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General practice management of sepsis

Introduction

  • In primary care, the lack of laboratory services limits our ability to distinguish between sepsis, severe sepsis and septic shock (according to international definitions) in many cases
  • A high degree of vigilance is required for early identification of the septic patient. In the primary care setting, where perceived infection is one of the most common reasons for presentation, the clinical acumen of the general practitioner is essential in determining which patients to evaluate for sepsis

Suggested clinical indications for undertaking evaluation for sepsis

  • Undertake clinical evaluation for sepsis in patients:
    • with clinical evidence of systemic infection (such as recent history of fever)
    • in whom you are considering antibiotic prescription or stewardship discussion
    • you suspect to have ‘flu’
    • you suspect to have gastroenteritis
    • who are obviously unwell without clear cause
    • who are elderly or immunosuppressed and present with signs of infection
    • who have deteriorated on antibiotic therapy

Screening for systematic inflamatory response syndrome (SIRS)

SIRS is confirmed if ANY TWO of the following are present:

  • Immediate:
    • new onset of confusion or altered mental state
    • temperature >38.3 or <36°C
    • heart rate >90 beats per minute*
    • respiratory rate (counted over 60 seconds) >20 breaths per minute
  • Point of care testing (POCT; commonly available)
    • blood glucose >7.7 mmol/l in the absence of known diabetes
  • POCT (not yet widely available)
    • white cell count >12 or <4 x109/l

Evaluation for red flag sepsis

  • Act immediately if ANY ONE of the following are present:
    • Systolic blood pressure <90 mmHg (or >40 mmHg fall from baseline)*
    • heart rate >130 per minute
    • oxygen saturations <91%
    • respiratory rate >25 per minute
    • responds only to voice or pain/unresponsive
  • POCT (not yet widely available)
    • lactate>2.0 mmol/l
* Values are guides. Interpret observations in the context of the normal physiology for the patient. For example, in a young man who runs 3 times a week and has a baseline pulse of 56 a heart rate of 90 beats per minute is very significantly raised, whereas it might be relatively normal for an older patient with mitral regurgitation. Similarly for an older person, a blood pressure (BP) of 106/60 mmHg is likely to be lot lower than their baseline BP, whereas for an athlete a systolic pressure of <90 mmHg may be perfectly normal.

† Some patients with chronic pulmonary disease may display low oxygen saturations and elevated respiratory rates ‘normally’. Consider whether values are abnormal for the individual patient.General practice sepsis screening and action tool

Suggested clinical guidelines for the management of patients with sepsis in primary care

  • Sepsis (no red flag signs):
    • a documented decision whether to manage patient in the community or refer to hospital
    • discussion with a senior doctor (where initial assessment has been by trainee) within 30 minutes of diagnosis
    • a full set of observations including heart rate, respiratory rate, blood pressure, temperature, conscious level recorded and documented
    • if to be treated in the community, safety netting advice offered and documented
    • if to be treated in the community, arrangements to be made for review within 24 hours
    • if to be referred for hospital assessment, handover including relevant clinical history and antibiotic history including allergies to be provided
  • ‘Red flag’ sepsis pending confirmatory tests:
    • immediate discussion with a senior doctor (where initial assessment has been by trainee)
    • immediate request for 999 ambulance with paramedic crew
    • handover including relevant clinical history and antibiotic history including allergies to be provided
    • where resources available, administer oxygen therapy
    • where transfer times may be prolonged, consider need for intravenous antibiotics and fluid therapy if available

Exemplar standards for primary care management of sepsis

  • The standards below are those which have been identified by the UK Sepsis Trust and the All Party Parlimentary Group for sepsis as important in the management of sepsis with specific relevance to primary care. They are the ‘exemplar standards’ which organizations should aspire to deliver. Achieving these standards will place a primary care organization well on the road to the provision of excellent sepsis care
  1. Clear written guidance, policies and clinical pathways to be in place for the recognition and management of sepsis and red flag sepsis
  2. Clear written criteria for which patients should be screened for sepsis
  3. According to local criteria for screening, 100% of patients satisfying criteria to have, as a minimum, heart rate, respiratory rate, blood pressure, conscious level, oxygen saturations and blood glucose measured and recorded (unless precluded by equipment failure)
  4. Risk assessment to be undertaken and maintained regarding the need for point of care testing for lactate and white blood cell count
  5. 100% of patients identified with red flag sepsis to be transported for hospital assessment unless limitations of treatment agreed
  6. Clear written and verbal handovers to accompany all patients referred for hospital assessment
  7. Oxygen therapy to be available and considered for all patients with red flag sepsis
  8. Where transit times to hospital are routinely in excess of 60 minutes, risk assessment to be undertaken and maintained regarding the need for administration of antibiotics and intravenous fluids
  9. Documented decision to treat in the community or transfer to hospital in 100% of patients with sepsis without red flag signs
  10. Where patients with sepsis without red flag signs are to be managed in the community, documented safety netting advice and review plans to be in place for all patients

full guideline available from…
sepsistrust.org

The UK Sepsis Trust. Executive summary: General practice management of sepsis. 2014
The UK Sepsis Trust. General practice sepsis screening and action tool. 2014
First included: October 2015.