CKMP Sepsis

Identifying people with suspected sepsis

This guidance should be used together with the algorithms organised by age group and treatment location and the risk stratification tools. There are algorithms for:

There are also risk stratification tools for:

1.1.1Think ‘could this be sepsis?’ if a person presents with signs or symptoms that indicate possible infection.

1.1.2Take 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.

1.1.3Pay particular attention to concerns expressed by the person and their family or carers, for example changes from usual behaviour.

1.1.4Assess 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).

1.1.5Assess people with any suspected infection to identify:

possible source of infection
factors that increase risk of sepsis (see section 1.2 on risk factors for sepsis)
any indications of clinical concern, such as new onset abnormalities of behaviour, circulation or respiration.

1.1.6Identify factors that increase risk of sepsis (see section 1.2 on risk factors for 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.

1.1.7Use a structured set of observations (see section 1.3 on 1.3 face-to-face assessment on people with suspected sepsis) to assess people in a face-to-face setting to stratify risk (see section 1.4 on stratifying risk of severe illness or death from sepsis) if sepsis is suspected.

1.1.8Consider using an early warning score (NEWS2 has been endorsed by NHS England) to assess people with suspected sepsis in acute hospital settings.

1.1.9Suspect neutropenic sepsis in patients having anticancer treatment who become unwell. [This recommendation is from NICE’s guideline on neutropenic sepsis.]

1.1.10Refer patients with suspected neutropenic sepsis immediately for assessment in secondary or tertiary care. [This recommendation is from NICE’s guideline on neutropenic sepsis.]

1.1.11Treat people with neutropenic sepsis in line with NICE’s guideline on neutropenic sepsis.

1.2 Risk factors for sepsis

1.2.1Take 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 (see recommendation 1.1.9 in the section on identifying people with suspected sepsis)
- 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.

1.2.2Take into account that women who are pregnant, have given birth or had a termination of pregnancy or miscarriage in the past 6 weeks are in a high risk group for sepsis. In particular, women who:

have impaired immune systems because of illness or drugs (see recommendation 1.1.5 in the section on identifying people with suspected sepsis)
have gestational diabetes or diabetes or other comorbidities
needed invasive procedures (for example, caesarean section, forceps delivery, removal of retained products of conception)
had prolonged rupture of membranes
have or have been in close contact with people with group A streptococcal infection, for example, scarlet fever
have continued vaginal bleeding or an offensive vaginal discharge.

1.2.3Take into account the following risk factors for early-onset neonatal infection:

invasive group B streptococcal infection in a previous baby
maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
prelabour rupture of membranes
preterm birth following spontaneous labour (before 37 weeks’ gestation)
suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth
intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis
parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth (this does not refer to intrapartum antibiotic prophylaxis)
suspected or confirmed infection in another baby in the case of a multiple pregnancy.
[This recommendation is from NICE’s guideline on neonatal infection.]

1.3 Face-to-face assessment of people with suspected sepsis

1.3.1Assess temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults with suspected sepsis.

1.3.2Assess temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation and capillary refill time in children under 12 years with suspected sepsis. [This recommendation is adapted from NICE’s guideline on fever in under 5s.]

1.3.3Measure blood pressure of children under 5 years if heart rate or capillary refill time is abnormal and facilities to measure blood pressure, including a correctly-sized blood pressure cuff, are available. [This recommendation is adapted NICE’s guideline on fever in under 5s.]

1.3.4Measure blood pressure of children aged 5 to 11 years who might have sepsis if facilities to measure blood pressure, including a correctly-sized cuff, are available.

1.3.5Only measure blood pressure in children under 12 years in community settings if facilities to measure blood pressure, including a correctly-sized cuff, are available and taking a measurement does not cause a delay in assessment or treatment.

1.3.6Measure oxygen saturation in community settings if equipment is available and taking a measurement does not cause a delay in assessment or treatment.

1.3.7Examine 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.

1.3.8Ask the person, parent or carer about frequency of urination in the past 18 hours.

1.4 Stratifying risk of severe illness or death from sepsis

1.4.1Use the person’s history and physical examination results to grade risk of severe illness or death from sepsis using criteria based on age (see tables 1, 2 and 3).

Adults, children and young people aged 12 years and over

References

https://www.nice.org.uk/guidance/ng51/chapter/Recommendations#risk-factors-for-sepsis

https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 News score

https://www.clinicaltoolkit.co.uk/work/national-early-warning-score-news/ – Bris doc interactive tool

https://www.nice.org.uk/guidance/ng143/resources/support-for-education-and-learning-educational-resource-traffic-light-table-pdf-6960664333 – traffic light system for identifying illness under 5 Nice 2019

https://www.clinicaltoolkit.co.uk/knowledgebase/pediatric-reference-ranges/?highlight=paediatric+reference+card – Paediatric Ref card

https://www.nice.org.uk/guidance/ng143/chapter/Recommendations – Under 5’s assessment and initial management Nice 2019