What are the criteria for managing a patient with suspected sepsis?

Sepsis Management Criteria

The National Early Warning Score 2 (NEWS2) should be used to stratify risk in patients with suspected sepsis, with a score ≥7 indicating high risk of severe illness or death, 5-6 indicating moderate risk, and lower scores indicating lower risk. 1

Initial Assessment and Risk Stratification

NEWS2 Score Interpretation

• High risk: Score ≥7 (or deteriorating condition) - suggests high risk of severe illness or death from sepsis
• Moderate risk: Score 5-6 - suggests moderate risk of severe illness or death
• Low risk: Score 1-4 - suggests low risk of severe illness or death
• Very low risk: Score 0 - suggests very low risk of severe illness or death
• Note: A score of 3 in any single parameter may indicate increased risk 2

Additional Risk Factors to Consider

• Mottled or ashen appearance
• Non-blanching petechial or purpuric rash
• Cyanosis of skin, lips, or tongue
• Deteriorating condition despite interventions
• No improvement since previous assessment 2

Monitoring Requirements Based on Risk

• High risk patients: Reassess every 30 minutes
• Moderate risk patients: Reassess every hour
• Low risk patients: Reassess every 4-6 hours
• Very low risk patients: Follow standard protocol 2

Antibiotic Administration Timing

• High risk patients: Administer antibiotics within 1 hour
• Moderate risk patients: Administer antibiotics within 3 hours
• Low risk patients: Administer antibiotics within 6 hours 2

Management Steps

1. Initial Resuscitation:

   • Stabilize airway, breathing, and circulation
   • Administer at least 30 mL/kg of IV crystalloid fluid (preferably balanced crystalloids)
   • Obtain at least 2 sets of blood cultures before starting antibiotics
   • Collect cultures from all potential infection sites 1

2. Antimicrobial Therapy:

   • Start broad-spectrum antibiotics based on suspected source, local epidemiology, and patient risk factors
   • Review antibiotic choice when source of infection is confirmed or microbiological results are available
   • Consider changing to narrower spectrum antibiotic treatment based on results 1

3. Source Control:

   • Identify anatomical source of infection rapidly
   • Implement source control measures within 12 hours when feasible (drain abscesses, debride infected tissue, remove infected devices) 1

4. Vasopressor Support (if hypotension persists despite fluid resuscitation):

   • First choice: Norepinephrine (target MAP ≥65 mmHg)
   • For septic shock: Start vasopressin at 0.01 units/minute, titrate up by 0.005 units/minute at 10-15 minute intervals
   • Maximum recommended dose for septic shock: 0.07 units/minute 1, 3

5. Monitoring and Reassessment:

   • Document consciousness level using Glasgow Coma Scale
   • Monitor therapeutic endpoints: capillary refill time, blood pressure, pulses, urine output, lactate levels
   • Recalculate NEWS2 score at appropriate intervals based on risk level
   • Consider senior review and/or intensive care admission within the first hour for high-risk patients 1

Special Considerations

• Rural/Remote Settings: If transfer time to hospital exceeds 1 hour, administer antibiotics before transfer for high-risk patients 2
• Ambulance Services: Alert hospital for patients with consecutive NEWS2 scores of 5 or above or showing significant clinical concern 2
• Mental Health Settings: Follow local emergency protocols on treatment and ambulance transfer for high-risk patients 2

Common Pitfalls to Avoid

• Delayed Recognition: Failing to recognize clinical deterioration promptly can be life-threatening. Use NEWS2 for initial assessment and repeat monitoring 2
• Overtreatment: Not all patients initially diagnosed with sepsis have infectious conditions. About 32% may have noninfectious mimics of sepsis 4
• Rigid Adherence to Timeframes: Clinical judgment should be used when considering individual patient needs. Timeframes are maximum times until prescription rather than targets 2
• Failure to Reassess: Interpret NEWS2 scores in context of underlying physiology and comorbidities, and reassess at appropriate intervals 2

By following these criteria systematically, clinicians can ensure early recognition and appropriate management of patients with suspected sepsis, potentially reducing morbidity and mortality.