Sepsis is an infection with evidence of organ dysfunction. Septic shock is when a patient with sepsis is hypotensive despite appropriate fluid resuscitation.
One study has shown that for every hour delay in receiving treatment mortality increases by 7.4%. There is NO diagnostic test for sepsis. Your Trust will likely have a Sepsis Screening Tool to help identify patients who are at high risk of having sepsis.
- Evidence of new confusion
- Respiratory rate ≥25pm
- New oxygen requirement (40% FiO2 +)
- Systolic blood pressure ≤90mmHg or 40mmHg below usual
- Heart rate >130bpm
- Anuria/ low urine output
- Mottled, cyanosis or non-blanching skin rash
- Recent chemotherapy
Patients identified as being high risk should have the Sepsis-6 care bundle commenced as soon as possible to improve their chances of survival.
(1) Oxygen therapy
Remember, this is a drug and requires a prescription. As with all drugs, there are potential adverse events- the most important of which is type 2 respiratory failure. Patients at risk (hypercapnic/home NIV etc) should have lower target saturations and receive controlled oxygen. If in doubt, ask for help.
Oxygen should be titrated down to the lowest concentration required to maintain the appropriate target range, as evidence shows that saturations of 100% whilst on oxygen can have harmful effects.
(2) Intravenous fluids
Usually, 500ml bolus of a crystalloid but assess fluid status first and consider a reduction to 250ml boluses in the elderly or patients with known cardiac disease.
You must check the Trust antibiotic guidance which is often available on Microguide (an app). Guidance is based on local resistance profiles. In some hospitals, resistance is so high for broad-spectrum antibiotics that two antibiotics are advised. Secondly, the recommended antibiotic for a particular source may vary based on whether the patient triggers for sepsis or not. For example, in my trust, patients with severe pneumonia may receive IV benzylpenicillin & clarithromycin whereas patients with pneumonia & features of chest sepsis receive IV Pip-Taz & clarithromycin.
Remember, patients at risk of neutropenic sepsis (recent chemo) may trigger a separate antibiotic pathway.
The quick delivery of antibiotics in high-risk patients is an attempt to buy time for further diagnostics. If on review the patient is not felt to have an infection it is vital to stop antibiotic therapy to avoid resistance and side effects such as C. Diff and MRSA.
This is no different from screening for cancer & finding out a patient does not have it after further tests.
(4) Blood cultures
Ideally, these should be taken before the administration of antibiotics. However, if a significant delay is anticipated then give antibiotics first. Some trusts may recommend two sets (4 bottles) as this increases the chance of culturing an organism & helps microbiologists decide if a positive result is a contaminant.
Once an organism has been cultured and sensitivities ascertained antibiotics could be changed to something more narrow spectrum. This stewardship is critical to reducing resistance to first-line broad-spectrum antibiotics.
It is for these reasons that other relevant microbiology samples should be sent early too. Eg: sputum, wound swabs, urine, vaginal swabs.
If the patient has a central venous access line, peripheral and line blood cultures are best practice as sometimes the line can be saved if felt not to be the source.
Checking lactate is part of the screening tool (>2.0 suggesting a risk of sepsis) but people often forget to repeat the test as a means of assessing response to treatment.
Remember, sepsis is NOT the only cause of a high lactate. A high lactate in a patient with infection suggests they are septic. If you don’t think a patient has infection consider other causes such as bowel ischaemia or a heart attack.
The fastest method of checking lactate is via a venous (or arterial) blood gas. A laboratory lactate level takes longer to process and the sample needs to be transported from patient to lab ‘on ice’.
(6) Accurate urine output (fluid balance) measurement
Avoid urinary catheterisation if possible. However, if you don’t think the patient will be able to consistently use a bottle/bedpan/conveen for men/other or there is already evidence of renal failure, then catheterisation is advised.
This is a good time to review diuretic therapy, antihypertensives and other potentially nephrotoxic medication.
The local protocol may recommend escalating all septic patients to a senior, or at least critical care outreach.
All patients with signs of shock, high oxygen requirements or low urine output should be discussed with a senior as they may not respond to your treatments. The earlier decisions around ceilings of care are made the better for patients, their relatives and staff.
If a patient is already on antibiotic therapy and deteriorates with signs of sepsis, complete the sepsis-6 but have a low threshold to speaking to a microbiologist for advice on the best antibiotic. If the patient has been in for a prolonged period they may have a new hospital-acquired infection, therefore, don’t assume it is a failure to respond. Reassess for a secondary source.
Does your patient require isolation?
- Diarrhoea and vomiting
- Possible TB/ flu
- Fever in a returning traveller
- Recent hospital stay overseas
- Possible bacterial meningitis
- Other. If in doubt check local policy
Written By Dr Ruwani Rupesinghe (SpR)
With thanks to Dr Gemma Williams (Clinical Leadership Fellow & Paediatric Registrar)
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