by Dr Chris Eades
World Sepsis Day, on 13 September, focuses our attention on avoidable patient harms from the delayed recognition and treatment of sepsis. This post sets out what sepsis is, how to spot it early, and what to do, considering prominent cases within the public domain.
WHAT IS SEPSIS AND WHY IS IT IMPORTANT?
Sepsis is a medical emergency caused by a life-threatening response to infection leading to organ dysfunction. Without medical attention and prompt treatment, irreversible organ damage and death can result.
The UK Sepsis Trust estimates that sepsis affects around 245,000 patients every year, causing more than 26,000 deaths. The early recognition and treatment of sepsis can change outcomes dramatically, saving lives that might otherwise be lost.
The tragic case of Martha Mills, who died of sepsis aged 13, illustrates how lapses in care can result in preventable harm to patients with sepsis:
- Martha developed sepsis whilst hospitalised after a pancreatic injury; a coroner found she would probably have survived with earlier recognition and escalation to the intensive care unit (ICU).
- Martha’s case prompted “Martha’s Rule” – now being rolled out across acute hospitals in England – to give patients and families a 24/7 route to request an urgent review by a different team when deterioration is suspected.
Patterns across cases are consistent: Delayed recognition, over-reliance on pathways or single data points, late antibiotics and escalation, weak handover, and family concerns not acted upon.
WHEN TO CONSIDER SEPSIS
With sepsis, recognition starts with suspicion. In adults, consider a diagnosis of sepsis when there is:
- New confusion or slurred speech;
- Severe breathlessness;
- Mottled, bluish or very pale skin;
- A non-blanching rash;
- Reduced urine output; or
- At temperature greater than 38 degrees Celsius or lower than 36 degrees Celsius.
In children, watch for the following:
- Very fast breathing;
- Reduced urine output;
- Seizures (fits);
- Mottled, blue or very pale skin, or a non-blanching rash – for individuals with darker skin, check the palms and soles;
- Not waking or not responding as normal;
- Feeling abnormally cold to the touch.
]WHAT TO DO IF YOU SUSPECT SEPSIS
Time matters with sepsis; the sooner help arrives, the better the outcomes.
FOR PATIENTS OUTSIDE OF HOSPITAL
- Call 999 without delay
- Give clear instructions and descriptions to the Ambulance Service operator.
- Tell the operator that you are concerned the individual may have sepsis
- Keep the patient warm and calm until expert help arrives
FOR PATIENTS IN HOSPITAL
- Escalate the patient’s care to a senior decision-maker, stating that you suspect sepsis
- Institute the “sepsis six”:
- Broad-spectrum intravenous (IV) antibiotics
- Blood cultures (preferably before, but should not delay, antibiotics)
- Goal-directed intravenous fluids +/- vasopressors – aim for a mean arterial pressure (MAP) of 65 mmHg
- Measurement of venous lactate
- Supplemental oxygen (O2) targeted to maintain patient-specific peripheral saturation goal (SpO2)
- Accurate measurement of urine output – may require urinary catheterisation
Consult local guidelines regarding the initial (empirical) choice of antimicrobial therapy, whether targeted to a specific infective syndrome or otherwise
Where unsure, or in patients with a complex history of infection (including colonisation by resistant organisms), please consult a specialist in infectious diseases or medical microbiology.
Consider an escalation plan appropriate to the patient – is a referral to critical care appropriate?
For more information, consult the following resources:
The UK Sepsis Trust: https://sepsistrust.org/
National Institute for Health and Care Excellence Guideline (NG51) – “Suspected sepsis: recognition, diagnosis and early management”: https://www.nice.org.uk/guidance/ng51/resources
e-Learning for Health (e-LFH) Sepsis Awareness package: https://www.e-lfh.org.uk/programmes/sepsis/