Three large scale multi-centre trials into Severe Sepsis and Septic Shock: ProCESS (USA), ARISE(Aus), ProMISe(UK), all showed the same thing. What works is good early resuscitation (Not the fancy stuff from ICU – however, that does have its place later on).
1. Severity
The 2024 NICE guidance has redefined the severity based on NEWS2 scale
- 7 or more = High risk of severe illness or death from sepsis
- 5 or 6 = Moderate risk of severe illness or death from sepsis
- 1 to 4 = Low risk of severe illness or death from sepsis
- 0 = Very low risk of severe illness or death from sepsis
Considerations – the presence of following increases the NEWS2 based risk:
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- a single parameter contributes 3 points to their NEWS2 score and a medical review has confirmed that they are at high risk
- mottled or ashen appearance
- non-blanching petechial or purpuric rash
- cyanosis of skin, lips or tongue
- lactate over 2 mmol/litre or evidence of acute kidney injury
2. Antibiotics
Ideally cultures should be taken prior to giving antibiotics. However, obtaining cultures should not delay delivery.
- High risk – <1hour from calculation of NEWS2
- Any suspicion of infection prescribe antibiotics immediately
- Moderate risk – <3hours from calculation of NEWS2
- You have limited time to perform basic tests if you are clinically uncertain
- Low risk – <6hours for calculation of NEWS2
3. Fluids
For most need for fluids will be individualised however in;
- High risk – <1hour if lactate over 2 mmol/litre or systolic blood pressure (sBP) less than 90 mmHg
- Septic Shock – mean BP (MAP) 65 mmHg or less and having a serum lactate level greater than 2 mmol/litre after adequate fluid resuscitation
- If the patient has required 30ml/kg of fluid to maintain a MAP >65mmHg a decision on Vassopressors must be made
4. Investigations
- Investigations will be clinically dictated, and should not delay delivery of antibiotics.
- In High/Moderate risk the following should be carried out;
- Blood Gas
- Blood Culture (More Blood = Better pick-up)
- FBC
- U&E, CRP, LFT
- Clotting
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