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:

• • 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

Links:

• Antibiotic guidance
• NICE