Sepsis
Sepsis is a life-threatening condition defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a time-critical emergency in the ED—early recognition and treatment markedly improve survival.
I. Recognition and Triage (NEWS2 + Clinical Judgement)
In the UK, NEWS2 is the standard hospital tool to identify patients at risk of deterioration and sepsis, but clinical judgement remains paramount.
Sepsis “Red Flags” (High-risk Sepsis)
Any sign of organ dysfunction in a patient with suspected infection should trigger the immediate sepsis pathway (Sepsis Six).
| Organ dysfunction / deterioration (NEWS2 ≥5 or clinical concern) | Risk factor examples |
|---|---|
| Respiratory rate ≥22/min or need for high-flow O₂ | Extremes of age (<1 or >75 years) or frailty |
| Altered mental status/new confusion (GCS <15 or AVPU ≠ Alert) | Immunosuppression (chemotherapy, HIV, steroids) |
| Systolic BP ≤100 mmHg or MAP <65 mmHg | Indwelling lines/catheters, recent surgery |
| Lactate ≥2 mmol/L (hypoperfusion) | Pregnancy or <6 weeks postpartum |
| New haematuria/oliguria/AKI (renal dysfunction) | Diabetes or significant chronic disease |
II. The Sepsis Six (1-Hour Bundle)
A care bundle of three TAKE (diagnose/monitor) and three GIVE (treat/resuscitate) actions—all within 1 hour of recognising sepsis.
| TAKE (diagnosis & monitoring) | GIVE (resuscitation & treatment) |
|---|---|
| 1) Blood cultures and seek the source | 4) High-flow oxygen (titrate to target sats) |
| 2) Lactate and VBG | 5) IV fluids (initial 500 mL crystalloid over 10–15 min, repeat to response; in septic shock aim up to ~30 mL/kg while reassessing) |
| 3) Urine output/strict fluid balance | 6) Broad-spectrum IV antibiotics |
Management pearls
- Antibiotics STAT: In septic shock, each hour of delay increases mortality—give within 1 hour (after cultures) and de-escalate to culture results.
- Fluids: Use balanced crystalloid (e.g., Hartmann’s) or saline in small boluses with frequent reassessment (airway, breathing, circulation, lungs, IVC if available). If hypotension persists, start vasopressors (noradrenaline first-line) with ICU input.
- Source control: Urgent control of the source (e.g., drain abscess, remove infected catheter, relieve obstruction, surgery for perforation).
III. NEWS2 vs qSOFA
- NEWS2: UK-preferred screening tool (more sensitive than qSOFA); includes 7 physiological parameters and COPD-specific O₂ targets.
- qSOFA: RR ≥22, SBP ≤100, altered mentation—simpler but less sensitive for initial screening; may help risk-stratify outside the ICU.
SBA Exam Tips and Tricks
| Concept | SBA differentiator clue | Action / key fact |
|---|---|---|
| Time target | Meets sepsis criteria | Complete Sepsis Six within 1 hour |
| Initial fluid challenge | Hypotensive septic patient | 500 mL IV crystalloid over 10–15 min; reassess and repeat |
| Source control | Obstructed infected system (e.g., pyonephrosis/prostatic abscess) | Antibiotics alone are inadequate → urgent drainage |
| Septic shock definition | Vasopressors to keep MAP ≥65 and lactate >2 mmol/L despite fluids | Manage as septic shock: fluids, early vasopressors, close monitoring/ICU |
References
- NICE NG51. Suspected sepsis: recognition, diagnosis and early management (2024 update).
- UK Sepsis Trust. Sepsis Manual (7th ed., 2024).
- RCEM Learning. Sepsis – Induction (2018); Sepsis in Adult Patients Clinical Guideline (2024).
- StatPearls (NCBI Bookshelf). Early Recognition and Initial Management of Sepsis in Adult Patients (2024).
- RCEM Learning. Infected Obstructed Kidney (2024); Respiratory Failure (2024).