Could it be sepsis? What to look out for
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Could it be sepsis? What to look out for

Lynne Pearce Health journalist

What nursing students need to know about sepsis in adults and children, and next steps if you suspect a patient is at risk

Sepsis causes up to 48,000 deaths in the UK each year – more than breast, bowel and prostate cancer combined, says the UK Sepsis Trust.

Nursing Standard. 38, 3, 73-74. doi: 10.7748/ns.38.3.73.s22

Published: 01 March 2023

It can be life-threatening and hard to spot, but nursing students can play an active role in helping to recognise warning signs at an early stage, ensuring patients get the timely treatment they need.

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Septic shock has a mortality rate of more than 50%

Picture credit: iStock

What is sepsis and what causes it?

‘Sepsis is a leading cause of avoidable death in all ages,’ says the National Institute for Health and Care Excellence (NICE) in its 2017 guidance on recognising, diagnosing and managing sepsis.

Sepsis is a clinical syndrome caused by the body’s immune and coagulation systems being switched on by an infection, the guidance states. It can lead to septic shock, a life-threatening condition characterised by low blood pressure despite adequate fluid replacement, and organ dysfunction or failure.

Most cases of sepsis are caused by common bacteria, says the UK Sepsis Trust. It can happen as a result of any injury or infection, anywhere in the body.

These causes include chest infections leading to pneumonia, urine infections, a burst ulcer or a hole in the bowel, an infected cut or bite, a wound from trauma or surgery, a leg ulcer or cellulitis.

What are the key signs and symptoms?

‘Sepsis is difficult to diagnose with certainty,’ says NICE. ‘The signs and symptoms of sepsis can be non-specific and can be missed if clinicians do not think – could this be sepsis?’

Initial symptoms can look like flu, gastroenteritis or a chest infection, says the UK Sepsis Trust. There is no one sign, and sepsis symptoms present differently between adults and children, the charity states.

‘When I’m teaching at my own trust, I’m always keen to stress the importance of looking at vital signs,’ says Oxford University Hospitals NHS Foundation Trust sepsis and infection nurse specialist Clare Hird.

‘Taking a set of vital signs is one of the tasks routinely delegated to nursing students. It’s a key skill. You’re getting to know your patient and building that rapport, and you can recognise what’s normal – and what’s not – for that person.’

In common with most other organisations, the Oxford trust uses the National Early Warning Score (NEWS2) to detect clinical deterioration in patients.

‘Sepsis is difficult to diagnose with certainty. The signs and symptoms can be non-specific’

NICE guidance

‘You need to look at whether there are any red flags present in the scores,’ says Ms Hird. These might include a heart rate of more than 130 beats per minute, a respiratory rate above 25 breaths per minute, and oxygen saturation levels less than 90%.

‘Acute mental dysfunction can be another sign,’ she says. ‘Has someone become disorientated or more confused? We encourage staff and students alike to do that head-to-toe assessment. You’re not looking at things in isolation.’

It is also vital to remember that not all patients with sepsis will present with a fever, says Ms Hird. ‘This applies especially to older patients, who are among the most vulnerable to infections and sepsis, but around half of them won’t have a fever.’

Why is early identification so important?

‘Evidence continues to suggest that the earlier we recognise sepsis, the earlier we can treat it and stop it in its tracks,’ says Ms Hird. ‘What we’re trying to do is prevent that severe side of sepsis – septic shock – which has a mortality rate of more than 50%.

‘Reducing the pathogen load will hopefully stop the systemic, inflammatory process from happening that leads to organ dysfunction and potentially death.’

But recognising sepsis is extremely complicated, says Shrewsbury and Telford Hospital NHS Trust deteriorating patient specialist nurse Angela Windsor. ‘That’s why we’re heavily reliant on all these additional systems, such as NEWS, to support us,’ she says. ‘We don’t look for a diagnosis of sepsis – it’s impossible within the time frame. What we’re trying to do is identify risk.’

Nursing students play a key role in early identification, she believes. ‘At the moment, they’re probably the ones spending a lot of time with patients, getting to know them better,’ she says. ‘It’s usually those initial thoughts, when you’re looking at someone and thinking something’s not quite right. You might not have quantifiable data, but you do have a gut instinct. Often that’s telling you a lot more.

‘Communicate it to senior nursing colleagues and doctors. Nurses aren’t there to diagnose, but to recognise deterioration and the risk of sepsis and then pass this on to clinical colleagues.’

Sepsis signs

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In adults, they include:

  • » Slurred speech or confusion

  • » Extreme shivering or muscle pain

  • » Passing no urine in a day

  • » Severe breathlessness

  • » Skin looking mottled or discoloured

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In children, they include:

  • » Very fast breathing

  • » Having a fit or convulsion

  • » Skin looks mottled, bluish or pale

  • » A rash that doesn’t fade when pressed

  • » Being lethargic or hard to wake

  • » Feeling abnormally cold to the touch

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For children under five, signs include:

  • » Not feeding

  • » Vomiting repeatedly

  • » Not passing urine for 12 hours

Source: UK Sepsis Trust

How should sepsis be managed and treated?

At the outset, there should be an immediate review by the senior clinical decision-maker, who should assess the person and also think about any alternative diagnoses to sepsis, advises NICE.

This is the first step in the Sepsis Six. Developed by the UK Sepsis Trust in 2005 and drawn from international guidelines, today it is used in 30 countries. Evidence published by the charity in 2011 showed the treatment pathway was associated with a 50% reduction in mortality.

The Sepsis Six pathway works because it’s simple, memorable, evidence-based and empowers all staff to act, says the UK Sepsis Trust.

In the trust’s sepsis manual, it says the Sepsis Six should be delivered as quickly as possible, but for the sickest patients always within the first hour following recognition of sepsis.

This time frame can be tight, says Ms Windsor. ‘As a nursing student, you can help to prepare what’s needed for your colleagues,’ she advises. Some wards may have a sepsis trolley or box. ‘Make sure there is equipment for cannulation, for example,’ she says. ‘You’re not stepping outside your boundaries, but being helpful.’

There can be a fine line between treating sepsis quickly and potentially over-diagnosing it, says Ms Hird. ‘We’re trying to improve antimicrobial stewardship,’ she says. ‘Talk to microbiology and infection specialists. They can help make sure your patient is getting the right treatment.’

What is the NEWS2 and why is it important? rcni.com/news2-score

Find out more

UK Sepsis Trust sepsistrust.org

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