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Visual summary How to assess risk and identify Evidence level

NICE sepsis guidance


appropriate level of monitoring and Based on the opinion of the guideline development committee,
management for suspected sepsis supported by generally very low quality evidence

Person with possible infection


Infection +/- Fever Feeling unwell

Young children
Think: High People with sepsis may Pay particular ?
temperature have non-specific, attention to concerns Different first language
Could this could be non-localising Take particular care if
be sepsis? expressed by the person
present presentations, such as and family/carer there are communication People with
or absent feeling very unwell barriers to overcome communication problems

Assessment Age 75+ Age under 1 Pregnant Pregnant in last 6 weeks


Assess people with suspected infection to identify: Frail with complex comorbidities Particularly if:
Gestational diabetes Diabetes
Trauma
Likely source Indicators of clinical concern: Risk factors Within last Required invasive procedure
Surgery 6 weeks such as caesarean section
of infection Behaviour Circulation Respiration for sepsis Invasive procedure Forceps delivery
Removal of retained
Impaired immunity products of conception
Indwelling lines or catheters Prolonged rupture of membranes
Intravenous drug users
Close contact with someone with
Sepsis not suspected Suspected sepsis Any breach of skin integrity:
group A streptococcal infection

Cuts Burns Blisters Have continued bleeding or


No clinical cause for concern No risk factors an offensive vaginal discharge
Stratify risk of severe illness Skin infections
and death from sepsis
Use clinical judgment to treat the person

In hospital
Detailed risk assessment H High risk M Moderate to high risk

Age (years) Under 1 1–2 3–4 5 6–7 8–11 12+ and adults
H Weak, high-pitched or continuous cry H Objective evidence of new mental state
In primary care
H Appears ill to a healthcare professional M History from patient,
friend or relative of altered
H M M
H Does not wake or, if roused, does not stay awake behaviour / mental state
M Parent or carer concern that child is behaving differently from usual M Deterioration of functional 1+ 2+ 1 No high or
M Decreased activity ability high risk moderate moderate moderate to
Behaviour M Not responding normally to social cues M Not behaving normally M Impaired immune system H M criteria
met
to high risk
criteria met
to high risk
criteria met
high risk
criteria met
and M No smile M Trauma, surgery or
history M Wakes only with prolonged stimulation
procedure in last 6 weeks
1+ 1+ No high or
moderate to
M Poor feeding high risk moderate
criteria to high risk high risk
criteria met Review by Clinical
Breaths per minute (resting rate) met criteria met Clinician
H 60+ senior clinical assessment
60 review and
H 50+ decision maker3
M 50–59 H 40+ consider
40 M 40–49 H 29+ H 27+ blood tests Manage
H 25+ H 25+ Give IV4
M 30–39 Age under 18 according
20 M 24–28 M 24–26 M 22–24 M 21–24 antibiotics Within
with immunity to clinical
H without 1 hour
Breathing
Grunting
H New requirement of oxygen compromised judgment
delay
H Moderate or severe chest indrawing 0.4+ FiO2 to maintain
saturation above 92%
H Oxygen saturation 90% or less in air
or 88% in known COPD1
M Oxygen saturation 92% or less in air
Pre-alert Can definitive
M Increased work of breathing Perform tests Escalate to high risk
M Nasal flaring secondary condition be Lactate
M Crackles in the chest care diagnosed and Blood culture
treated? Clinician and
Heart rate (beats per minute) Full blood count
170 H 160+ results review
Clotting screen
H 150+ No Yes
150 M 150–159 H 140+ C-reactive protein Within 1 hour
M 140–149 H 130+ H 130+ U/E and creatinine
130 M 130–139 H 120+ Blood gas
M 120–129 H 115+ Lactate
110 M 110–119 M 105–114 M 91–129
Send to Treat definitive <2 2+
90 emergency condition and/or Lactate (mmol/L)
Circulation H Less than 60 beats per minute H Systolic BP2 Under 90 mmHg department provide information
<2 2–4 4+ Assessed as having AKI5
M Capillary refill time 3+ seconds
or 40+ mmHg below normal to safety net
Consider Give IV4 fluid No Yes
M Cold hands / feet M Systolic BP2 91–100 mmHg IV4 fluids bolus injection
M Leg pain M Pregnant: 100–130 BPM
Discuss with consultant
M New onset arrythmia Only consider giving antibiotics if
Refer to Definitive condition identified?
transfer time will be greater than 1 hour critical
H Colour of skin / lips / tongue is mottled or ashen or blue care
No Yes
H Non-blanching rash
H Reduced skin turgor M Signs of infection
M Pale or flushed Increased redness Repeat structured Manage
Swelling or discharge
1
Chronic obstructive pulmonary disease Carry out assessment definitive
at surgical site
Blood pressure observations
Skin
2

Breakdown of wound condition /


Continuously in At least infection
3
NICE provides the following examples of senior clinical decision hourly
makers in the UK: emergency
department
H Under 36°C
M Elevated M Rigors For adults For under 18s or every 30 min
Temperature Under 3 months: 38+ °C
3—6 months: 39+ °C
Review by senior Within
Consultant to 3 hours
CT3 or ST3 or Advanced nurse Paediatric clinical decision maker3
H Not passed urine in 18 hours practitioner ST4 or above attend if patient
M Reduced urine output M Not passed urine in the does not improve Consider antibiotics
Urine last 12–18 hours 4
Intravenous
5
Acute Kidney Injury

© 2016 BMJ Publishing group Ltd.


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