Date: Sepsis

Time:

Integrated Care Pathway

Use this sheet WITH admission/clinical notes

Sepsis Assessment

Please refer to Guideline 36 on the Trust Intranet and not the pathway below for neutropenic sepsis or sepsis where the patient has a recent history of chemotherapy (i.e. where there are grounds to suspect neutropenic sepsis).

(1) Suspicion of new infection

plus

(2) SEPSIS = Any two of Systemic Inflammatory Response Syndrome (SIRS) Criteria

Tick relevant boxes

Temperature / >38.3ºC*
<36.0ºC / £
£ / WBC >11 X 109/L OR
WBC <4 X 109/L
neutrophils <0.5 X 109/L# / £
£
£
* Not due to DVT, PE, Heterotrophic calcification or heated surroundings.
Pulse >90 beats/min / £ / Glucose >7.7 mmol/L without diabetes / £
RR >20 breaths/min / £ / GCS <15 / £

# use Clinical Guideline 36 Care of Adult Neutropenic Patients

(3) SEVERE SEPSIS = Any one Criteria of Organ Dysfunction present and new to patient

Systolic BP <90 mmHg or acute change / £ / Urine output <0.5 ml/kg/hr
(not due to dehydration) / £
O2 needed to keep sats >90% / £ / Lactate >2.5 mmol/L / £
INR >1.5 (unless on warfarin) / £ / Creatinine >176 μmol/L / £
Bilirubin >34 μmol/L / £ / Capillary refill >2 secs / £
Initial Management
ALL SEPSIS: steps1 - 6 / TARGET <1 hr
SEVERE SEPSIS: steps 1 - 8 / Time started/done
1.  Oxygen / O2 sats >95% (>90% in COPD)
2.  Hourly obs / Hourly urine output and EWS
3.  IV fluids / Initial minimum 20 ml/kg/30 min (Crystalloids)
Monitor intake and output
4.  Bloods and ABG / FBC U&E CRP LFT INR Lactate
5.  Blood cultures x 2 / Also urine/sputum/swabs
6.  Antibiotics – ensure given before leaving bedside / As per Trust Guidelines – identify source +/-remove focus / Time prescribed
Time given
7.  Increased fluids (avoid overloading) / 40 ml/kg (Crystalloids) if no response to 3 (above).
8.  Urinary catheter (stop Flip Flow if in place) / Monitor urine output and EWS every 10 mins
Signed……………………………………...... …………….. / Date……..…….. / Time…..…….
Department of Microbiology, Buckinghamshire Healthcare NHS Trust, Jan 2011, modified from Royal Hampshire County Hospital
WZZ / PTO

Date:

Time:

Parameters of success (1 hour)

Systolic BP >90 mmHg / Urine output >0.5 ml/kg/hour / Pulse <90 beats/min / RR <20 breaths/min
GCS 15 / Capillary refill <2 sec / Lactate <2.5 mmol/L / Infective source identified

Further assessment/investigation

Identify and control source TARGET : Within 6 hours

Time done

SAMPLES (as relevant): sputum/BAL, CSU, CSF, wound swab, HVS, faeces, pus. Before starting antibiotics if possible.
IMAGING: CXR, USS, CT, MRI
REMOVAL OF INFECTIVE FOCUS: debridement, drainage, removal of infected device

Signed……………………………………...... ………………. Date……..……. Time…..…….

Persistent hypotension despite fluid resuscitation and/or lactate >2.5

(NB Hypotension may be normal for a patient with a high spinal lesion)

Time started/done

Registrar review and discuss with ITU Registrar / SMH: Medical Registrar, 623, ITU Registrar 957
WH: Medical Registrar 9112, ITU Registrar 9101
Signed……………………………………...... …………….. / Date……..…….. / Time…..…….
Department of Microbiology, Buckinghamshire Healthcare NHS Trust, Jan 2011, modified from Royal Hampshire County Hospital
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