Week 4

Context

Sepsis is one of the leading causes of death in the UK and worldwide, more than heart attacks. Most patients (70%) that develop sepsis require critical care facilities, at an average cost of £1500 per day (UK Sepsis Trust, 2014¹) Mortality from sepsis in a recent European study was 36% , with the older population faring poorly. National Confidential Enquiry into Patient Outcome and Death -NCEPOD (2015) have highlighted how sepsis is the leading cause of avoidable death. Every year in the UK there are 150,000 of sepsis , resulting in a staggering 44,000 deaths- more than bowel,breast and prostate cancer combined. ( UK Sepsis Trust 2016).

The UK Sepsis Trust has worked tirelessly to reduce this number of deaths. This has been achieved in part by establishing quick check list guidelines ( SIRS criteria) for recognising sepsis in children and adults for the lay person and health care professional. The SEPSIS 6 guideline has enabled health care practitioners to act quickly after sepsis has been recognised.Their public awareness campaign has highlighted how sepsis can be recognised and managed effectively with an aim to saving 12,500 lives each year . (UK Sepsis Trust 2016).

NICE (2016) Draft consultation- Sepsis , the recognition,diagnosis and management of sepsis , aims to produce algorithms for managing sepsis in adults , children and young people. Thus enabling health care professionals to reduce deaths from sepsis.

Content

Definition of Sepsis

Sepsis is a life threatening condition brought on by an infection . The UK Sepsis Trust define it as “ a time-critical condition that can lead to organ damage, multi-organ failure, septic shock and eventually death. It affects the whole body and brings about an inflammatory response". Sepsis often originates from the lungs, bowel, skin, soft tissues and urinary tract. Associated terms include, septicaemia (another term for Sepsis), and bacteraemia (presence of live bacteria in blood).

Signs of sepsis

Sepsis is defined by the patient demonstrating two of the Systemic Inflammatory Response Syndrome (SIRS) criteria that are new to the patient:

Immediate
- New onset of Confusion or Altered Mental State
- Temperature > 38.3^o or < 36^o Celsius
- Heart Rate > 90 beats per minute
- Respiratory Rate (counted over 60 seconds) > 20 breaths per minute
POCT (commonly available)
- Blood Glucose > 7.7mmol/L in the absence of known diabetes
Laboratory (unless POCT available)

WCC > 12 or < 4 x109/L

(UK Sepsis Trust, 2016)

Signs of Severe Sepsis

Sepsis is considered to be severe if any one of the following are present, and otherwise unexplained:

Immediate
- SBP < 90mmHg or > 40mmHg fall from baseline
- MAP < 65mmHg
- Heart rate > 131 per minute
- New need for supplemental oxygen to maintain saturations > 90% should prompt emergent chest radiograph
- Respiratory rate > 25 per minute
- AVPU = V, P or U*
POCT (commonly available)
- PaO2/ FiO2 ratio < 300 (mmHg) or < 39.9 (kPa)
- Lactate > 2.0mmol/L
Radiology (only if clinically indicated, e.g. SpO2 < 90%)
- Bilateral pulmonary infiltrates AND new need for supplemental oxygen to maintain oxygen saturations > 90%
Laboratory (unless POCT available)
- Creatinine > 176.8μmol/L
- INR > 1.5
- aPTT > 60s
- Platelet count < 100 x109/L
- Bilirubin > 34.2μmol/L
Urine output monitoring

Urine output < 0.5mL/kg for two consecutive hours

(UK Sepsis Trust, 2016

The Sepsis Six campaign

The Sepsis Six campaign (UK Sepsis Trust, 2016) has been introduced to make UK practitioners aware of the presentation, screening and immediate management of a patient who presents with sepsis. They suggest that by doing these 6 things in the first hour you double your patient's chance of survival :

Administer high flow o2- oxygen demands in sepsis are high. Giving O2 early can prevent multi-organ failure
Take blood cultures – before administering antibiotics, but do not allow them to delay antibiotics
Give broad spectrum antibiotics and review after 24-48hrs, antibiotic choice should be informed by local policy and the patient’s history
Give intravenous fluid challenges to increase stroke volume. Reassess after each fluid challenge. 500ml crystalloid in patients without heart failure or chronic kidney disease.
Measure serum lactate and Hb – consider transfusion. Serum Lactate values can indicate the severity of the sepsis and also the response to the treatment
Measure urine output hourly

Immediate management

Following the completion of the Sepsis Six guidelines, it is imperative to lower the patient temperature gradually. Monitor NEWS as dictated by the scoring, and record accurate fluid balance charting. Maintain personal hygiene and offer fluids orally if condition allow.

References and Further Reading

NCEPOD (2015) National Confidential Enquiry into Patient Outcome and Death Just say sepsis! summary (www) http://ncepod.org.uk

UK Sepsis Trust (2014¹) I need to help my organisation [WWW] http://sepsistrust.org/info-for-professionals/i-need-to-help-my-organisation/

UK Sepsis Trust (2014²) Executive Summary: Ward Management of Sepsis [WWW] http://sepsistrust.org/wp-content/files_mf/1409313022WardExecSummary2014.pdf

UK Sepsis Trust (2016) Home Page [WWW] http://sepsistrust.org

UK Sepsis Trust (2016) SEPSIS SIX video (www) http://sepsistrust.org/professional/educational-tools/

UK SEPSIS trust (2016) Sepsis in Primary care settings (www) https://www.guidelines.co.uk/sepsis-trust/sepsis