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Sepsis: recognition, diagnosis and early management
NICE guideline [NG51]Published: 13 July 2016 Last updated: 13 September 2017
This guideline covers the recognition, diagnosis and early management of sepsis for all populations.
Sepsis is an important cause of death in people of all ages. Both a UK Parliamentary and Health Service Ombudsman enquiry (2013) and a UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 2015) highlighted sepsis as being a leading cause of avoidable death that kills more people than breast, bowel and prostate cancer combined.
Sepsis:
Defined as a life-threatening organ dysfunction due to a dysregulated host response to infection.
Septic shock:
Defined as persisting hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of 65 mmHg or more and having a serum lactate level of greater than 2 mmol/l despite adequate volume resuscitation.
Think ‘could this be sepsis?’ if a person presents with signs or symptoms that indicate possible infection.
Take into account that people with sepsis may have non-specific, non-localised presentations, for example feeling very unwell, and may not have a high temperature.
Pay particular attention to concerns expressed by the person and their family or carers, for example changes from usual behaviour.
Assess people who might have sepsis with extra care if they cannot give a good history (for example, people with English as a second language or people with communication problems).
Assess people with any suspected infection to identify:
possible source of infection
factors that increase risk of sepsis
any indications of clinical concern, such as new onset abnormalities of behaviour, circulation or respiration.
Identify factors that increase risk of sepsis or indications of clinical concern such as new onset abnormalities of behaviour, circulation or respiration when deciding during a remote assessment whether to offer a face-to-face-assessment and if so, on the urgency of face-to-face assessment.
Use a structured set of observations to assess people in a face-to-face setting to stratify risk if sepsis is suspected.
Consider using an early warning score (NEWS2 has been endorsed by NHS England) to assess people with suspected sepsis in acute hospital settings.
Suspect neutropenic sepsis in patients having anticancer treatment who become unwell.
Refer patients with suspected neutropenic sepsis immediately for assessment in secondary or tertiary care.
Take into account that people in the groups below are at higher risk of developing sepsis:
the very young (under 1 year) and older people (over 75 years) or people who are very frail
people who have impaired immune systems because of illness or drugs, including:
people being treated for cancer with chemotherapy
people who have impaired immune function (for example, people with diabetes, people who have had a splenectomy, or people with sickle cell disease)
people taking long-term steroids
people taking immunosuppressant drugs to treat non-malignant disorders such as rheumatoid arthritis
people who have had surgery, or other invasive procedures, in the past 6 weeks
people with any breach of skin integrity (for example, cuts, burns, blisters or skin infections)
people who misuse drugs intravenously
people with indwelling lines or catheters.
Assess temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults with suspected sepsis.
Assess temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation and capillary refill time in children under 12 years with suspected sepsis.
Examine people with suspected sepsis for mottled or ashen appearance, cyanosis of the skin, lips or tongue, non-blanching rash of the skin, any breach of skin integrity (for example, cuts, burns or skin infections) or other rash indicating potential infection.
Ask the person, parent or carer about frequency of urination in the past 18 hours.
Use the person’s history and physical examination results to grade risk of severe illness or death from sepsis using criteria based on age
Category | High risk criteria | Moderate to high risk criteria | Low risk criteria |
History | Objective evidence of new altered mental state | History from patient, friend or relative of new onset of altered behaviour or mental state History of acute deterioration of functional ability Impaired immune system (illness or drugs including oral steroids) Trauma, surgery or invasive procedures in the last 6 weeks | Normal behaviour |
Respiratory | Raised respiratory rate: 25 breaths per minute or more New need for oxygen (40% FiO2 or more) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease) | Raised respiratory rate: 21–24 breaths per minute | No high risk or moderate to high risk criteria met |
Blood pressure | Systolic blood pressure 90 mmHg or less or systolic blood pressure more than 40 mmHg below normal | Systolic blood pressure 91–100 mmHg | No high risk or moderate to high risk criteria met |
Circulation and hydration | Raised heart rate: more than 130 beats per minute Not passed urine in previous 18 hours. For catheterised patients, passed less than 0.5 ml/kg of urine per hour | Raised heart rate: 91–130 beats per minute (for pregnant women 100–130 beats per minute) or new onset arrhythmia Not passed urine in the past 12–18 hours For catheterised patients, passed 0.5–1 ml/kg of urine per hour | No high risk or moderate to high risk criteria met |
Temperature |
| Tympanic temperature less than 36°C |
|
Skin | Mottled or ashen appearance Cyanosis of skin, lips or tongue Non-blanching rash of skin | Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound | No non-blanching rash |
Recognise that adults, children and young people aged 12 years and over with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis:
objective evidence of new altered mental state
respiratory rate of 25 breaths per minute or above, or new need for 40% oxygen or more to maintain oxygen saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)
heart rate of more than 130 beats per minute
systolic blood pressure of 90 mmHg or less, or systolic blood pressure more than 40 mmHg below normal
not passed urine in previous 18 hours (for catheterised patients, passed less than 0.5 ml/kg/hour)
mottled or ashen appearance
cyanosis of the skin, lips or tongue
non-blanching rash of the skin.
Do not use a person’s temperature as the sole predictor of sepsis.
Do not rely on fever or hypothermia to rule sepsis either in or out.
Ask the person with suspected sepsis and their family or carers about any recent fever or rigors.
Take into account that some groups of people with sepsis may not develop a raised temperature. These include:
people who are older or very frail
people having treatment for cancer
people severely ill with sepsis
young infants or children.
Take into account that a rise in temperature can be a physiological response, for example after surgery or trauma.
Interpret the heart rate of a person with suspected sepsis in context, taking into account that:
baseline heart rate may be lower in young people and adults who are fit
baseline heart rate in pregnancy is 10–15 beats per minute more than normal
older people with an infection may not develop an increased heart rate
older people may develop a new arrhythmia in response to infection rather than an increased heart rate
heart rate response may be affected by medicines such as beta-blockers.
Interpret blood pressure in the context of a person’s previous blood pressure, if known. Be aware that the presence of normal blood pressure does not exclude sepsis in children and young people.
Interpret a person’s mental state in the context of their normal function and treat changes as being significant.
Be aware that changes in cognitive function may be subtle and assessment should include history from patient and family or carers.
Take into account that changes in cognitive function may present as changes in behaviour or irritability in both children and in adults with dementia.
Take into account that changes in cognitive function in older people may present as acute changes in functional abilities.
Take into account that if peripheral oxygen saturation is difficult to measure in a person with suspected sepsis, this may indicate poor peripheral circulation because of shock.
For adults, children and young people aged 12 years and over who have suspected sepsis and 1 or more high risk criteria:
arrange for immediate review by the senior clinical decision maker to assess the person and think about alternative diagnoses to sepsis
carry out a venous blood test for the following:
blood gas including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinine
a clotting screen
give a broad-spectrum antimicrobial at the maximum recommended dose without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting)
discuss with a consultant.
For adults, children and young people aged 12 years and over with suspected sepsis and any high risk criteria and lactate over 4 mmol/litre, or systolic blood pressure less than 90 mmHg:
give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting) in line with recommendations i
and
For adults, children and young people aged 12 years and over with suspected sepsis and any high risk criteria and lactate between 2 and 4 mmol/litre:
give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria in an acute hospital setting)
For adults, children and young people aged 12 years and over with suspected sepsis and any high risk criteria and lactate below 2 mmol/litre:
consider giving intravenous fluid bolus (in line with recommendations in.
Monitor people with suspected sepsis who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on setting. Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings.
Monitor the mental state of adults, children and young people aged 12 years and over with suspected sepsis. Consider using a scale such as the Glasgow Coma Scale (GCS) or AVPU (‘alert, voice, pain, unresponsive’) scale.
Alert a consultant to attend in person if an adult, child or young person aged 12 years or over with suspected sepsis and any high risk criteria fails to respond within 1 hour of initial antibiotic and/or intravenous fluid resuscitation. Failure to respond is indicated by any of:
systolic blood pressure persistently below 90 mmHg
reduced level of consciousness despite resuscitation
respiratory rate over 25 breaths per minute or a new need for mechanical ventilation
lactate not reduced by more than 20% of initial value within 1 hour.
Ensure urgent assessment mechanisms are in place to deliver antibiotics when any high risk criteria are met in secondary care (within 1 hour of meeting a high risk criterion in an acute hospital setting).
For patients in hospital who have suspected infections, take microbiological samples before prescribing an antimicrobial and review the prescription when the results are available.
If meningococcal disease is specifically suspected (fever and purpuric rash) give appropriate doses of parenteral benzyl penicillin in community settings and intravenous ceftriaxone in hospital settings.
For all people with suspected sepsis where the source of infection is clear use existing local antimicrobial guidance.
For people aged 18 years and over who need an empirical intravenous antimicrobial for a suspected infection but who have no confirmed diagnosis, use an intravenous antimicrobial from the agreed local formulary and in line with local (where available) or national guidelines. [This recommendation is adapted from NICE’s guideline on antimicrobial stewardship.]
For people aged up to 17 years with suspected community acquired sepsis of any cause give ceftriaxone 80 mg/kg once a day with a maximum dose of 4 g daily at any age.
For children younger than 3 months, give an additional antibiotic active against listeria (for example, ampicillin or amoxicillin)
If patients over 16 years need intravenous fluid resuscitation, use crystalloids that contain sodium in the range 130–154 mmol/litre with a bolus of 500 ml over less than 15 minutes.
If children and young people up to 16 years need intravenous fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 130–154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes. Take into account pre-existing conditions
Reassess the patient after completion of the intravenous fluid bolus, and if no improvement give a second bolus. If there is no improvement after a second bolus alert a consultant to attend.
Do not use starch based solutions or hydroxyethyl starches for fluid resuscitation for people with sepsis.
Consider human albumin solution 4–5% for fluid resuscitation only in patients with sepsis and shock.
Give oxygen to achieve a target saturation of 94−98% for adult patients or 88−92% for those at risk of hypercapnic respiratory failure.
Oxygen should be given to children with suspected sepsis who have signs of shock or oxygen saturation (SpO2) of less than 92% when breathing air. Treatment with oxygen should also be considered for children with an SpO2 of greater than 92%, as clinically indicated.
Carry out a thorough clinical examination to look for sources of infection, including sources that might need surgical drainage, as part of the initial assessment.
Tailor investigations of the sources of infection to the person’s clinical history and findings on examination.
Consider urine analysis and chest X-ray to identify the source of infection in all people with suspected sepsis.
Consider imaging of the abdomen and pelvis if no likely source of infection is identified after clinical examination and initial tests.
Involve the adult or paediatric surgical and gynaecological teams early on if intra-abdominal or pelvic infection is suspected in case surgical treatment is needed.
Do not perform a lumbar puncture without consultant instruction if any of the following contraindications are present:
signs suggesting raised intracranial pressure or reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 points or more)
relative bradycardia and hypertension
focal neurological signs
abnormal posture or posturing
unequal, dilated or poorly responsive pupils
papilloedema
abnormal ‘doll’s eye’ movements
shock
extensive or spreading purpura
after convulsions until stabilised
coagulation abnormalities or coagulation results outside the normal range or platelet count below 100×109/litre or receiving anticoagulant therapy
local superficial infection at the lumbar puncture site
respiratory insufficiency in children.