Sepsis is a potentially life-threatening clinical syndrome in which the body’s immune and coagulation system are activated by an infection. It may be accompanied by the ‘systemic inflammatory response syndrome’ (see below) and lead to septic shock. This guide gives an overview of the recognition and immediate management of sepsis (using an ABCDE approach).
This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not intended to be relied upon for patient care.
Definitions
Sepsis: life-threatening organ dysfunction due to a dysregulated host response to infection.
Systemic inflammatory response syndrome (SIRS):
Two or more of the following:
- Temperature >38°C or <36°C
- Tachycardia: >90 beats per minute
- Tachypnoea: >20 breaths per minute) or PCO2 <4.3kPa
- WCC >12 or <4 (or >10% immature (band) forms)
Septic shock: sepsis with hypotension that does not respond to adequate fluid resuscitation and/or evidence of end-organ dysfunction or failure (e.g. hypoxaemia, oliguria, lactic acidosis or cerebral hypoperfusion)
Clinical features of sepsis
Symptoms (often non-specific)
- Drowsiness
- Confusion
- Dizziness
- Malaise
- Localising symptoms of infection (e.g. productive cough, vomiting, diarrhoea, dysuria etc.)
Signs
- Tachycardia
- Hypotension
- Tachypnoea
- Cyanosis
- Fever/hypothermia
- Reduced urine output
- Rash
- Mottled/ashen appearance
Treatment principles
The Sepsis 6
Follow the sepsis six care bundle (complete within the first hour):
- Give high flow oxygen (monitor oxygen saturations – aim for SaO2 over 94%)
- Take blood cultures (see our guide here)
- Measure lactate levels
- Give IV antibiotics
- Give IV fluids (see our guide here)
- Monitor urine output
I like to remember these by pairing them as take 3 and give 3:
- Take blood cultures, give IV antibiotics
- Take lactate, give oxygen
- Take urine output, give IV fluids
Tips before you begin
- Treat all problems as you find them
- Re-assess regularly and after every intervention to see if your management is effective
- Make use of the team around you to delegate tasks where appropriate – is another clinical member of staff available to help you?
- All critically unwell patients should have continuous monitoring equipment attached for accurate observations (e.g. pulse oximetry)
- If you need senior input for your patient, call for help early using an appropriate SBARR handover structure (check out the guide here)
- Review results (e.g. laboratory investigations) as they become available
- Make use of medical school/hospital guidelines and algorithms for managing specific situations such as sepsis
- Any medications or fluids will need to be prescribed
- Your assessment and management should be documented in the notes (however this should not delay clinical management)
Initial steps
You are likely to see this patient after a brief handover from another member of staff.
Introduction
- Introduce yourself to the patient
- Ask the patient how they are feeling
- Pay attention to their ability to speak in full sentences (an inability to do this suggests significant respiratory distress)
Inspection
Perform a quick general inspection of the patient to get a sense of how unwell they are:
- Check consciousness level using AVPU
- How do they look?
- How is their breathing?
- What is around the bedside? (look for IV lines, sputum cup, vomit bags etc)
Preparation
- Make sure the patient’s notes, observation chart and prescription chart are on hand (however this should not delay initial clinical assessment and management)
- Ask for another clinical member of staff to assist you if possible
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Airway
Assessment
Can the patient talk?
YES:
- Airway is patent; move on to breathing assessment
NO:
- Look for signs of airway compromise (e.g. see-saw breathing, use of accessory muscles, diminished breath sounds, added sounds)
- Is the patient cyanosed?
- Open the mouth and inspect: is there anything obviously compromising the airway (e.g. secretions)?
Intervention
In any case of airway obstruction, seek immediate expert help from an anaesthetist. You may need the crash team. In the meantime, you can perform some basic airway manoeuvres to help maintain the airway.
Maintain the airway whilst awaiting senior input
1. Perform head tilt, chin lift manoeuvre.
2. If noisy breathing persists try a jaw thrust.
3. If airway still appears compromised use an airway adjunct:
- Insert an oropharyngeal airway (Guedel) only if unconscious (as otherwise patient may gag/aspirate)
- Alternatively, use a nasopharyngeal airway (better tolerated if the patient is partially conscious)
Breathing
Assessment
- Respiratory rate: likely to be high (if >20 this fulfils one of the criteria for SIRS)
- Oxygen saturations: aim for saturations above 94%
- Inspection: look for signs of respiratory distress (e.g. sweating, use of accessory muscles, abdominal breathing) as the chest may be the source of sepsis
- Palpation: chest expansion, tracheal deviation
- Percussion: dull percussion note with consolidation
- Auscultation: throughout both lungs noting air entry, reduced breath sounds, coarse crackles etc
Intervention
Oxygen
- High flow oxygen (15L / min) via a non-rebreather mask (provided patient is not a CO2 retainer)
Investigations
Chest x-ray
- To assess for evidence of a septic source (e.g. consolidation or effusion)
- This investigation is a key component of a full septic work up
- Check out our CXR interpretation guide here
Circulation
Assessment
Observations
Blood pressure: assess evidence of haemodynamic compromise
- If BP is unrecordable call the crash team/cardiac arrest team
Capillary refill time: should be <2 seconds
Pulse: rate, rhythm, volume and character
- A bounding pulse may be an indicator of sepsis and a weak pulse suggestive of poor cardiac output
- An irregularly irregular pulse could be evidence of atrial fibrillation (which may or may not have been caused by sepsis)
Temperature: may be high or low in sepsis. If hypothermic (cold sepsis) consider warming with caution – seek senior help
Fluid output: oliguria may be a sign of severe sepsis (organ hypoperfusion)
Examination
Feel peripheries: warm/cold/cyanosed
Assess JVP: likely low in the context of septic shock
Cardiac auscultation:
- New murmur suggestive of endocarditis?
- Pericardial rub or muffled heart sounds (pericarditis)?
Investigations
Blood tests
- Full blood count (FBC) – to assess for raised white cells and anaemia
- Urea and electrolytes (U&Es) – to assess for acute kidney injury and electrolyte disturbances
- C-reactive protein – to assess for evidence of infection
- Lactate – if raised suggests reduced end-organ perfusion
- Glucose – part of the sepsis screen
- Coagulation studies – to assess for evidence of disseminated intravascular coagulation
- Blood cultures – to isolate the causative organism – ideally these need to be taken before administration of antibiotics (but antibiotics should not be significantly delayed as a result)
Arterial blood gas
- Assess the extent and severity of any respiratory failure
- Measure lactate
- See our guide to taking an ABG and interpreting an ABG
Intervention
IV access
Gain IV access to allow administration of antibiotics and fluids (see our guide here)
Antibiotics
- If sepsis is suspected, broad-spectrum IV antibiotics should be commenced as soon as possible (within 1 hour of presentation), as this has been shown to significantly improve outcome
- Antibiotics should be prescribed in keeping with local guidelines
IV fluids
Patient’s with sepsis often have signs of hypovolaemia or shock due to shifts in fluid distribution within the body. As a result, they require IV fluid resuscitation to maintain adequate end-organ perfusion. See our guide to prescribing IV fluids.
ECG
All patient presenting with tachycardia should have a 12 lead ECG (see ECG interpretation).
Disability
Assessment
- Assess level of consciousness using AVPU or GCS
- Check drug chart for opioids, sedatives, anxiolytics and antihypertensives
- Check blood glucose: 4.0 – 11.0 mmol/L is normal
Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. The crash team may be needed. Be very cautious of a patient not maintaining their own airway if the GCS is reduced.
Exposure
Assessment
It may be necessary to fully expose the patient to complete a full assessment. Remember to prioritise patient dignity and conservation of body heat.
Look for:
- Rashes – e.g. the non-blanching petechial rash of meningococcal sepsis
- Evidence of wound/surgical site infections
Reassess ABCDE
It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows continual reassessment of the response to treatment and early recognition of deterioration.
If the patient does not respond to treatment or deteriorates, critical care input should be involved as soon as possible.
Next steps
Well done! You’ve stabilised the patient and they’re doing much better. Just a few more things to do…
Take a history
Take a more detailed history of what has happened and how the patient has been. Involve staff or family members as appropriate.
Check out our history taking guides here
Review
Review the patient’s notes, observations, fluid charts, and any investigation findings. Double check the medications you have just prescribed, and any routine medications the patient is taking.
Document
Document your ABCDE assessment clearly, including examination, observations, investigations, interventions, and patient response/changing condition. Write down any pertinent details from your history-taking.
Discuss with seniors
If a senior doctor hasn’t already been involved, it is important to contact them and make them aware of the unwell patient. As a junior doctor, it would be appropriate to give an SBARR handover outlining your assessment and actions, and to discuss the following:
- Are any further assessments or interventions required?
- Does the patient need a referral to HDU/ICU?
- Should they be referred for a review by a speciality doctor?
- Should any changes be implemented to the management of any underlying conditions?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has become acutely unwell.
References
- BMJ Best Practice. Available here: http://bestpractice.bmj.com/best-practice/monograph/245/treatment/step-by-step.html
- UK Sepsis Trust. Clinical Tools: Sepsis 6. Available here: https://sepsistrust.org/education/clinical-tools/
Editor
Andrew Gowland
