Nice | Detection and management of sepsis

This is a new guideline from NICE on the detection and management of sepsis. None of this is likely to be new, but it is worth looking through. I think the main reason is, sadly, from a medico-legal point of view. I guess if we have not documented obs that have been clearly laid out, or ignored listed high risk features, we will be at higher medico-legal risk. The good news is that there are quite easy to follow guidelines on what to do and what constitutes high and medium risk. Maybe worth printing out...

What assessment to carry out in patients with suspected sepsis:

  • Temperature
  • Heart Rate
  • Respiratory Rate
  • Level of consciousness
  • Oxygen saturation (young people and adults)
  • Capillary Refill (children under 12)
  • Appearance (eg skin mottling / lip colour etc)
  • Amount of urine passed in last 18 hrs
  • Blood Pressure
    • In all over 12s.
    • 5 to 11 year olds with suspected sepsis, if you have an appropriately sized cuff available and if its measurement doesn't cause a delay in assessment or treatment.
    • Under 5s if heart rate or capillary refill is abnormal.

High, moderate and low risk features to watch out for:

There are too many to document here. NICE have created handy single page tables with the features. Maybe worth printing out and referring to if needed...

Information about specific features

Fever

Do not use fever alone, or its absence to rule out or rule in sepsis.

Some groups are less likely to get fever:

  • Elderly or frail
  • Treatment for cancer
  • Young infants / children
  • Severely ill with sepsis

Heart Rate

Some people may not develop a raised heart rate:

  • Elderly (may develop an arrhythmia instead)
  • Those on certain medications (eg b-blockers)
  • Those with a lower starting pulse (eg the very fit)

Management of patients in the community

All people with any moderate or high risk features need face to face assessment.

Refer to hospital by 'the most appropriate means of transport' (usually 999) if there is:

  • Suspected sepsis AND any high risk features OR
  • Under 17s who have their immunity impaired by drug or illness AND who have any moderate or high risk features.

Pre-alert the hospital if sending in any patients with suspected sepsis and any high risk features.

Sending patients home.

If sending patients home, ensure they have information on what to look for in case of deterioration. Handy information leaflets can be found on patient.co.uk:

Use of antibiotics

  • If the transfer time is likely to be over an hour, give those with suspected sepsis antibiotics if they have any high risk features. Use local guidelines to guide what antibiotic to give. For suspected meningococcal disease, give benzylpenicillin.

Use of oxygen

  • Adults - aim for 94-98% (88 - 92% if at risk of hypercapnic respiratory failure).
  • Children - given O2 if their sats are below 91%, or if there are signs of shock. Consider the use of O2 if the sats are higher, but it is clinically indicated.

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