Sepsis

Sepsis is a serious condition that is a major cause of avoidable death (National Confidential Enquiry into Patient Outcome and Death (NCEPOD), 2015). It is estimated that there are about 123 000 episodes of sepsis per year, with resulting mortality estimated at 37 000 (NHS England, 2015), with an estimated total cost to the NHS of £1.5 billion per year (Daniels and Nutbeam, 2017). Improvements in addressing sepsis within hospital trusts has the potential to save £1.25 million annually (NHS England, 2015). Therefore, prompt identification and management are essential in reducing the sepsis-related morbidity, mortality and financial burden on the NHS.

Pathophysiology of sepsis

Sepsis can be caused by any pathogenic microbe and may arise from pneumonia, urinary tract infection and infection in the skin and soft tissue (Brent, 2017). Pneumonia is the most common cause of sepsis, with bacteria being the most common causative organism (Gaieski et al, 2010).

In clinical practice it can be difficult to determine whether sepsis is occurring because the signs and symptoms vary and can be subtle in certain patient groups (Brent, 2017).

In sepsis, a raised respiratory rate in a patient is a key indicator of deterioration. Decreased oxygen transfer across the alveoli occurs as a result of proteins and fluids leaking into the tissues of the lungs. This leads to an increased breathing rate to compensate for the reduced surface area available for oxygenation. The circulatory system is also affected in sepsis, with the release of nitric oxide and interleukins causing vasodilation (Daniels and Nutbeam, 2017). This results in hypotension in patients, leading to inadequate perfusion of tissues (Gauer, 2013). The body attempts to compensate for the low blood pressure by increasing the work of the heart, which is known as compensatory tachycardia. In early stages of sepsis, the patient may present

Rapid clinical assessment and prompt management is required if a deteriorating patient presents with a risk factor for sepsis, a NEWS 2 score of 5 or more (or local equivalent), and a clinical suspicion of infection (Daniels and Nutbeam, 2017). The Sepsis Six is a care bundle designed to be delivered within the first hour of diagnosis (Brent, 2017) (Box 1). This includes supplementing oxygen to improve oxygenation to maintain saturations between 94% and 98%. If the patient is critically ill, this can be given as high-flow oxygen using a mask with a reservoir at 15 litres (Resuscitation Council, 2014).

Box 1. Sepsis Six care bundle

• Deliver oxygen to achieve saturations of 94-98% or 88-92% in patients who retain CO2
• Take blood cultures and other cultures
• Administer intravenous (IV) antibiotics within 1 hours of diagnosis
• Commence crystalloid IV infusion 500 ml in 15 minutes an reassess
• Measure venous bloods: glucose,

Sepsis can be difficult to identify because the signs and symptoms can be variable and subtle. Assessment tools, such as NEWS 2 and qSOFA, can aid health practitioners in determining a patient's risk of sepsis with the management of sepsis guided by NICE (2017b) and the Sepsis Trust (Daniels and Nutbeam, 2017). Oxygen, fluid and antibiotics are aimed to be delivered within the first hour of diagnosis, with blood cultures, measurement of lactate and urine output all guiding management.