Sepsis is back making headlines for all the wrong reasons. The Parliamentary and Health Service Ombudsman (PHSO) has criticised a Surrey hospital for the 2 hour delay in diagnosing sepsis and the 4 hour delay before giving antibiotic treatment. The PHSO stated that failures at the hospital reduced the man's chances of survival. The shocking part of this story is that failure to recognise a septic patient and start antibiotics is a well-recognised lapse in care which occurs with worrying frequency in hospitals across globe.
“Sepsis claims over 37,000 lives in the United Kingdom annually; more than breast cancer and bowel cancer combined”1. Back in 2005 the Surviving Sepsis Campaign attempted to rectify this by raising awareness and improving the management of septic patients with evidence based guidelines. However these guidelines are “delivered in fewer than 1 in 5 [septic] patients in the UK”1.
So could you recognise a patient with sepsis and reel-off an initial management plan? No?
“Sepsis claims over 37,000 lives in the United Kingdom annually; more than breast cancer and bowel cancer combined”1. Back in 2005 the Surviving Sepsis Campaign attempted to rectify this by raising awareness and improving the management of septic patients with evidence based guidelines. However these guidelines are “delivered in fewer than 1 in 5 [septic] patients in the UK”1.
So could you recognise a patient with sepsis and reel-off an initial management plan? No?
For every hour appropriate antibiotics are delayed in septic patients the mortality increases by 7%. The most common reason for failing to give antibiotics early enough is the failure of medical staff to recognise that the patient is septic in the first place.
Sepsis is a clinical diagnosis not a laboratory test. It requires the doctor to make the diagnosis. Sepsis is infection with evidence of the systemic response to that infection e.g. hypoxia, oliguria, confusion. Severe sepsis is sepsis with organ dysfunction, hypoperfusion or hypotension. “Sepsis is better thought of as the body’s severe response to an infection rather than a severe infection”1. Sepsis is life threatening and an emergency. The recognition of the septic patient is one of the key skills a medical student or junior doctor needs to learn.
Often when I ask medical students and junior doctors what the criteria are for diagnosing sepsis I get told it’s based on the Modified Early Warning Score (MEWS) or Paediatric Early Warning Score (PEWS) but this is not the case. These scoring systems are designed to help other ward staff, such as nurses, recognise a deteriorating patient and empower them to call medical support. It doesn’t make sense for the arriving doctors to then use the same tool to try and decide why the patient is unwell. Early warning scores (see images below) are essentially a numerical value assigned to the physiological parameters on the observation chart, i.e. they quantify the observations. Sepsis is just one reason why a patient may have a high MEWS or PEWS score. It is the doctor’s job to try and work out what the diagnosis is.
Sepsis is a clinical diagnosis not a laboratory test. It requires the doctor to make the diagnosis. Sepsis is infection with evidence of the systemic response to that infection e.g. hypoxia, oliguria, confusion. Severe sepsis is sepsis with organ dysfunction, hypoperfusion or hypotension. “Sepsis is better thought of as the body’s severe response to an infection rather than a severe infection”1. Sepsis is life threatening and an emergency. The recognition of the septic patient is one of the key skills a medical student or junior doctor needs to learn.
Often when I ask medical students and junior doctors what the criteria are for diagnosing sepsis I get told it’s based on the Modified Early Warning Score (MEWS) or Paediatric Early Warning Score (PEWS) but this is not the case. These scoring systems are designed to help other ward staff, such as nurses, recognise a deteriorating patient and empower them to call medical support. It doesn’t make sense for the arriving doctors to then use the same tool to try and decide why the patient is unwell. Early warning scores (see images below) are essentially a numerical value assigned to the physiological parameters on the observation chart, i.e. they quantify the observations. Sepsis is just one reason why a patient may have a high MEWS or PEWS score. It is the doctor’s job to try and work out what the diagnosis is.
 MEWS - Click for larger image |  PEWS - Click for larger image |
The diagnostic criteria for sepsis and severe sepsis are shown below in the form of 3 questions:
Click for larger image
If YES to questions 1, 2 and 3 then patient meets the criteria for SEVERE SEPSIS
These questions should be asked and investigated as rapidly as possible in order to try and give appropriate antibiotics within the first 45-60 minutes “The Golden Hour” see flowchart below. The antibiotics chosen should cover the common bacteria such as Staphylococcus aureus, Enterobacteriaceae,
Pseudomonas spp. as well as Neisseria meningitidis
in younger patients (usually <18 years old).
These questions should be asked and investigated as rapidly as possible in order to try and give appropriate antibiotics within the first 45-60 minutes “The Golden Hour” see flowchart below. The antibiotics chosen should cover the common bacteria such as Staphylococcus aureus, Enterobacteriaceae,
Pseudomonas spp. as well as Neisseria meningitidis
in younger patients (usually <18 years old).
Click for larger image
The other key aspects of the management of sepsis are to provide oxygen, fluid resuscitation and identify and treat the underlying cause of the sepsis such as an UTI, abscess or intra-abdominal perforation (surviving sepsis call this “source control”). See clinical scenarios, Sepsis for further information.
Remembering the full guidelines can be complex and requires collaboration between A&E, ward and ITU doctors, but the initial management can be simplified to six steps, now commonly known as the “Sepsis Six”.
Try the mnemonic “SEPTIC” to remember them:
Start high-flow oxygen
Extract blood cultures
Prescribe and give empiric antibiotics
Take lactate and send full blood count
IV fluid resuscitation
Check urine output
Implementing the Sepsis Six within one hour has been shown to facilitate the full Surviving Sepsis Resuscitation Bundle; by following the Resuscitation Bundle a patient is given a 20-30% better chance of surviving sepsis1.
It is one thing for a patient to die when you have recognised how unwell they are and done everything possible to try and save their life. This is one of the hard truths of medicine. But it is another, unacceptable thing, for a patient to die because someone failed to recognise how unwell they were and failed to take the necessary steps to manage them properly. All medical students and doctors should become familiar with the surviving sepsis guidelines in order to try and prevent avoidable deaths from sepsis.
The Surviving Sepsis campaign published new guidelines in 2012
Ref1 http://sepsistrust.org/
Remembering the full guidelines can be complex and requires collaboration between A&E, ward and ITU doctors, but the initial management can be simplified to six steps, now commonly known as the “Sepsis Six”.
Try the mnemonic “SEPTIC” to remember them:
Start high-flow oxygen
Extract blood cultures
Prescribe and give empiric antibiotics
Take lactate and send full blood count
IV fluid resuscitation
Check urine output
Implementing the Sepsis Six within one hour has been shown to facilitate the full Surviving Sepsis Resuscitation Bundle; by following the Resuscitation Bundle a patient is given a 20-30% better chance of surviving sepsis1.
It is one thing for a patient to die when you have recognised how unwell they are and done everything possible to try and save their life. This is one of the hard truths of medicine. But it is another, unacceptable thing, for a patient to die because someone failed to recognise how unwell they were and failed to take the necessary steps to manage them properly. All medical students and doctors should become familiar with the surviving sepsis guidelines in order to try and prevent avoidable deaths from sepsis.
The Surviving Sepsis campaign published new guidelines in 2012
Ref1 http://sepsistrust.org/
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