Sepsis in adults

Suspect sepsis based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Have a low threshold for suspicion.

Think ‘Could this be sepsis?’ whenever an acutely unwell person presents with likely infection, even if their temperature is normal. Remember that sepsis represents the severe, life-threatening end of infection.

The key to improving outcomes is early recognition and prompt treatment, as appropriate, of patients with suspected or confirmed infection who are deteriorating and at risk of organ dysfunction. By the time the diagnosis becomes obvious, with multiple abnormal physiological parameters, risk of mortality is very high.

Your clinical judgement is crucial to how you approach the individual patient. Be aware that signs and symptoms are extremely variable and often non-specific.

Assess acute deterioration using your clinical judgement alongside a validated scoring system, such as the National Early Warning Score 2 (NEWS2); consult local guidelines for the recommended scoring system at your institution. Arrange urgent assessment by a senior clinical decision-maker for any patient with an aggregate NEWS2 score of 5 or more.

Within 1 hour of the risk being recognised: take two sets of blood cultures, measure serum lactate on a blood gas, and assess the patient’s hourly urine output.

Within 1 hour of the risk being recognised: give intravenous broad-spectrum antibiotics (after taking blood cultures), if there is evidence of a bacterial infection; intravenous fluids, if there is any sign of circulatory insufficiency; and oxygen, if needed.

Ensure any patient with suspected sepsis has frequent and ongoing monitoring (e.g., using an early warning score such as NEWS2).

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. http://jama.jamanetwork.com/article.aspx?articleid=2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com The definition of sepsis was updated in 2016 following publication of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. http://jama.jamanetwork.com/article.aspx?articleid=2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com This recommended that organ dysfunction should be defined using the Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria or the 'quick' (q)SOFA criteria.

The 2016 consensus definitions marked a shift away from the previous systemic inflammatory response syndrome (SIRS) definition, which classified sepsis as two or more of the following in the context of infection: temperature >38.3°C (101°F) or <36.0°C (96.8°F); tachycardia >90 beats per minute; tachypnoea >20 breaths/minute or arterial carbon dioxide level (PaCO₂) <4.3 kPa (32 mmHg); hyperglycaemia (blood glucose >7.7 mmol/L [>140 mg/dL]) in the absence of diabetes mellitus; acutely altered mental status; leukocytosis (white blood cell [WBC] count >12×10⁹/L [12,000/microlitre]); leukopenia (WBC count <4×10⁹/L [4000/microlitre]); or a normal WBC count with >10% immature forms.[2]Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250-6. http://www.ncbi.nlm.nih.gov/pubmed/12682500?tool=bestpractice.com

In the first international consensus definitions, which date from 1991, severe sepsis was defined as sepsis associated with organ dysfunction, hypoperfusion, or hypotension; septic shock was defined as sepsis with hypotension despite adequate fluid replacement.[2]Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250-6. http://www.ncbi.nlm.nih.gov/pubmed/12682500?tool=bestpractice.com

However, the 2016 Third International Consensus Group (Sepsis-3) definitions state that the term 'severe sepsis' should be made redundant in light of the revisions to the definition of sepsis.[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. http://jama.jamanetwork.com/article.aspx?articleid=2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com Septic shock has also been redefined as a subset of sepsis, in which there is co-existence of: persistent hypotension requiring vasopressors to maintain mean arterial pressure ≥65 mmHg; and serum lactate >2 mmol/L (>18 mg/dL).[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. http://jama.jamanetwork.com/article.aspx?articleid=2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com

Septic shock indicates profound circulatory, cellular, and metabolic deterioration, and is associated with a greater risk of mortality than with sepsis alone.[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. http://jama.jamanetwork.com/article.aspx?articleid=2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com