Last reviewed: November 2017
Last updated: November  2017

Important updates

qSOFA may be inferior to other bedside early warning scores

In 2016 the qSOFA was suggested by the Third International Consensus Group as a bedside assessment tool to identify those patients at risk of deterioration due to sepsis. However, a large study comparing qSOFA with other early warning scores found that qSOFA has poor sensitivity and is a late indicator of deterioration compared with other scoring systems.

See Diagnosis: approach

Original source of update

Updated Surviving Sepsis Campaign guidelines

  • The Surviving Sepsis Campaign’s updated guidelines advise that early recognition of patients with infection and organ dysfunction (i.e., sepsis) remains paramount.

  • Patients with sepsis-induced hypoperfusion should receive at least 30 mL/kg of intravenous crystalloid within the first 3 hours. Further fluid should be guided by reassessment of the patient’s haemodynamic status.

  • Intravenous antimicrobials should be administered as soon as possible after recognition of sepsis or septic shock, and at the very latest within one hour.

See Management: approach

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • high (>38°C) or low (<36°C) temperature
  • tachycardia
  • tachypnoea
  • acutely altered mental status
  • poor capillary refill, mottling of the skin, or ashen appearance
  • signs associated with specific source of infection
  • low oxygen saturation
  • arterial hypotension
  • decreased urine output
  • cyanosis

Other diagnostic factors

  • purpura fulminans
  • jaundice
  • ileus

Risk factors

  • underlying malignancy
  • age >65 years
  • immunocompromise
  • haemodialysis
  • alcoholism
  • diabetes mellitus
  • recent surgery or other invasive procedures
  • breached skin integrity
  • indwelling lines or catheters
  • intravenous drug misuse
  • pregnancy
  • urban residence
  • lung disease
  • male sex
  • non-white ancestry
  • winter season

Diagnostic investigations

1st investigations to order

  • FBC with differential
  • blood urea and serum electrolytes
  • serum creatinine
  • LFT
  • coagulation studies (INR, aPTT)
  • serum glucose
  • lactate levels
  • CRP
  • blood culture
  • other cultures (e.g., of sputum, stool, urine, wounds, catheters, prosthetic implants, epidural sites, pleural or peritoneal fluid)
  • arterial blood gas (ABG) or venous blood gas (VBG)
  • chest x-ray
  • ECG
Full details

Investigations to consider

  • lumbar puncture
  • echocardiogram (transthoracic or transoesophageal)
  • ultrasound scan
  • CT chest or abdomen
  • serum procalcitonin
Full details

Emerging tests

  • PhenoTest™ BC Kit
Full details

Treatment algorithm

Contributors

Authors VIEW ALL

Chief Executive

United Kingdom Sepsis Trust

Chief Executive

Global Sepsis Alliance

Programme Director

Survive Sepsis

Consultant in Critical Care and Anaesthesia

Heart of England NHS Foundation Trust

Birmingham

UK

Disclosures

RD has received payment for consultancy on sepsis from Kimal Plc, manufacturers of vascular access devices, from the Northumbria Partnership, a patient safety collaborative, and, where annual leave or other income was compromised in fulfilling his charity duties, from the UK Sepsis Trust. RD has received sponsorship to attend and speak at one meeting from Abbott Diagnostics. He is CEO of the UK Sepsis Trust and Global Sepsis Alliance, and advises HM Government, the World Health Organisation and NHS England on sepsis. Each of these positions demands that he express opinion on strategies around the recognition and management of sepsis.

Consultant in Emergency Medicine

Clinical Academic

University of Plymouth

Lead Doctor

Devon Air Ambulance Trust

Derriford Hospital

Plymouth

UK

Disclosures

TN is a clinical advisor to the UK Sepsis Trust.

Specialty Registrar in Emergency Medicine

Derriford Hospital

Plymouth

UK

Disclosures

EC declares that he has no competing interests.

Dr Ron Daniels, Dr Tim Nutbeam, and Dr Edward Berry would like to gratefully acknowledge Dr Lewys Richmond and Dr Paul Kempen, the previous contributors to this monograph. LR and PK declare that they have no competing interests.

Peer reviewers VIEW ALL

Professor of Medicine

Infectious Disease Division

Rhode Island Hospital

Alpert Medical School of Brown University

Providence

RI

Disclosures

SMO declares that he has no competing interests.

Associate Professor

NYU School of Medicine

Medical Director of Critical Care

Bellevue Hospital Center

New York

NY

Disclosures

LE serves as the guidelines co-chair and on the steering committee of the Surviving Sepsis Campaign.

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