Immediate Management of the Septic Patient

Objectives

To guide the immediate management of patients with sepsis.

Scope

The guideline describes the management of patients with sepsis in a forward medical context or deployed emergency department.

There is additional guidance within the accordion section regarding the ‘immediate management of neutropenic sepsis’.

Audience

This guideline is intended for registered healthcare professionals fulfilling a general role in forward medical locations or an emergency department during deployed operations.

Initial Assessment & Management

Recognition:

Clinicians should suspect a diagnosis of sepsis in any person with risk factors for sepsis (see accordion content), who present with the following features: 

• Confirmed infection or symptoms/signs indicating a possible infection.
• NEWS2 Score of 5 or above (see accordion content).
• Recent chemotherapy or immunotherapy.
• Lactate of 2mmol/L or above.
• Assessment giving clinical cause for concern -  this may be non specific and non localised, including general malaise, agitation, confusion or behavioural change

Management:

Overall management should follow a systematic, structured (MARCH) approach.

Airway:

• Patients with sepsis will benefit from early optimal airway management with meticulous detail, particularly those with a reduced GCS.
• Interventions, if appropriate, will range from simple airway manoeuvres to adjuncts including NPA, OPA, and i-Gel.
• Prolonged requirement for airway support despite resuscitation should prompt early escalation for critical care support and early evacuation to a higher level of care.

Respiration:

• Clinically shocked or unconscious patients should immediately receive high-flow oxygen at 15l/min via NRB facemask if available.
• All other patients with Sepsis will require supplemental oxygen if SpO2 <92%, aiming for 94-98% saturations.
• Escalating oxygen requirement or prolonged need for high flow oxygen should prompt early escalation for critical care support and early evacuation to a higher level of care.

Circulation:

• Early IV or IO access is essential in the management of sepsis to facilitate blood sampling and drug administration. 
• As above once IV/IO access has been gained IV antibiotics should be given in line with current deployed antimicrobial guidance. If equipped then take blood cultures before administering antibiotics - but do not delay antibiotic therapy.
• Maintaining adequate circulatory function is a key priority to restore and optimise tissue perfusion initially via early and effective hypovolaemic shock management. 
• If the casualty is showing signs of clinical shock (systolic BP <90mmHg, tachycardia, altered mental state, prolonged capillary refill time or if available, lactate >2mmol/l), 500ml crystalloid fluid should be administered as quickly as possible.
• Casualties should receive up to 20ml/kg of crystalloid fluid within the first hour of treatment to achieve the advised haemodynamic targets:
  • Systolic BP >90 mmHg.
  • Normal conscious level.
  • Respiratory rate <25 breaths per minute.
  • Lactate <2mmol/l (If able to measure)
• Initiate urine output and fluid balance monitoring. 
• Persistent clinical shock despite fluid resuscitation should prompt early escalation for critical care support and early evacuation to a higher level of care.

Hypothermia/Head injury:

• Check blood sugar and treat hypoglycaemia if present.
• Persistently low GCS despite resuscitation should prompt early escalation for critical care support and early evacuation to a higher level of care.
• Do not rely solely on pyrexia for diagnosis of sepsis, normal temperatures and hypothermia may exist and may be associated with increased mortality.
• Ensure full top to toe examination is completed for sources of infection and signs of peripheral perfusion.

Advanced Assessment & Management

Assessment:

Regular re-assessment and monitoring of the patient with sepsis should be continued throughout the patient care pathway looking for the degree systemic impact and organ injury.

Alongside degree of severity, assessment should focus on the identification of the source of sepsis to allow specific treatment options to be considered.

Once capable blood should be taken to check as a minimum blood gas (including lactate) full blood count, U&Es, CRP, and clotting. Further blood tests should be taken as able and required to distinguish source of sepsis and degree of systemic response.

Should a patient be identified as neutropenic (neutrophil count of 0.5 x 109/l or less), this should be treated a neutropenic sepsis (see accordion content below).

If possible cultures should be taken to identify the pathogen involved. These may include blood, urine, sputum, wounds amongst others.

Imaging should be used to support diagnosis and source of sepsis as well as the degree of systematic response (e.g. CXR for pneumonia and ARDS, Ultrasound for biliary/renal pathology and echo for cardiac function).

Management:

Airway:

• Intubation (via PHEA or in hospital RSI) may be required in line with standard indications to secure the airway, facilitate ventilation and manage patients with low GCS or agitation.

Breathing:

• Casualties may require ventilatory support, particularly in cases of acute respiratory failure, neurological deterioration, ARDS or a lack of response to conventional oxygen therapy.
• If mechanically ventilated, a lower tidal volume of 6ml/kg is advised alongside other lung protective measures, such as limiting peak airway pressures to 30cm H2O and increased PEEP. Further detail can be found in the critical care guideline Invasive Mechanical Ventilation 

Circulation:

• If a casualty has a continued state of tissue hypoperfusion despite 20ml/kg of fluid resuscitation, they may require the introduction of vasoactive medications, aiming for a MAP of 65mmHg.
• Invasive blood pressure monitoring should be considered concurrently, as it allows for continuous monitoring, early detection of deterioration, and increased accuracy of targeted management.
• The choice of vasoactive medication will depend on clinical capabilities, availability in deployed modules and routes of IV access. Further detail can be found in the critical care guidelines for circulatory support (link to follow)
• Invasive urine output monitoring via a urinary catheter is recommended along with diligent fluid balance monitoring. 

Antimicrobials:

• Broad spectrum IV antibiotics should be continued initially in accordance with current deployed antimicrobial guidance.
• If a source is identified consideration should be given to narrowing the spectrum of antimicrobials.

Prolonged Casualty Care

Further considerations are as follows:

Oxygenation:

• Prolonged casualty care on oxygen will place a significant demand on supply.
• Cautious SpO2 monitoring, aiming for 94-98%, will optimise both oxygen delivery to tissues and limit resource exhaustion.

Fluid Management:

• Casualties with sepsis are prone to extracellular fluid shift and insensible losses. Fluid resuscitation should therefore be performed judiciously to avoid pushing the patient into overload.
• Close monitoring of urine output, aiming for a minimum of 0.5ml/kg/hr, is essential in guiding further fluid challenges; catheters should be avoided in ambulatory patients and urine output instead measured non-invasively.
• The ambulatory/conscious patient should be encouraged to drink water +/- rehydration solution to reduce reliance on limited stocks of IV fluid. 

Antimicrobials:

• Responsible antibiotic stewardship should be considered including reviewing the decision to keep the casualty on IV antibiotics at 24, 48 and 72 hours.
• With clinical improvement consider a switch to oral antibiotics in accordance with current deployed antimicrobial guidance.
• It is important to remember that not all sepsis is caused by bacteria; a failure to respond to treatment should alert the clinician to the need to escalate the spectrum of antibiotic coverage or to consider fungal or atypical bacterial causes. 

Paediatric Considerations

Sepsis is a major cause of death in the under-five population worldwide. Clinicians should maintain a high index of suspicion in children and a low threshold for escalation of treatment. 

Although age based sepsis risk stratification tools are available to support diagnosis, in the operational environment attempting to differentiate between amber (moderately unwell) and red (severely unwell) is not considered to be helpful:

Screening should take place for all infants and children who look unwell or are feverish:

• <3 months with temperature > 38C
• >3 months with temperature >39C

Children often compensate well during a disease process like sepsis. Identification of subtle changes in physiology can be highlighted using the Paediatric Early Warning Score (PEWS) with an appropriate escalation plan.

General measures:

• Do not routinely use NSAIDs as an antipyretic.
• IV/IO Antimicrobials should be administered via weight based dosing in accordance with current deployed antimicrobial guidance.
• Fluid resuscitation with 5ml/kg IV fluid (Crystalloid) boluses should be given initially.
• If there is limited improvement following 40ml/kg of fluid, consider inotropic support.