a senior decision-maker and consider critical care input
For adults at moderate risk:
- assess urgently and look for alternative diagnoses
- antibiotics may be deferred for up to 3 hours while diagnostic information is gathered
- if antibiotics are indicated, give them without further delay
- if there is lactate >2 mmol/L, acute kidney injury or other evidence of hypoperfusion, manage as high risk
For adults at low risk:
- investigate and treat the likely infection
- antibiotics may be deferred for up to 6 hours while clarifying the diagnosis
- give safety-netting advice and review if the patient deteriorates
Oxygen targets:
- aim for SpO2 94-98% in most adults
- aim for SpO2 88-92% if at risk of hypercapnic respiratory failure, for example COPD
Intravenous fluids:
- use an isotonic crystalloid, preferably a balanced crystalloid such as Hartmann's solution
- give an initial 250 ml bolus over 10-15 minutes, unless contraindicated
- reassess after each bolus
- repeat boluses if needed, up to 1 litre in total
- seek senior advice if there is inadequate improvement after 1 litre
If hypotension or hypoperfusion persists despite adequate fluid resuscitation:
- discuss urgently with critical care or a senior clinical decision-maker
- noradrenaline is usually the first-line vasopressor
- it is ideally given via a central venous catheter
- however, it may be started peripherally if central access would delay treatment
- if given peripherally, use local protocols for concentration, dose limits, cannula site and monitoring
- monitor the cannula site closely for extravasation
Neutropenic sepsis
Suspect neutropenic sepsis in any patient who becomes unwell after systemic anticancer treatment, particularly within the previous 30 days. It should also be considered in patients receiving immunosuppressive treatment if neutropenia is possible. Suspected neutropenic sepsis requires immediate emergency assessment and treatment.
+PassMedicine Notes
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. It is an important cause of morbidity and mortality and can be difficult to distinguish from uncomplicated infection early in the illness.
The old term severe sepsis is no longer used. Septic shock is a more severe form of sepsis associated with circulatory, cellular and metabolic abnormalities and a higher risk of mortality.
NICE guidance now separates suspected sepsis guidance for:- adults aged 16 years and over
- children and young people
- pregnant or recently pregnant people
Risk assessment
In acute hospital, ambulance and acute mental health settings, NICE recommends using NEWS2 to assess risk of severe illness or death from sepsis in adults.
NEWS2 score _ Risk category| 7 or more _ High risk| 5-6 _ Moderate risk| 1-4 _ Low risk| 0 _ Very low risk| Clinical judgement should also be used. Concerning features include:- mottled or ashen appearance
- cyanosis
- non-blanching rash
- acute deterioration in functional ability
- new confusion or altered mental state
- failure to improve despite treatment
In the community, NICE recommends assessing suspected sepsis using history, examination and clinical judgement.
High-risk features _ Moderate- to high-risk features|- Responds only to voice or pain, or unresponsive
- New confusion
- Systolic BP 40 mmHg below normal
- Heart rate >130/min
- Respiratory rate >=25/min
- New need for oxygen
- Mottled, ashen or cyanotic appearance
- Non-blanching rash
- Not passed urine in previous 18 hours
- Lactate >=2 mmol/L
- Recent systemic anticancer treatment _
- Relatives concerned about mental state
- Acute deterioration in functional ability
- Immunosuppression
- Trauma, surgery or invasive procedure in previous 6 weeks
- Respiratory rate 21-24/min
- Systolic BP 91-100 mmHg
- Heart rate 91-130/min, or new dysrhythmia
- Not passed urine in previous 12-18 hours
- Temperature =75 years
- frailty
- impaired immune function
- severe chronic disease or multimorbidity
- indwelling vascular lines or urinary catheters
- breach of skin integrity
- recent surgery or invasive procedure
- communication difficulties, including learning disability, cognitive impairment or language barrier
Management
Management depends on the risk category, clinical setting and likely source of infection. The underlying infection should be identified and treated, with appropriate source control where required.
For adults at high risk of severe illness or death from sepsis:- arrange urgent assessment by a clinician competent in acute illness
- take bloods, including FBC, U&E, CRP, blood gas with glucose and lactate, and blood cultures
- give broad-spectrum intravenous antibiotics within 1 hour of calculating the NEWS2 score
- give oxygen if needed to achieve target saturations
- give intravenous fluids if there is shock or evidence of hypoperfusion
- monitor urine output
- escalate to a senior decision-maker and consider critical care input
- assess urgently and look for alternative diagnoses
- antibiotics may be deferred for up to 3 hours while diagnostic information is gathered
- if antibiotics are indicated, give them without further delay
- if there is lactate >2 mmol/L, acute kidney injury or other evidence of hypoperfusion, manage as high risk
- investigate and treat the likely infection
- antibiotics may be deferred for up to 6 hours while clarifying the diagnosis
- give safety-netting advice and review if the patient deteriorates
- aim for SpO2 94-98% in most adults
- aim for SpO2 88-92% if at risk of hypercapnic respiratory failure, for example COPD
- use an isotonic crystalloid, preferably a balanced crystalloid such as Hartmann's solution
- give an initial 250 ml bolus over 10-15 minutes, unless contraindicated
- reassess after each bolus
- repeat boluses if needed, up to 1 litre in total
- seek senior advice if there is inadequate improvement after 1 litre
- discuss urgently with critical care or a senior clinical decision-maker
- noradrenaline is usually the first-line vasopressor
- it is ideally given via a central venous catheter
- however, it may be started peripherally if central access would delay treatment
- if given peripherally, use local protocols for concentration, dose limits, cannula site and monitoring
- monitor the cannula site closely for extravasation
Neutropenic sepsis
Suspect neutropenic sepsis in any patient who becomes unwell after systemic anticancer treatment, particularly within the previous 30 days. It should also be considered in patients receiving immunosuppressive treatment if neutropenia is possible. Suspected neutropenic sepsis requires immediate emergency assessment and treatment.
