sepsis part 3: management in an acute hospital setting

The implementation of the Sepsis Six care bundle is the recommended best practice for the treatment of sepsis. It is now used in more than 30 countries. The UK Sepsis Trust developed the Sepsis Six in 2005 and last revised it in 2019, adding a new first action intended to conserve antibiotic efficacy: to ensure that an experienced clinician attends as soon as possible in order to confirm the diagnosis and guide treatment. The final action now combines general monitoring using the National Early Warning Score 2 (NEWS2) with monitoring of urine output and blood lactates (UK Sepsis Trust, 2019). Implementing the bundle within 1 hour of identifying sepsis significantly reduces mortality rates (NHS England, 2015).

Most actions can be completed at the bedside by nursing staff who have the competence and knowledge to perform such tasks as venepuncture. These checks all aid prompt and effective decision making when dealing with sepsis (McClelland & Moxon, 2014) and should not be delayed while arranging an immediate review by a senior clinician (NICE, 2017). Completing the Sepsis Six within 1 hour of the identification of sepsis is a significant clinical challenge, but similar “golden hour” targets have been met in the care of trauma, stroke and myocardial infarction. The guidelines recommend

adopting a team approach for the identification, management and treatment of sepsis (McClelland & Moxon, 2014). Hence, sepsis is now typically covered as part of hospital induction programmes for all staff groups. Staff who are responsible for the assessment and monitoring of patients should have regular and appropriate training in the recognition and initial management of sepsis, according to their local strategy and treatment protocol. It is important to initiate and follow pathways to trigger early treatment and escalation (NICE, 2017). Follow local guidelines on infection prevention and control and the use of personal protective equipment.

Patients who recover from sepsis may experience post-sepsis syndrome (PSS) which consists of a variety of physical, psychological and emotional problems and can commonly last 6–18 months. It is unclear why patients develop PSS but physical symptoms can range from muscle weakness, pain and hair loss to changes in vision, reduced renal function, insomnia and amputation. Some patients are left with emotional and psychological issues such as anxiety, poor concentration, memory loss, post-traumatic stress disorder (PTSD) and nightmares (UK Sepsis Trust, 2019). This procedure outlines the application of the Sepsis Six, including escalation and aftercare.

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Adults

Sepsis Part 3: Management in an acute hospital setting

Claire Walker, Lecturer, University of Liverpool

©2021 Clinical Skills Limited. All rights reserved

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Management ofMedical Emergencies

The Sepsis Six care bundle (UK Sepsis Trust, 2019)

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(4) Give IV antibiotics (5) Give IV fluids (6) Monitor

Why? Sepsis is a complex condition that needs management from experienced clinical staff to confirm diagnosis and deliver the right care.

Why? To increase levels of oxygen in the blood and improve its delivery to the tissues.

Why? Lab tests help to stratify risk and identify pathogens in order to determine the source of infection and target antibiotic therapy.

Why? To control the underlying infection and remove the trigger for immune overreaction.

Why? To correct hypovolaemia, improving cardiac output and blood pressure.

Why? NEWS2, urine output and lactate levels can help to guide therapy and a decision to escalate the level of care.

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1hPlease change elephant tubing and mask to nasal cannulae as on p2, she may well be leaning back a bit rather than leaning forward

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Ensure a senior clinician attends Give oxygen (a)

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(d) Take intravenous blood samples, including cultures

Request a senior clinician (ST3+ or equivalent senior nurse) to assess the patient as soon as possible (UK Sepsis Trust, 2019). Experience is needed to distinguish between sepsis and other conditions with similar presentations, such as pancreatitis, severe dehydration due to gastroenteritis and blast cell crises. An experienced clinician will be able to determine the likely source of the infection and select the most appropriate initial antimicrobial therapy.

Do not wait for oxygen to be prescribed in an emergency: administer oxygen immediately and the doctor will prescribe it as soon as they arrive (Vaughan & Parry, 2016; The Human Medicines Regulations, 2012). Administering oxygen as soon as possible will correct hypoxia, preventing tissue death, and reduce confusion and loss of consciousness (Vaughan & Parry, 2016).

Give oxygen at 15 L/min via a non-rebreathe reservoir mask to achieve saturation levels of 94–98 per cent. Aim for saturations of 88–92 per cent in patients with a chronic lung condition who are at risk of hypercapnic respiratory failure (NICE, 2017; O’Driscoll et al., 2017).

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Monitor the patient closely and consider an arterial blood gas measurement if they have suspected respiratory failure; see clinicalskills.net procedures on obtaining a sample for arterial blood gas measurement. If a patient’s respiratory rate is over 25 breaths per minute an hour after commencing treatment and their level of consciousness is reduced, alert a consultant to attend (NICE, 2017).

Take blood samples for antimicrobial investigation using a sterile technique (UK Sepsis Trust, 2019). Include cultures, glucose, lactate, full blood count, urea and electrolytes, C-reactive protein and clotting. If possible, take blood cultures before the patient starts antimicrobial therapy to determine the correct choice of antimicrobial for them, but do not delay antibiotic treatment if cultures cannot be taken immediately (UK Sepsis Trust, 2019). Take two to three sets of blood cultures within 24 hours of an episode of sepsis.

If the patient has received high-flow oxygen for more than 4–6 hours, provide humidified oxygen to prevent dehydration, retained secretions and loss of heat (UK Sepsis Trust, 2019; Robson & Daniel, 2008). Ensure that you give regular mouth care.


Patient’s target oxygen saturation (circle as appropriate):

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Source control: other suspected sources Serum lactate levels

Take cultures from other suspected sources of infection, such as urine, sputum or cerebrospinal fluid samples. The results will usually be available within 48 hours and many centres use molecular techniques for identifying particular organisms, giving much faster results (McClelland & Moxon, 2014). Consider further investigations such as imaging, which may identify treatable causes such as an abscess that requires drainage.

A raised lactate level provides evidence of severe sepsis and metabolic compromise (NICE, 2017; McClelland & Moxon, 2014). Corroborate a high venous lactate result with an arterial sample (UK Sepsis Trust, 2019). Lactate levels help identify patients with circulatory problems whose blood pressure may still be normal. Patients with high lactate levels may need critical care admission (UK Sepsis Trust, 2019).

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A low haemoglobin level impacts on the delivery of oxygen to tissues, a raised leucocyte count and C-reactive protein are strong indicators of infection and levels of urea, electrolytes and creatinine give an insight into renal function (McClelland & Moxon, 2014). Other blood tests such as liver function tests and clotting may be necessary; follow local guidelines and policy.

Repeat assessing lactate levels to ensure that treatment such as fluid replacement is effective and monitor for further deterioration. The lactate level should reduce by more than 20 per cent of its initial value within 1 hour; if it does not, the patient is failing to respond to treatment, and a consultant needs to attend in person to review the patient (NICE, 2017).

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Sample type: venous blood cultureReceived: 10:00 27/08/2021Isolated after 24 hours incubation. Culture results. Escherichia coliCiprofloxacin – resistantGentamicin – resistant Meropenem – sensitive Please contact infectious disease team or microbiology for advice and support

Allergy Notes

Administer an intravenous antibiotic (a) (b) Review treatment based on microbiology results

Within 1 hour, and immediately after taking blood cultures, check the patient’s allergies and administer a broad-spectrum antibiotic intravenously. The initial choice of antimicrobial will be guided by clinical findings about the likely source of infection, and local microbiology policy and guidelines (NICE, 2017; McClelland & Moxon, 2014; Siddiqui et al., 2010). Many trusts use applications such as MicroGuideTM to enable pharmacists and prescribers to access the latest local antimicrobial guidance at the point of care. Delaying antibiotics increases patient mortality by nearly 8 per cent per hour (Kumar et al., 2006).

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Antibiotic choice should continue to be guided by the suspected focus of infection. This will depend on the clinical, microbiological and radiological evidence for infection. The prescriber will review antimicrobial treatment in response to the microbiological results from the blood cultures and other samples taken. This may mean continuing treatment with a broad-spectrum antimicrobial (if the source of infection is unclear, for example) or switching to a more appropriate antimicrobial that would deal more effectively with the identified infection (NICE, 2015).

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<2 mmol/L Consider giving a fluid bolus following local guidance

In patients who are pregnant or breastfeeding, it is important to be aware that all medicines cross the placenta, and some medicines can enter breast milk. Taking serum levels of some antimicrobials such as gentamicin, amikacin and vancomycin will ensure that therapeutic levels are achieved while minimising toxicity.

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Give a rapid fluid challenge (a) (b) Give a second bolus more slowly, if necessary

Not all sepsis is caused by bacteria; sepsis may be caused by any infectious agent, e.g., fungi, viruses and protozoa. Certain risk factors should prompt consideration of antifungal treatment, including patients with solid organ transplants, those who have received multiple or prolonged courses of antibiotics, or those with complicated bowel perforation. Failure to respond to therapy should alert the clinician to the possibility of an alternative diagnosis and the need to widen the spectrum of antibiotic cover.

Although patients usually tolerate antimicrobial treatment well, it is important to be aware of the possible side-effects and risks associated with their use. Antimicrobials are metabolised or excreted by the liver and/or kidneys. In patients with hepatic and renal problems, carefully consider whether to use antibiotics such as aminoglycosides and glycopeptides. Even penicillins and cephalosporins may cause toxicity if used in high doses in patients with renal failure (BNF, 2021).

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Fluid resuscitation is important: cannulate and start intravenous fluids immediately in any patient with lactate levels >2 mmol/L AND either a single red flag criterion OR two amber flag criteria (UK Sepsis Trust, 2019; Vaughan & Parry, 2016). Fluid resuscitation aims to restore and improve cardiac output and circulating volume, in order to reverse hypotension and thus improve tissue perfusion (McClelland & Moxon, 2014). Administer up to 20 mL per kg body weight of crystalloid fluid containing sodium 130–154 mmol/L; give the first bolus of 500 mL rapidly in under 15 minutes (UK Sepsis Trust, 2019).

After the completion of the first bolus, reassess the patient for signs of improvement, such as an increase in blood pressure, decrease in lactate levels or an increased urine output. If the patient fails to respond to treatment, for example if their systolic blood pressure remains below 90 mmHg, give a second bolus. If there is still no improvement after the second bolus, alert a consultant to attend for urgent review of the patient (NICE, 2017).

Emerging antimicrobial resistance in some bacteria and viruses means that available antimicrobials are no longer effective against them. NICE (2015) has released specific guidelines on using antimicrobials safely and wisely. Responsible antibiotic stewardship involves reviewing the decision to keep the patient on IV antibiotics at 24, 48 and 72 hours, to have a plan to convert to oral therapy once the patient improves, and to have a fixed course of therapy. Discussion with microbiology or infectious diseases teams can be very helpful; follow local policy (UK Sepsis Trust, 2019; NICE 2015).


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You may need to catheterise the patient in order to ensure accurate urine measurement; however, carefully consider the risk of infection that catheterisation itself poses (Vaughan & Parry, 2016). Catheters should be in place for the minimum amount of time necessary; never use in ambulatory patients (UK Sepsis Trust, 2019).

Regularly review the response to the initial management of sepsis and adjust treatment accordingly. Form an ongoing management plan, which you should record in writing; include the observation schedule and any escalation, decisions and support. Use a communication tool such as SBAR (Situation, Background, Assessment, Recommendation) (NHS Institute for Innovation and Improvement, 2010).

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General Notes

Fluid bolus in process1-hourly obs to be completedRepeat lactate after 4 hoursNEWS2 was 5 on admission, now 2Escalate patient if NEWS2 score increases by 1Blood cultures have been taken Patient catheterised. On 40% oxygenSepsis pathway completed

Allergy Notes






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Monitoring: Measure urine output (a)

(b) Consider catheterisation Ongoing care

Escalation of treatment Patient support and follow-up care

Regular assessment of level of consciousness, mental state, urine output, blood pressure, pulse and decreasing serum lactate levels during the fluid bolus(es) is vital to check that perfusion is improving (Vaughan & Parry, 2016). Carefully monitor patients with known cardiac and renal failure who are at risk of fluid overload. Involve senior staff and specialist teams to guide fluid resuscitation if appropriate (Robson & Daniel, 2008).

Monitor urine output hourly, accurately completing the fluid balance chart every time (UK Sepsis Trust, 2019). Urine output is an excellent window on the circulation and may identify a problem with the circulation before the blood pressure begins to fall. This is essential in guiding further fluid challenges (Rhodes et al., 2017). See also clinicalskills.net procedure on “Assessing and measuring fluid balance”.

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It may be necessary to transfer to critical care those patients who have not responded effectively, who require invasive monitoring or further interventions. Treatment in the critical care setting will aim to optimise cardiac output, correct severe anaemia, safeguard the airway, assist oxygenation and tissue perfusion and monitor multi-organ function, including glycaemic control and renal function (McClelland & Moxon, 2014).

Give patients who have had sepsis, along with their families and carers, the opportunity to discuss why they developed sepsis and what they should expect during recovery. Give them arrangements for follow-up as well as information regarding any community care needed, for example care of invasive lines (NICE, 2017). The UK Sepsis Trust has produced a guide for patients recovering from sepsis caused by COVID-19; see Key Reading.

(c) Assessment during fluid bolus(es)

After delivering the Sepsis Six, call critical care/senior support if the patient:

• Still has a reduced level of consciousness despite resuscitation;

• Has a respiratory rate over 25 breaths per minute; and

• Has raised lactate levels that are not reducing; or

• Is clearly critically ill at any time.


sepsis part 3: management in an acute hospital setting

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