Patient priorities for treatment and care
The priorities of care need to be addressed for each patient. When sepsis is suspected from the initial assessment, these priorities of care need to be addressed to ensure care is appropriate and timely.
Blood tests need to be assessed. Urea and electrolytes and FBC will assess the different components and chemicals found in blood. The physiological effects of sepsis will be seen in the blood results, e.g. haemoglobin level falls, CRP and serum lactate levels rise. Blood cultures are taken to help to identify the pathogen causing the infection and therefore help to narrow down antibiotic choice.
Serum lactate is the main blood test that indicates the level of severity in sepsis. High (red) risk sepsis is diagnosed when the lactate level is above 2 mmol/L in the presence of two or more moderate (amber) risk criteria. A moderately high level of 1.8 mmol/L means this test will need repeating. Where the serum lactate level is high, a further intravenous fluid bolus needs to be started.
Depending on the potential cause, antimicrobial medication may need to be given quickly, but should be regularly reviewed to ensure SMART use of targeted antimicrobial medications. A full patient examination, chasing results of tests completed and further investigations to establish the cause of the sepsis should continue (e.g. swabs, specimens, x-ray).
An assessment of the person's level of hydration needs to be undertaken. Patients with sepsis easily become dehydrated as fluid moves out of the blood stream into the interstitial space as the infections cause capillaries to become leaky. Dehydration often leads to one of the initial signs - a reduced urine output.
It is vital to monitor the respiratory and cardiovascular stability of the patient. As haemoglobin is affected in sepsis, the oxygen carrying capacity of the red blood cells falls. Consequently, respiratory and heart rates rise. The BP will fall usually in response to the drop in blood circulating volume. Lowered oxygen levels will require oxygen therapy to be titrated to maintain SaO2 94-98% or 88-92% in known COPD.
Monitoring closely is necessary in patients in the moderate (amber) risk group as they are at risk of deteriorating and developing a high (red) risk of death from sepsis.
If the risk of sepsis is increasing, more invasive monitoring and cardiovascular support using inotropes and vasopressors may be required. Early escalation to appropriately experienced healthcare professionals (e.g. Registrar, consultant, or Critical Care team) is essential.
