2.5. Recognition and Management of Sepsis

Question 1

From a History, what is the Sepsis:

1. High Risk criteria?
2. Moderate Risk criteria?
3. Low Risk criteria?

Answer 1

1. Objective evidence of new altered mental state
2. a) History of new onset of altered mental state
3. b) History of acute deterioration of functional ability
4. c) Impaired immune system (illness or drugs)
5. d) Trauma / Surgery / Invasive Procedure in the last 6 weeks
6. Normal behaviour

Question 2

From a Respiratory Examination, what is the Sepsis:

1. High Risk criteria?
2. Moderate Risk criteria?
3. Low Risk criteria?

Answer 2

1. a) Raised Respiratory Rate (25 breaths/min)
2. b) New need for O2 to maintain sats > 92%
3. Raise Respiratory Rate (21-24 breaths/min)
4. No High / Moderate Risk criteria met

Question 3

From a Blood Pressure Examination, what is the Sepsis:

1. High Risk criteria?
2. Moderate Risk criteria?
3. Low Risk criteria?

Answer 3

1. Systolic B.P. > 90mmHg (or 40mmHg below normal)
2. Systolic B.P. 91-100mmHg
3. No High / Moderate Risk criteria met

Question 4

From a Circulation and Hydration Examination, what is the Sepsis:

1. High Risk criteria?
2. Moderate Risk criteria?
3. Low Risk criteria?

Answer 4

1. a) Raised Heart Rate (> 130bpm)
2. b) Not passed urine in the past 18hrs
3. c) >0.5ml/kg/hr urine passed (catheterized patients)
4. a) Raised Heart Rate (91-130bpm)
5. b) Not passed urine in the passed 12-18hrs
6. c) 0.5-1.0ml/kg/hr urine passed (catheterized patients)
7. No High / Moderate Risk criteria met

Question 5

From a Temperature Examination, what is the Sepsis:

1. High Risk criteria?
2. Moderate Risk criteria?
3. Low Risk criteria?

Answer 5

1. N/A
2. Tympanic temperature less than 36 degrees
3. N/A

Question 6

From a Skin Examination, what is the Sepsis:

1. High Risk criteria?
2. Moderate Risk criteria?
3. Low Risk criteria?

Answer 6

1. a) Mottled or Ashen appearance
2. b) Cyanosis of skin, lips or tongue
3. c) Non-blanching rash of skin
4. Signs of potential infection at a wound (Redness, swelling, discharge etc)
5. a) No non-blanching rash

Question 7

What are the management stages of a patient over the age of 12, with Sepsis?

Answer 7

1. Patient with suspected Sepsis
2. a) NICE pathway on acutely ill patients in hospital
3. b) Information for patients (+ families) with Sepsis
   (Follow on from 2. b)
4. Identify the source of infection
5. Assess the Risk Criteria for the condition is (SOFA)
6. Treat with the Sepsis 6
7. Discharge information

Question 8

What does the “Sepsis 6” include?

Answer 8

"You take 3":
1. Blood Cultures 
2. Blood Lactate
3. Measure urine output
"You give 3":
4. Oxygen (aim O2 saturation bwteen 94-98%)
5. I.V. Antibiotics 
6. I.V. Fluid Challenge

Question 9

1. Why are blood cultures taken (in the Sepsis 6)?

2. When are they taken?

Answer 9

1. To make a microbiological diagnosis (30-50% are positive)
2. As soon as posible after onset of Fever / Chills
   Note - if spike in temperature then take 2 sets

Question 10

Why is blood lactate taken (in the Sepsis 6)?

Answer 10

It is a marker of generalised hypoperfusion / severe sepsis / poor prognosis

Question 11

Why is urine output measured (in the Sepsis 6)?

Answer 11

It is a marker of Renal Dysfunction

Question 12

How is the antibiotic prescribed worked out?

Answer 12

1. Based on working diagnosis from History / Examination
2. Local antibiotic guidlines
   Note - remember most infections below the diaphragm are Gram Negative, and above are Gram Positive

Question 13

What should be considered when prescribing antibiotics?

Answer 13

1. Allergy
2. Previous MRSA (Methicillin-Resistant Staphylococcus Aureus), ESBL (Extended Spectrum Beta Lactamases), CPE (Carbapenemase Producing Enterobacteriaceae)
3. Antibiotics toxicity / interactions

Question 14

How much I.V. Fluid Challenge is given to a person with Sepsis?

Answer 14

30ml/Kg (2.1L for a 70Kg patient)

Question 15

Other than giving fluid, what is also done in the I.V. Fluid Challenge?

Answer 15

Stop any anti-hypertensive medication

Note - they’re not going to die instantly from hypertension but will from septic shock

Question 16

When should HDU referral be considered in a Septic patient?

Answer 16

1. Low B.P. responsive to fluids
2. Lactate > 2 despite Fluid Resuscitation
3. Elevated Creatinine
4. Oliguria
5. Liver Dysfunction
6. Bilateral infiltrates, hypocaemia

Question 17

What test should be done to see if a patient should be referred to the HDU?

Answer 17

qSOFA

Question 18

When should a Septic patient be considered for the ICU?

Answer 18

1. Septic Shock
2. Multi-organ failure
3. Requires sedation, intubation and ventilation