Sepsis in Adults Pathway

Symptoms

Patients with high severity community-acquired pneumonia (CAP):

• Unwell Patient (fever, chills, confusion)
• Non specific deterioration

Is patient >20 wks pregnant or 6 weeks post partum?

Yes

Contact Obstetric ST3 Inform Senior Midwife

Follow the Hospital Severely Ill Pregnant / Postnatal Woman Pathway

Has patient received chemotherapy or immunesuppressants
within last 2 months or undergone
bone marrow or stem cell transplantation?
SUSPECT NEUTROPENIC SEPSIS

Yes

• Check vital signs and document
• Insert Cannula
• Arrange initial blood tests FBC, U&E, LFT’s CRP, G&S,
  INR, APTT, Fibrinogen using CyberLab Sepsis Order Set.
• Check Serum Lactrate (arterial or venous).
• Blood cultures to be taken peripherally using aseptic non
  touch technique and from CVC if one insitu. PRIOR TO
  ANTIBIOTIC ADMINISTRATION.
• Piperacilin-tazobactam and gentamicin is first line for
  treatment of suspected neutropenic sepsis. Patients on
  platinum based chemotherapy (e.g. Cisplatin) or history of
  rash only with penicillins should receive meropenem. Refer to
  antibiotic guideline if known antibiotic allergies or renal failure
  Never wait for results before starting IV antibiotics.
• Prompt prescription and administration of first line antibiotic
  therapy or nursing staff to administer IV Antibiotic according
  to Patient Group Direction for patients suspected of
  neutropenic sepsis (this is only applicable to Haematology
  nursing staff, giving meropenem only)
• IV antibiotics must be administered within 1 hour of arrival
  to Emergency Department or of direct admission to
  Haematology Ward
• If already an inpatient on the ward, IV antibiotics to be
  administered within 1 hour of suspected neutropenic sepsis.
• Time of antibiotics given must be documented in case notes
• Medical Review within 1 hour
• Consider need for barrier nursing and platelets
• Contact on call microbiologists, and haematologist or oncologists for advice

Follow the Management of Neutropenic Sepsis in Adults Pathway

Are any 2 of the following present and new to the
patient?

Yes

• Temperature <36C or >38C
• Heart Rate more than 90bpm
• Respiratory Rate more than 20/Min
• White cells <4 or >12
• Plasma Glucose >7.7 mmol in the absence of diabetes
• Never wait for results before starting IV antibiotics.

No

• Follow standard EWS protocol
• Re-apply screening tool if situation changes
• Consider source of infection without inflammatory response

Are the clinical features suggestive of a new infection?

• Pneumonia
• UTI
• Diarrhoea
• Peritonitis
• Meningitis
• Endocarditis
• Cellulitis/Septic Arthritis/Fasciitis/Wound infection
• Catheter/other Infection (including Central Line Infection)

Yes

Patient has Sepsis - WITHIN THE FIRST HOUR ANTIBIOTICS MUST HAVE BEEN PRESCRIBED AND ADMINISTERED

No

Look for non-infective causes

• Pancreatitis
• Transfusion reaction
• Trauma
• Burns
• Thromboembolism

Management of Sepsis Patient

• Give oxygen to maintain target saturations > 94%-99% (or 88%-92% following senior clinical review if at risk of type II respiratory failure)
• Blood cultures: take at least one set plus FBC, U&E’s, LFT’s, CRP, INR, APTT, Fibrinogen, Grp/Save (using CyberLab Sepsis order set). Check Serum Lactrate (arterial or venous). ABG, if patient
  requiring >40% oxygen to maintained target saturation or if hypotension/raised lactrate.
• Prescribe and administer IV antibiotics within 1 hour of diagnosis as per Trust guidelines.
• Give fluid challenge in the event of Hypotension (systolic <90mmHg or >40mmHg fall from baseline or MAP <65mmHg) and/or lactrate >4 mmol/L: Deliver an initial bolus of up to 30ml/kg of Plasma-lyte 148 in water (or colloid equivalent) in the 1st hour intravenously (some patients may require greater volumes). Fluids must be titrated to BP response. Consider maintenance fluids as required. Caution with fluid load > 30ml/kg in patients with significant heart disease.
• Continue EWS every 30 mins
• Monitor fluids and record fluid balance hourly
• Address source control for definitive treatment of underlying cause of sepsis
• Request senior review (Consultant or Registrar)
• Seek critical care opinion if concerns

• Give oxygen to maintain target saturations > 94%-99% (or 88%-92% following senior clinical review if at risk of type II respiratory failure)
• Blood cultures: take at least one set plus FBC, U&E’s, LFT’s, CRP, INR, APTT, Fibrinogen, Grp/Save (using CyberLab Sepsis order set). Check Serum Lactrate (arterial or venous). ABG, if patient
  requiring >40% oxygen to maintained target saturation or if hypotension/raised lactrate.
• Prescribe and administer IV antibiotics within 1 hour of diagnosis as per Trust guidelines.
• Give fluid challenge in the event of Hypotension (systolic <90mmHg or >40mmHg fall from baseline or MAP <65mmHg) and/or lactrate >4 mmol/L: Deliver an initial bolus of up to 30ml/kg of Plasma-lyte
  148 in water (or colloid equivalent) in the 1st hour intravenously (some patients may require greater volumes). Fluids must be titrated to BP response. Consider maintenance fluids as required. Caution with
  fluid load > 30ml/kg in patients with significant heart disease.
• Continue EWS every 30 mins
• Monitor fluids and record fluid balance hourly
• Address source control for definitive treatment of underlying cause of sepsis
• Request senior review (Consultant or Registrar)
• Seek critical care opinion if concerns

Review patient every 30 mins Are any of the following present and new to the patient?

• Act on blood results
• Systolic Blood Pressure < 90mmHg or MAP < 65mmHg
• New or increased need for oxygen to keep SpO2 >90%
• Lactrate > 2mmol/l. Consider Severe Sepsis.
• Creatinine > 177 mmol/l or Urine output < 0.5ml/kg/hr for 2 hrs
• Bilirubin > 34μmol/l Platelets < 100
• Coagulopathy: INR >1.5 or APTT >60 s
• Catheterise and commence hourly urine output measurement to maintain >0.5mls/
  kg/hr if hypotension or raised creatinine, oliguria, raised lactrate >4mmol/l
• Acutely altered mental status
  

Yes

• Patient Has Severe Sepsis

No

• Reassess patient
• Document appropriate management plan

Systolic BP <90mmHg or MAP <65mmHg or a fall of >40mmHg or
lactrate >4mmol from baseline after resuscitation?

Yes

Septic Shock

No

Severe sepsis, no shock

• Refer to Critical Care Outreach Team/
  Acute Response Team
• Ensure management plan is documented
  in notes
• Ensure hourly EWS taken, recorded and
  acted upon.
• Monitor urine output
• Record hourly fluid balance
• Monitor blood test for signs of AKI
• Daily antibiotic review
• Medical review at 6 hrs

If patient fails to respond to treatment continue the above.

If Septic Shock consider the following...

Refer to Critical care

• Accepted for ITU/HDU
• Transfer ITU/HDU
• Ensure patient has received adequate fluid resuscitation: boluses of 30ml/kg 0.9% saline or Plasma-lyte 148 in water
• If still shocked (low BP/ low urine output/ high lactrate) insert central venous catheter under USS guidance (only if competent; otherwise seek help)
• Aim to achieve CVP 8-12mmHg with Care, Check CVP Monitor
• Consider noradrenaline if still shocked or dobutamine if ScvO2 < 70%. Consider +/-blood transfusion
• Take heparinised sample from central line (use ABG syringe): check ScvO2>70%
• Consider blood transfusion if haematocrit < 30 and ScvO2 <70%.
• Recheck Lactrate if initially high >4 mmol/L
• Review Antibiotics

Ward Management

• Agree Ceiling of treatment
• Consider DNAR
• Consider patient for Care of the Dying Patient Plan?

Follow Care of the Dying Patient Pathway