What is the initial assessment and management for a patient suspected of sepsis, including sepsis screening assessment tools like Systemic Inflammatory Response Syndrome (SIRS) or quick Sepsis-related Organ Failure Assessment (qSOFA)?

Sepsis Screening Assessment

Use the National Early Warning Score 2 (NEWS2) as the primary screening tool for sepsis risk stratification in adults aged 16 and over with suspected or confirmed infection. 1

Initial Risk Stratification with NEWS2

The NEWS2 system evaluates six physiological parameters to generate an aggregate score that determines sepsis risk 1:

• Respiratory rate (per minute)
• Oxygen saturation (SpO2)
• Supplemental oxygen requirement (air vs oxygen)
• Systolic blood pressure (mm Hg)
• Heart rate (per minute)
• Level of consciousness (Alert vs CVPU: Confusion, Voice, Pain, Unresponsive)
• Temperature (°C)

NEWS2 Risk Categories

Interpret NEWS2 scores in the context of underlying physiology and comorbidities 1:

• High risk: NEWS2 ≥7 1, 2
• Moderate risk: NEWS2 5-6 1, 2
• Low risk: NEWS2 1-4 2
• Very low risk: NEWS2 0 2

A score of 3 in any single parameter may indicate increased sepsis risk regardless of total score. 1

Critical Clinical Signs That Override NEWS2

Immediately escalate risk assessment if any of these signs are present, regardless of NEWS2 score 1, 2:

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

Monitoring Frequency Based on Risk

Re-calculate NEWS2 and re-evaluate sepsis risk at the following intervals 1:

• High risk (NEWS2 ≥7): Every 30 minutes
• Moderate risk (NEWS2 5-6): Every hour
• Low risk (NEWS2 1-4): Every 4-6 hours
• Very low risk (NEWS2 0): Standard protocol

Escalate the risk category if the patient's condition deteriorates or fails to improve despite interventions. 1

Antibiotic Administration Timeframes

Administer IV antibiotics based on risk stratification 1:

• High risk: Within 1 hour 2
• Moderate risk: Within 3 hours 1
• Low risk: Within 6 hours 1

These are maximum timeframes, not targets—use clinical judgment for individual patients. 1

Diagnostic Workup

Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobials if this causes no substantial delay (>45 minutes). 1, 2

Additional diagnostic steps 2:

• Sample fluid or tissue from suspected infection sites when possible
• Perform imaging promptly to identify infection source

Initial Resuscitation

Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion. 1, 2

Following initial fluid resuscitation 1, 2:

• Guide additional fluids by frequent hemodynamic reassessment
• Use dynamic variables over static variables to predict fluid responsiveness when available
• Target mean arterial pressure (MAP) of 65 mm Hg in patients requiring vasopressors

Important Caveats About qSOFA and SIRS

Do not rely on qSOFA (Quick Sequential Organ Failure Assessment) as a primary screening tool in the emergency department. Research demonstrates that qSOFA has poor sensitivity for identifying sepsis at ED presentation, with sensitivity ranging from only 28.5-31.2% for ICU admission and mortality outcomes 3, 4, 5. qSOFA was designed for prognostication in patients with established infection, not for initial sepsis screening. 6

Similarly, SIRS criteria alone have suboptimal performance, with sensitivity of 58.8-86.1% for sepsis outcomes 3, 4, 5. NEWS2 consistently outperforms both qSOFA and SIRS for early sepsis identification, with area under the curve (AUC) of 0.837-0.91 compared to 0.697-0.744 for qSOFA and 0.631-0.88 for SIRS. 4, 5

Common Pitfalls to Avoid

• Delaying antimicrobial therapy beyond one hour in high-risk patients (NEWS2 ≥7) 2
• Failing to obtain cultures before antibiotics when this can be done without significant delay 2
• Inadequate initial fluid resuscitation (less than 30 mL/kg in first 3 hours) 2
• Using qSOFA as a screening tool rather than NEWS2 in the ED setting 3, 4, 5
• Not reassessing patients frequently enough based on their risk category 1
• Ignoring clinical deterioration when NEWS2 score remains stable 1