Sepsis

• Sepsis: Life threatening organ dysfunction caused by a dysregulated host response to infection 

• Septic shock: subtype of sepsis (with much higher mortality) characterised by a vasopressor requirement to maintain a mean arterial pressure of ≥65mmHg and a serum lactate of >2mmol/L in the absence of hypovolaemia

• Patients with a NEWS score of ≥5 should be screened for sepsis and consider red flags

Risk factors

• A patient with any breach in the skin, including burns, blisters, cuts and infections is at increased risk of sepsis. Other risk factors for sepsis are:

• Age under one year or over 75 years, or very frail

• Impaired immunity, e.g. diabetes, post-splenectomy, sickle cell disease or long-term steroids

• Immunosuppressant drugs, e.g. chemotherapy or some disease-modifying antirheumatic drugs (DMARDs)

• Surgery in the last six weeks

• Misuse of drugs intravenously

• Indwelling lines or catheters

• Pregnant, postnatal or termination of pregnancy in last six weeks

Red flags

• Acute confusional state / new deterioration in conscious level/GCS / responds only to voice or pain/unresponsive

• RR >25

• Needs O2 to maintain sats >92% (or >88% in COPD)

• Systolic BP <90 mmHg (or >40 mmHg below patient’s normal)

• HR >130

• Not passed urine in the last 18 hours (UO <0.5ml/kg/hr)

• Non-blanching rash or mottled/ashen/cyanotic

• Recent chemotherapy (within last 6 weeks)

• Lactate ≥2 mmol/l

Sepsis 6

• Give 3: oxygen as needed, IV fluid challenge, antibiotics

• Take 3: blood cultures, bloods (lactate, FBC, UE, clotting), measure fluid balance

Screening tools

• National Early Warning Score (NEWS) (to determine degree of illness of a patient and prompts critical care intervention); qSOFA (Quick SOFA Score) for Sepsis Identification (predicts poor outcome in infection patients)

Recognition & management​

• Sepsis: recognition, diagnosis and early management (NICE guideline 51, July 2016), Sepsis in children (BMJ, 2015)​, Neutropenic sepsis (CKS)​, Sepsis (NHS Choices), (Sepsis Trust (sepsistrust.org)

Febrile neutropenia / neutropenic sepsis

• Patients with febrile neutropenia/neutropenic sepsis can become ill very quickly, and cases continue to be missed at initial presentation

• Not all patients have access to a dedicated chemotherapy helpline, although all patients receiving chemotherapy should have written details about their treatment, including side effects.

• All patients with a fever who are receiving chemotherapy should be referred immediately for assessment and an urgent FBC

The peak of presentation for neutropenia is 7–10 days post chemotherapy, and the following are risk factors:

• >65 years

• Haematology malignancy

• Heavily pre-treated

• Comorbidity

• Malnourished

• Skin or mucous membrane defect

• Past history of neutropenic sepsis

The patient often complains of feeling non-specifically unwell, and sometimes presents with diarrhoea and/or vomiting, or a sore mouth. Mucositis often presents the portal of entry.  Although classically presenting with fever, hypothermia can be a sign in the early stages. An inability to mount an adequate inflammatory response means that signs and symptoms of infection may be minimal.