Sepsis Management Guidelines - ( Adults )

Publication: 01/11/2007  --
Last review: 10/11/2020  
Next review: 10/11/2023  
Clinical Guideline
CURRENT 
ID: 886 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Adult Sepsis Management Guidelines

Sepsis is the life-threatening organ dysfunction caused by a dysregulated host response to infection.

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Introduction

This guidance applies to all adult (16+) inpatient areas, acute admission areas and the emergency department.

This guidance applies to all clinical staff - nursing, medical and AHP (including temporary, agency staff and students). All staff must take responsibility for following the process described in these guidelines within their clinical competencies. When actions need to be taken that require another, or a more senior, member of the clinical team then referral must be made promptly and documented. Good team communication is key.

The management of Neutropenic sepsis is outside the scope of this document – please see Guidelines for the Management of Suspected Neutropenic Sepsis (Adults).

The management of sepsis in children is outside the scope of this document – please see “Considering Sepsis in Paediatrics” and “Guideline for the management of septic shock in children after the first hour”.

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Management Summary

RED FLAG SEPSIS IS A MEDICAL EMERGENCY AND SHOULD BE MANAGED AS SUCH

This process can be initiated by any member of the clinical team. When actions are required that are beyond your clinical competencies then refer promptly and document that you have done so. Teamwork and communication are key.

Patient looks unwell or NEWS is ≥ 5 or NEWS is ≥ 3 in any one parameter
Could this be sepsis? If probable or possible

Complete sepsis screening tool

  • Follow algorithm for Red Flag or Amber Flag as appropriate
  • Consider other/concomitant diagnoses
  • Document diagnosis of sepsis and inform patient and/or next of kin where feasible

RED FLAG SEPSIS

Any one of:

  • Evidence of new or altered mental state
  • Systolic BP <90mmHg (or drop of >40 from normal)
  • Heart rate >130 per minute
  • Respiratory Rate >25 per minute
  • Requires oxygen to keep SpO2 >92% ( >88% in COPD)
  • Non-blanching rash / mottled/ashen/cyanotic
  • Lactate >2 mmol/l
  • Recent Chemotherapy
  • Not passed urine in the last 18 hours (<0.5ml/hr if catheterised)
  • News  ≥7

IF RED FLAG SEPSIS CONFIRMED OR PROBABLE -> BUFALOS
If no Red Flags -> Assess for Amber Flags

B

Take Bloods

  • Take a minimum of 1 set of blood cultures aseptically (even if afebrile)
  • Before starting antibiotics unless this causes significant delay (>45 minutes delay to administration of antibiotics)
  • Paired cultures (ideally peripheral and central, taken simultaneously) should be sent when a central line is present
  • Take samples for FBC, U&E, LFT, clotting, glucose, and Venous gas.
  • Consider Group & Save
  • Clearly identify sepsis on request form
  • Send other cultures as appropriate (sputum, urine, wound swabs, CSF) for microbiology culture/sensitivity depending on suspected source of sepsis
  • Take 2 sets of blood cultures in a patients with prosthetic heart valves, pacemakers, known or new heart valve disease and vascular grafts
  • Link to blood culture sampling SOP

U

Monitor Urine Output and NEWS

  • Initiate strict hourly fluid balance
  • Urinary catheterisation strongly recommended unless contraindicated

F

Fluid Resuscitation

  • If BP systolic <90 mmHg or lactate >4 mmol/L give up to 30 mL/kg of Hartmann’s and reassess (in 250-500 ml boluses, assessing response each time)
  • Additional boluses of 250-500ml up to 60mL/kg can be given but get senior help before this
  • In patients with cardiac failure use 250 mL boluses with more frequent reassessment and get help earlier. A single 250ml bolus in a hypotensive heart failure patient is unlikely to cause significant harm

A

Antibiotics (IV)

  • Within 1 hour
  • Do not delay early empirical antibiotic therapy as this may prove lifesaving particularly in patients with shock or signs of organ failure
  • Refer to the Trust Antimicrobial Guidelines
  • Check allergy status
  • Review history of colonisation/previous infection with resistant organisms e.g. MRSA, ESBLs, CPOs
  • Discuss with Microbiology in complex cases
  • Ensure good prescribing practice with indication e.g. “Red Flag Sepsis – pneumonia”, duration and review date, correct name “Piperacillin/tazobactam” not “Tazocin” and time of prescription and administration

L

Lactate Monitoring

  • >2mmol/L = Red Flag sepsis, >4mmol/L = severe sepsis and independent risk factor for mortality
  • Take blood for serum lactate; use blood gas syringe and analyser for venous or arterial sample
  • Venous lactate can be requested as part of blood profile sent to laboratory however will take longer for result to be returned and therefore shouldn’t be routinely (Glucose/ Grey Top tube)
  • Initially repeat hourly if raised to ensure clearing to normal levels and not rising

O

Oxygen

  • Prescribe and apply oxygen to achieve targeted saturations
  • Check for history of hypercarbia/previous NIV
  • Titrate to target saturations as necessary
  • In patients with no coexisting lung disease the aim is for saturations ≥94%
  • If the patient has a background of Chronic Obstructive Pulmonary Disease target saturations should be adjusted accordingly. In those at risk of hypercapnia usually aim for between 88 and 92% via controlled oxygen

S

Senior Review

  • Refer to ST3 (or equivalent Advanced Practitioner) or above and ask for urgent review within the hour
  • In specialties where there is no onsite ST3+ clinician out of hours - urgent review within 1 hour by the most senior clinician present
  • This should be immediately followed by telephone discussion with the on call ST3+ clinician and a review and treatment plan documented and put in place
  • Consider Critical Care Outreach referral
  • Document time of referrals and time of review
  • Ensure ReSPECT form completed

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Follow up to BUFALOS

  • Ensure source control considered and expedited if appropriate
  • Ensure all appropriate samples sent
    • Full clinical details should be on request form
    • All patients
    • Pneumonia
      • Nose/throat swab for Respiratory Virus (inc. Mycoplasma) PCR
      • Urine for legionella
    • Other
      • Consider CSF sampling – microscopy, culture and PCR
      • Consider EDTA sample for meningococcal and pneumococcal PCR
      • Consider need for viral testing/empirical antivirals
      • Consider sampling from indwelling lines/devices
  • Ensure RESPECT form completed after discussion with patient and/or their next of kin.
  • Ensure Day 3 review of Antibiotics including identification of source where “Sepsis of unknown origin” was initial indication.

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Consultant Review

Failure to improve within 1 hour of instigation of treatment should prompt immediate discussion with the Consultant responsible for the patient.

Failure to improve could include any one of the following:

  • Systolic BP persistently below 90mmHg
  • Persistently reduced level of consciousness
  • A NEWS score that is not reducing
  • Lactate not reduced by at least 20%

This list does not cover all possibilities, clinical judgement should be used.

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Suggested triggers for Critical Care review

  • Red Flag Sepsis
  • As per NEWS graded response (NEWS >7 or >3 in 1 parameter)
  • Senior clinician concern
  • Failure to achieve BP target despite 30ml/kg total fluid boluses
  • Rising lactate despite treatment

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Amber Flag Sepsis

If no Red Flags present - are any of these features present?

  • Concerns about mental status
  • Acute deterioration in functional ability
  • Immunosuppressed
  • Trauma/surgery/procedure in the last 8 weeks
  • Respiratory rate 21-24 bpm
  • Systolic BP 91-100 mmHg
  • Heart rate 91-130 bpm or new dysrhythmia
  • Temperature <36.0oC
  • Clinical signs of wound infection

If yes

  • Obtain IV access and take bloods and blood cultures
  • Senior review within 1 hour
  • Consider Antibiotics

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Blood Cultures

Blood cultures should be taken (see Blood Culture SOP) even if the above triggers are not met. Indications include:

  • Red or Amber Flag Sepsis
  • New temp >38oC
  • Rigors
  • If a patient is deemed to require intravenous antibiotics (excluding prophylaxis)

These should be taken before antibiotics are given/changed. The only exception to this is if that would result in a significant (>45 minute) delay in antibiotic administration. This should be a rare occurrence.

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Source Control

Patients with sepsis should have urgent imaging in line with the clinical history and signs. Chest radiograph in all patients with ultrasound and computed tomography as appropriate.

Aim for removal of all infected invasive devices immediately and send line/catheter tips to microbiology (in line with Guideline 1599 Management of infected temporary central venous catheters and arterial catheters in adults). Consider urgent surgical intervention if patient has a source amenable to draining or removal.

Patients with an indwelling catheter and symptomatic urinary tract infection should ideally have their catheter changed in addition to appropriate antibiotic treatment for infection (See Catheter Associated Infection guideline)

Whenever feasible significant sources of infection should be drained or removed within 12 hours of onset of severe sepsis/ shock in order to improve outcomes. Antibiotics alone are often inadequate to control systemic infection in the presence of collections of undrained pus or infected prosthetic devices such as intravascular lines or urinary catheters.

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Foreign Travel

Please ensure a travel history is taken in all septic patients.

Recent foreign travel, if present, should be included on all microbiology request forms.

Returning travellers may require special consideration and a discussion with the Infectious Diseases team is advised.

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ICU/HDU Based Care

  • Patient specific approach required
  • Screening tool does not apply to patients in Critical Care. However, vigilance is required as new sepsis can be insidious in the critically ill.
  • Typical aims:
    • Oxygen sats
      • >94% in unintubated patient with no respiratory comorbidity
      • 88-92% in intubated patients
    • Euvolaemia
      • Assessment options: history, straight leg raise, LiDCO or echocardiography
    • MAP 65 mmHg
      • First line peripheral vasopressor phenylephrine
      • First line central vasopressor noradrenaline
    • UO >0.5ml/kg/hr
    • Hb >70g/dl (90 in patients with cardiac history)
    • Ensure appropriate antibiotics prescribed on e-meds (see antimicrobial guidance) and source control has been considered
  • Send baseline procalcitonin
  • Ensure all appropriate samples sent (e.g. blood cultures, atypical serology)
  • Ensure RESPECT form completed if feasible

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Special Patient Groups

People with Learning Disabilities are at a higher risk of poor outcomes. Sepsis symptoms may be overlooked or falsely attributed to their Learning Disability.  Please consider reasonable adjustments to help assessment, such as checking their hospital passport for supportive strategies or talking to people who know them well.

Other patient groups where diagnosis and management of sepsis can be more challenging include people with dementia and mental health conditions.

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Documentation/Coding of Sepsis

Sepsis may arise from a range of infective sources e.g. urinary, respiratory, abdominal etc. As such, a huge range of terms are used for diagnosis, which makes it difficult to identify cases of sepsis – e.g. they may be coded as pneumonia, or urinary infection, rather than sepsis.

The terms ‘sepsis’, ‘severe sepsis’, ‘sepsis with organ failure’, or ‘septic shock’ should be routinely documented in the medical notes alongside associated source of infection, e.g. pneumonia, UTI and/or identified bacteria as grown on culture. This will ensure appropriate coding.

On discharge from hospital the diagnosis should again be clearly documented as above alongside an appropriate follow up plan.

Death certificates must align to cause of death and in cases of sepsis must align to this e.g. ‘UTI’ is not acceptable but ‘urinary sepsis’ is.

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Further Support

Please contact:
Dr James Beck (Lead Clinician for Sepsis) james.beck4@nhs.net
Lorna Attenborough (Sepsis Nurse)  lorna.attenborough1@nhs.net 

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Appendix

Definitions

Many different terms get used to describe sepsis and its sequelae and this can cause confusion in terms of both understanding and communication. Below are a set of definitions. Those highlighted in red are the terms that are used throughout document and in the Sepsis Screening Tool.

  • Care bundle: A set of evidence-based steps that when performed collectively and reliably have been proven to achieve a specific outcome.
  • Infection: microbiological phenomenon characterised by an inflammatory response in the presence of micro-organisms.
  • Systemic Inflammatory Response Syndrome (SIRS); group of clinic signs which the presence of two or more abnormalities may be an indicator of sepsis.
  • Sepsis: Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Sepsis can lead to shock, multiple organ failure and death.
  • Sepsis Screening Tool: The initial response to a patient who shows altered physiology (NEWS2 score) or an infection to identify the possibility of sepsis in adult patients.
  • Red Flag Sepsis: The presence of any of the “Red Flag” features on the screening tool. Predicts if the patient is at a higher risk of severe sepsis or septic shock. The Red Flag features correlate with markers of severity from the NEWS2 scoring tool.
  • Amber Flag Sepsis: A patient without any Red Flag features from screening but with one or more Amber features. Represents a patient at risk of deterioration.
  • Severe Sepsis: The presence of one or more organ system dysfunctions in the context of sepsis defines severe sepsis for example Acute Kidney Injury in a patient with pneumonia.
  • Septic shock: There is inadequate tissue perfusion to key organs. Severe sepsis plus hypotension (Mean Arterial Pressure ≤65mmHg or systolic BP ≤ 90mmHg) following an initial fluid bolus.
  • BUFALOS: The seven clinical management steps that should be applied within the first hour of identifying Red Flag Sepsis. Also known as the Sepsis Six (the additional item being senior review).
  • Time Zero: The time point where the patient first displays a NEWS score ≥5 or ≥3 in one category, or presents with signs and symptoms of an infection.

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Sepsis Screening Tool

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Educational Infographic

Provenance

Record: 886
Objective:
Clinical condition: Sepsis
Target patient group: Adult patients with possible sepsis
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

The Surviving Sepsis Campaign. www.survivingsepsis.org

The UK Sepsis Trust 

Daniels R, Nutbeam T, Mcnamara G et al 2011. The sepsis six and the severe sepsis resuscitation bundle; a prospective observational cohort study. Emerg Med J 28(6):507-12.

Jones A, Shaprio N, Trezeciak S et al. 2010. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomised clinical trial. JAMA 303(8):739-746.

Mouncey P, Osborn T, Power S, et al. 2015. Trial of early goal directed resuscitation for septic shock. N Engl J Med. DOI: 10.1056/NEJMoa1500896

Peak S, Delaney A, Bailey M, et al for the ARISE investigators. 2014. Goal directed resuscitation for patients with early septic shock. N Engl J Med 371: 1496-506

Angus D, Shapiro N, et al. 2014. A randomised trial of protocol based care for early septic shock. N Engl J Med. DOI:10.1056/NEJMoa1401602

Dipti A, Soucy Z, Surana A, et al. 2012. Role of inferior vena cava diameter in assessment of volume status: a meta analysis. Am J Emerg Med 30(8);1414-1419.

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

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