Background
Sepsis | SIRS + suspected infection |
Severe Sepsis | Sepsis + organ failure/evidence of tissue hypoperfusion |
Septic Shock | Severe sepsis + hypotension (fall by >40mmHg from patient’s normal) despite fluid resuscitation |
SIRS (caused by sepsis, burns, trauma and pancreatitis) with 2 or more criteria
Temperature >38 or <36
Tachypnoea >20 or PaCO2 <4.3 kPa
Heart rate >90
Hyperglycaemia in the absence of diabetes mellitus
Altered mental state
Leukocytosis/Leukopenia <4 or >12(x10 9/L)
Normal WBC with >10% immature forms
Presentation
Can be non-specific or poorly localised symptoms such as feeling unwell with a normal temperature
History
Age >65 years
Does the patient have underlying chronic disease? Alcoholism, diabetes, indwelling lines/catheters, pregnancy, malignancy?
Is there any reason for the patient to have impaired immunity? Immunosuppressant therapy, HIV/AIDS?
Has the patient had any recent (last 6 weeks) surgeries or invasive procedures?
Has the patient had any recent trauma to the skin?
Has the patient had any history of intravenous drug use?
Has the patient been passing urine?
Examination Findings
Poor capillary refill time, mottled skin
Altered mental state
Cyanosis
Signs related to source of infection (e.g. offensive smelling urine for signs on a urinary tract infection)
Skin rashes e.g. purpura fulminans
Jaundice
Vital Signs
Temperature of >38 or <36
Tachycardia/tachypnoea
Low oxygen saturations
Hypotensive (indicates end-organ dysfunction)
The aim of investigations is to identify the causative organism and source of infection and assess for end organ dysfunction
Bedside tests
ABG/VBG – to ascertain patients lactate
Laboratory Investigations
Blood cultures
Other cultures e.g. would site swab, urine etc
CRP
FBC – looking at WBC for leucocytosis or leukopenia
U+Es – urea and creatinine may be elevated, electrolytes should be measured regularly until the patient improves
LFTs
Coagulation studies (INR, PTT)
Radiological Investigations
Echocardiogram – if suspected bacterial endocarditis
Ultrasound scan – usually abdominal to help locate source of infection
CT chest/abdomen – if clinically indicated to establish source of infection e.g. suspected deep abscess
Special Investigations
Lumbar puncture – suspected meningitis
Management of sepsis of unknown origin
Sepsis Six all to be done within the golden hour (within one hour of the diagnosis)
1. Achieve oxygen saturations of >94% with high flow oxygen
2. Take blood cultures (and establish IV access)
3. Give IV broad spectrum antibiotics (if no clear source give tazocin 4.5g TDS + vancomycin (1g/12 hours IV) for MRSA + gentamicin (5mg/kg OD) or use local guidelines) be cautious in renal railure
4. Measure serum lactate
5. Start IV fluid resuscitation
6. Monitor hourly urine output
Consider referral to intensive care
If source of infection is known, alter investigations and antibiotics as per hospital protocol
Complications
Early:
Renal dysfunction
Acute respiratory distress syndrome
Disseminated intravascular coagulation
Multiple organ system failure
Late:
Neurological complications