What is the diagnosis and management of sepsis?

Diagnosis and Management of Sepsis

Sepsis should be diagnosed using the SOFA score to identify organ dysfunction and managed with immediate broad-spectrum antibiotics within 1 hour of recognition, along with at least 30 mL/kg IV crystalloid fluid resuscitation within the first 3 hours. 1, 2

Diagnosis of Sepsis

Definition and Diagnostic Criteria

• Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection 1
• Diagnosis requires evidence of:
  • Suspected or confirmed infection
  • Organ dysfunction as measured by the SOFA score (Sequential Organ Failure Assessment) 1

SOFA Score Components

The SOFA score evaluates six organ systems with points assigned for increasing dysfunction:

Parameter	SOFA score points
PaO2/FiO2 (mmHg)	<400 (1), <300 (2), <200 with ventilation (3), <100 with ventilation (4)
Glasgow Coma Scale	13-14 (1), 10-12 (2), 6-9 (3), <6 (4)
Mean arterial pressure	MAP <70 mmHg (1), Dopamine ≤5 or any dobutamine (2), Dopamine >5 or epi/norepi ≤0.1 (3), Dopamine >15 or epi/norepi >0.1 (4)
Bilirubin (mg/dL)	1.2-1.9 (1), 2.0-5.9 (2), 6.0-11.9 (3), >12.0 (4)
Platelets (×10³/μL)	<150 (1), <100 (2), <50 (3), <20 (4)
Creatinine (mg/dL)	1.2-1.9 (1), 2.0-3.4 (2), 3.5-4.9 or <500 mL/d urine (3), >5.0 or <200 mL/d urine (4)

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Early Warning Systems

• In acute hospital settings, use NEWS2 (National Early Warning Score 2) to determine risk of severe illness or death from sepsis 1
• NEWS2 risk interpretation:
  • Score 0: Very low risk
  • Score 1-4: Low risk
  • Score 5-6: Moderate risk
  • Score ≥7: High risk
  • Score of 3 in any single parameter may indicate increased risk 1

Additional Clinical Signs

Consider sepsis when the following are present:

• Mottled or ashen appearance
• Non-blanching petechial or purpuric rash
• Cyanosis of skin, lips, or tongue 1

Management of Sepsis

Initial Resuscitation (First 3 Hours)

1. Obtain blood cultures before starting antibiotics (but don't delay antibiotics >45 minutes) 2
2. Administer broad-spectrum antibiotics within 1 hour of sepsis recognition 2
3. Fluid resuscitation with at least 30 mL/kg IV crystalloids within the first 3 hours 2
4. Measure lactate level and re-measure if initially elevated 2

Antimicrobial Therapy

• Timing: Administer within 1 hour of sepsis recognition 2
• Selection: Use broad-spectrum antibiotics active against all likely pathogens 2
• Reassessment: Daily review of antimicrobial regimen for potential de-escalation 2
• Duration: Typically 7-10 days, guided by clinical response 2

Source Control

• Identify the anatomic source of infection as rapidly as possible 2
• Implement source control interventions (e.g., drainage of abscess, removal of infected device) as soon as medically and logistically practical 2
• Choose interventions with the least physiologic insult (e.g., percutaneous rather than surgical drainage) 2

Hemodynamic Support

• Target: Mean arterial pressure (MAP) ≥65 mmHg 2
• Vasopressors:
  • Start norepinephrine as first-choice vasopressor if hypotension persists despite fluid resuscitation 2
  • Consider adding vasopressin (up to 0.03 U/min) to raise MAP or decrease norepinephrine dosage 2
• Fluid responsiveness: Use dynamic variables (pulse pressure variation, stroke volume variation) to guide further fluid administration 2

Monitoring and Reassessment

• Recalculate NEWS2 score at specific intervals based on risk level:
  • High risk (score ≥7): Every 30 minutes
  • Moderate risk (score 5-6): Every hour
  • Low risk (score 1-4): Every 4-6 hours
  • Very low risk (score 0): According to local protocol 1

Supportive Care

1. Oxygen therapy: Apply immediately to address hypoxemia, targeting SpO2 92-96% 2
2. Nutrition: Provide preferentially via enteral route when possible 2
3. VTE prophylaxis: Administer LMWH (preferred over UFH) unless contraindicated 2
4. Stress ulcer prophylaxis: Consider for patients with risk factors for GI bleeding 2
5. Renal replacement therapy: Consider continuous RRT for hemodynamically unstable patients 2

Special Considerations

Community and Pre-hospital Settings

• In remote locations with prolonged transport times (>1 hour):
  • Consider administering antibiotics before hospital arrival for patients at high risk (NEWS2 score ≥7) 1
  • Follow local guidelines or seek advice from senior colleagues 1
• Alert receiving hospital for patients with consecutive NEWS2 scores ≥5 or significant clinical concern 1

Implementation Challenges

• NEWS2 may be less accurate in patients with altered baseline physiology (e.g., spinal injury, heart and lung disease) 1
• Always interpret NEWS2 within the context of the patient's underlying physiology and comorbidities 1

Early recognition and prompt intervention are critical for improving outcomes in sepsis, with evidence showing that nurse-based early recognition programs can reduce sepsis mortality and costs 3.