UNCONTROLLED WHEN PRINTED
Quick Chart
Quick Chart
 Introduction
  • Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection.
  • Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.
 Clinical Presentation
  • There is no single diagnostic test or clinical feature that identifies sepsis. Diagnosis is made through a combination of vital sign abnormalities and clinical features. A combination of factors is required to identify sepsis.
  • The sepsis guidelines differentiate between amber flag sepsis or red flag sepsis. Typically, red flag sepsis designates some level of organ dysfunction. Patients in this cohort are often time critical.
  • The child looks unwell, if there is parental concern, EWS ≥5  or there is an abnormal temperature (<36 °C or >38 °C)
  • Common risk factors:
    • Recent Trauma / surgery / invasive procedure
    • Impaired immunity (e.g. diabetes, steroids, chemotherapy, neutropenic patient, asplenia)
    • Indwelling lines / broken skin / indwelling devices
    • Rural, remote or low socioeconomic status
    • Re-presentation or delayed presentation to a health service
    • Infants < 3 months old
  • Consider if there is an obvious non-infective cause for the patient's presentation and observations? – if so, sepsis is unlikely

 Red Flag sepsis criteria indicates high risk of deterioration:

 

Evidence of organ dysfunction

 

  • BSL < 3 mmol/L (note: 2.6 mmol/L for neonates)
  • Doesn't wake when roused / won't stay awake
  • Child looks unwell to a healthcare professional
  • Weak, high-pitched or continuous cry
  • Tachypnoea:
    • <12 months:  ≥75 breaths / minute
    • 1 - 5 years: ≥55 breaths / minute
  • Tachycardia:
    • <12 months: ≥ 180 beats / minute
    • 1 -<5 years: ≥ 170 beats / minute
  • Bradycardia:
    • < 3 months: ≤ 100 beats / minute
    • 3-12 months: ≤ 90 beats / minute
    • 1 - 5 years: ≤80 beats / minute
  • Hypotension
    • <3 months: ≤ 50 mmHg systolic
    • 3 months - 5 years: ≤ 60 mmHg systolic
  • SpO2 < 88% on air, or O2 requirements ≥10 litres/ minute
  • Non-blanching rash
  • Lactate >4 mmol/L (if available)

 Amber flag sepsis criteria indicating moderate to high risk of deterioration, any of the below:

  • Family and/or clinician concern is continuing or increasing
  • Not responding normally / no smile / reduced activity / very sleepy
  • Unexplained pain, leg pain or cold extremities
  • Tachypnoea:
    • <12 months: ≥ 65 -74 breaths / minute
    • 1 - <5 years: ≥ 50 -54 breaths / minute
  • Tachycardia:
    • <12 months: ≥ 170 - 179 beats / minute
    • 1 - <5 years: ≥ 160 -169 beats / minute
  • Brady Cardia
    • <3 months: ≤100 beats / minute
    • 3 - 12 months: ≤90 beats / minute
    • 1 - 5 years:  ≤80 beats / minute
  • Hypotension
    • <3 months: ≤ 60 mmHg systolic
    • 3 months to 5 years:  ≤ 70 mmHg systolic
  • SpO2 < 91% on air, or O2 requirements >5 litres/ minute
  • Capillary refill time ≥ 3 seconds, mottled or cold extremities
  • Lactate 2-4 mmol/L (if available)
  • Nasal flaring
  • Reduce urine output
  • The child looks unwell, if there is parental concern, EWS ≥ 5 or there is an abnormal temperature (<36 °C or >38 °C)
  • Common risk factors:
    • Recent Trauma / surgery / invasive procedure
    • Impaired immunity (e.g. diabetes, steroids, chemotherapy, neutropenic patient, asplenia)
    • Indwelling lines / broken skin / indwelling devices
    • Rural, remote or low socioeconomic status
    • Re-presentation or delayed presentation to a health service
  • Consider if there is an obvious non-infective cause for the patients presentation and observations? – if so, sepsis is unlikely

 Red Flag sepsis criteria indicates high risk of deterioration:

 

Evidence of organ dysfunction:

  • BSL ≤3 mmol/L
  • Doesn't wake when roused / won't stay awake
  • Objective evidence of new or altered mental state
  • Child looks unwell to healthcare professional
  • Tachypnoea ≥50 breaths / minute
  • Tachycardia ≥170 beats / minute
  • Bradycardia (<60 bpm)
  • Hypotension (systolic BP <60 mmHg)
  • SpO2 < 88% on air, or O2 requirements >10 litres/ minute
  • Non-blanching rash
  • Lactate > 4 mmol/L (if available)

 Amber flag sepsis criteria indicating moderate to high risk of deterioration, any of the below:

  • Family and/or clinical concern is continuing or increasing
  • Behaving abnormally / not wanting to play / drowsy / confused
  • Unexplained pain, leg pain or cold extremities
  • Tachypnoea 45 to 49 breaths / minute
  • Tachycardia 160 -169 beats / minute
  • Hypotension (systolic BP <70 mmHg)
  • SpO2 < 91% on air, or O2 requirements >5 litres/ minute
  • Capillary refill time ≥ 3 seconds, mottled or cold extremities
  • Lactate 2 – 4 mmol / L (if available)
  • Reduce urine output (<1 mL/kg/hr if catheterised)
  • The patient looks unwell or has an aggregate NEWS2 score of ≥ 5
  • Common risk factors:
    • Recent Trauma / surgery / invasive procedure
    • Impaired immunity (e.g. diabetes, steroids, chemotherapy, neutropenic history)
    • Indwelling lines / IVDU / broken skin
    • Rural, remote or low socioeconomic status
    • Age > 75
  • Consider if there is an obvious non-infective cause for the patients presentation and observations? – if so, sepsis is unlikely

 

 Red Flag sepsis criteria indicates high risk of deterioration

Evidence of organ dysfunction:

  • Objective evidence of new or altered mental state
  • Systolic BP ≤ 90 mmHg (or drop of >40 mmHg from normal)
  • Heart rate ≥ 130 per minute
  • Temperature ≤ 35 ºC
  • Respiratory rate ≥ 25 per minute
  • Needs O2 to keep SpO2 ≥ 94% (88% in COPD)
  • Non-blanching rash / mottled / ashen / cyanotic
  • Not passed urine in 18 hours (<0.5mls/kg/hour if catheterised)
  • Lactate ≥ 2 mmol/l (if available)
  • Recent Chemotherapy

 Amber flag sepsis criteria indicating moderate to high risk of deterioration, any of the below:

  • Relatives concerned about mental status
  • Acute deterioration in functional ability
  • Trauma / surgery / procedure in last 8 weeks
  • Immunosuppressed
  • Respiratory rate 21-24 per minute
  • Heart rate 91-129 per minute or new dysrhythmia
  • Systolic BP 91-100 mmHg
  • Temperature range between 35.1°C - 36°C or ≥ 38°C
  • Clinical signs of wound infection
  • The patient looks unwell or has an aggregate NEWS2 score of ≥ 5
  • Common risk factors:
    • Recent Trauma / surgery / invasive procedure
    • Impaired immunity (e.g. diabetes, steroids, chemotherapy, neutropenic history)
    • Indwelling lines / IVDU/ broken skin
    • Rural, remote or low socioeconomic status
  • Consider if there is an obvious non-infective cause for the patients presentation and observations? – if so, sepsis is unlikely

 

 Red Flag sepsis criteria indicates high risk of deterioration

Evidence of organ dysfunction:

  • Objective evidence of new or altered mental state
  • Systolic BP ≤ 90 mmHg (or drop of >40 mmHg from normal)
  • Heart rate ≥ 130 per minute
  • Temperature ≤ 35 º C
  • Respiratory rate ≥ 25 per minute
  • Needs O2 to keep SpO2 ≥ 94% (88% in COPD)
  • Non-blanching rash / mottled / ashen / cyanotic
  • Not passed urine in 18 hours (<0.5mls/kg/hour if catheterised)
  • Lactate ≥ 2 mmol/l (if available)
    • Note: Lactate may be raised in and immediately after normal delivery

 Amber flag sepsis criteria indicating moderate to high risk of deterioration, any of the below:

If the patient is immunity impaired treat as per red flag sepsis
  • Behavioural / mental status change
  • Acute deterioration in functional ability
  • Respiratory rate 21-24 per minute
  • Heart Rate 100-129 per minute or new dysrhythmia
  • Systolic BP 91-100 mmHg
  • Has had an invasive procedure in the last 6 weeks (e.g. Cervical cerclage, forceps delivery, miscarriage, termination)
  • Temperature range between < 35.1°C – 36 °C or ≥ 38.1 °C
  • Has diabetes or gestational diabetes
  • Close contact with GAS (Group A Streptococcus)
  • Prolonged rupture of membranes
  • Bleeding / wound infection
  • Offensive vaginal discharge
  • Non-reassuring cardiotocography (CTG) / foetal tachycardia > 160 beats / minute
 Exclusion Criteria
Exclusion Criteria
 Risk Assessment
  • The very young (<1 year) and the older adult (>75 years) or those that are frail
  • People with impaired immune systems:
    • people being treated for cancer with chemotherapy
    • people who have impaired immune function (for example, people with diabetes, people who have had a splenectomy, or people with sickle cell disease)
    • people taking long-term steroids
    • people taking immunosuppressant drugs to treat non-malignant disorders such as rheumatoid arthritis
    • people who have had surgery, or other invasive procedures, in the past 6 weeks
    • people with any breach of skin integrity (for example, cuts, burns, blisters or skin infections)
    • people who misuse drugs intravenously
    • people with indwelling lines or catheters
  • Pregnant women who have given birth or had a termination of pregnancy or miscarriage:
    • have impaired immune systems because of illness or drugs
    • have gestational diabetes or diabetes or other comorbidities
    • have needed invasive procedures (for example, Caesarean section, forceps delivery, removal of retained products of conception)
    • had a prolonged rupture of membranes
    • have or have been in close contact with people with group A streptococcal infection, for example, scarlet fever
    • have continued vaginal bleeding or an offensive vaginal discharge
  • Children:
    • Children with impaired immunity (e.g. diabetes, long term use of steroids or children with asplenia)
    • Have had recent trauma / surgery / invasive procedures
    • Children that live in a rural, remote or low socioeconomic setting
    • Have had recent presentation or delayed presentation to a health service
    • Have indwelling lines/ broken skin / indwelling devices
  • Neonates:
    • invasive group B streptococcal infection in a previous baby
    • maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
    • premature rupture of membranes
    • preterm birth following spontaneous labour (before 37 weeks’ gestation)
    • suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth
    • intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis
    • parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection at any time during labour, or in the 24-hour periods before and after the birth (this does not refer to intrapartum antibiotic prophylaxis)
    • suspected or confirmed infection in another baby in the case of a multiple pregnancy
 Management

Sepsis Decision Tool

An online quick reference tool to assist with the diagnosis of sepsis.

Sepsis Decision Tree

Primary Care

 Red Flag Sepsis criteria:

 Amber Flag Sepsis criteria:

Intermediate Care
  • As per Primary Care guidelines
  • Cardiac monitoring if trained and authorised
Advanced Care
Critical & Extended Care
 Additional Information
  • Document either amber flag or red flag sepsis on ePCR at clinical handover
  • Sepsis specific clinical decision tools are available
Key Terms & Links
Sepsis Quick Charts

Under 5 Years

5 - 11 Years

Adult

Pregnancy

All age groups

Settings
Extended Care:
Colour assist:
References

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J. D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C., Martin, G. S., Opal, S. M., Rubenfeld, G. D., van der Poll, T., Vincent, J. L., & Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801–810. https://doi.org/10.1001/jama.2016.0287

Nutbeam T, Daniels R on behalf of the UK Sepsis Trust. Available at http://sepsistrust.org/professional-resources/clinical/. Last accessed: 15/02/2022

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