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Priorities of sepsis treatment and care: NICE guidelines (2016)


Identify at risk group
Consider any signs or symptoms that may suggest an infection is present
Take history from patient and/or relative


Start with assessing high (red) risk category, then moderate (amber) and then low (green) risk category

  • Mental state: AVPU, functional ability, rigors
  • Breathing: rate, rhythm, effort and pattern, SpO2
  • Cardio-vascular: heart rate, BP, capillary refill time, arrhythmia
  • Fluid status: urine output
  • Skin: colour, rashes, wound assessment

Care and treatment priorities:

Clinician review

  • Blood tests: Lactate level assessment (via blood gas measurement), FBC, blood cultures, CRP, urea and electrolytes
  • Early antibiotics: within 1 hour (if at high (red) risk) or within 3 hours (if at moderate (amber) risk)
  • Fluid status (perfusion):
    • Fluid resuscitation: 20mL/kg of a crystalloid solution over 10-15 minutes
    • Monitor urine output: (catheterise as necessary)
  • Vital signs observations: Regular monitoring and recording of breathing, cardiovascular status, temperature
  • Oxygen delivery: titrate supplemental oxygen to oxygen saturation level to keep patient's SpO2 within 94% to 98% (88% to 92% in patients who have a known COPD)
  • Infection screening: Does the patient have a cough? Leaking wound? Cloudy or smelly urine? Take samples. Ward based urinalysis