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 or there is an abnormal temperature (<36 °C or >38 °C)
  • Common risk factors:
    • Impaired immunity (e.g. diabetes, long term steroids, chemotherapy, neutropenic patient, asplenia)
    • Indwelling lines / broken skin / indwelling devices
    • Recent Trauma / surgery / invasive procedure
    • 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? – if so, sepsis is unlikely
 Red Flag sepsis criteria indicates a 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 to 5 years: ≥55 breaths / minute
  • Tachycardia:
    • <3 to 12 months: ≥ 180 beats / minute
    • 1 to <5 years: ≥ 170 beats/ minute
  • Bradycardia:
    • < 3 months: ≤ 50 beats / minute
    • 3 months to 5 years: ≤60 beats/ minute
  • SpO2 < 91% or O2 requirements >10 litres/ minute
  • Non-blanching rash / mottled / ashen / cyanotic
  • 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 to <5 years: ≥ 50 -54 breaths / minute
  • Tachycardia:
    • <12 months: ≥ 170 - 179 beats / minute
    • 1 to <5 years: ≥ 160 -169 beats / minute
  • SpO2 < 92% or increased O2 requirements
  • Temperature  ≤  36°C or ≥ 38°C
  • Capillary refill time > 3 seconds, mottled or cold extremities
  • Lactate 2-4 mmol/L
  • Nasal flaring
  • Reduce urine output

  • The child looks unwell, if there is parental concern or there is an abnormal temperature (<36 °C or >38 °C)
  • Common risk factors:
    • Impaired immunity (e.g. diabetes, long term steroids, chemotherapy, neutropenic patient, asplenia)
    • Indwelling lines / broken skin / indwelling devices
    • Recent Trauma / surgery / invasive procedure
    • Rural, remote or low socioeconomic status
    • Re-presentation or delayed presentation to a health service
  • Consider if there is an obvious non-infective cause? – if so, sepsis is unlikely
 Red Flag sepsis criteria indicates a 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)
  • Needs O2 to keep SpO2 ≥ 90%
  • Non-blanching rash / mottled / ashen / cyanotic
  • 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
  • SpO2 ≤ 92 % on air
  • Temperature ≤ 36°C or ≥ 38°C
  • 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)
Exclusion Criteria
Exclusion Criteria

  • The patient looks unwell or has an aggregate NEWS2 score of ≥ 5
  • Common risk factors:
    • Age > 75
    • Recent Trauma / surgery / invasive procedure
    • Impaired immunity (e.g. diabetes, steroids, chemotherapy, neutropenic history)
    • Indwelling lines / IVDU / broken skin
  • Consider if the presentation could be as consequence of infection. Common sources of infection include:
    • Respiratory
    • Urine
    • Skin / Joint / Wound
    • Indwelling devices
    • Brain
    • Surgical
    • Other

Note: If there is an obvious non-infective source for clinical presentation then consider other diagnosis

 Red Flag sepsis criteria indicates a 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
  • Systolic BP 91-100 mmHg
  • Heart rate 91-130 per minute or new dysrhythmia
  • 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
  • Consider if the presentation could be as consequence of infection. Common sources of infection include:
    • Respiratory
    • Urine
    • Infected caesarean / perineal wound
    • Breast abscess
    • Abdominal pain / distension
    • Chorioamnionitis / endometritis

Note: If there is an obvious non infective source for clinical presentation then consider other diagnosis

 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
  • Systolic BP 91-100 mmHg
  • Heart Rate 100-130 per minute or new dysrhythmia
  • Has had an invasive procedure in the last 6 weeks (e.g. Cervical cerclage, forceps delivery, Endoscopic Retrograde Cholangio-Pancreatograhy (ERPC), miscarriage, termination)
  • Temperature range between < 35.1°C – 36 °C or ≥ 39.1 °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

 


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
Intermediate Care (EMT / Level 2)
  • As per Primary Care guidelines
  • Cardiac monitoring if trained and authorised
Advanced Care (AP)
Critical & Extended Care (CCP, PSO)
Additional Information
  • Document either amber flag or red flag sepsis on ePCR at clinical handover
  • Sepsis specific clinical decision tools are available

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). JAMA315(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

Key Terms & Links
Colour assist:

Document Control


Directorate
Clinical Services

Responsible Manager
Head of Clinical Services

Published Date

Review Date

St John Ambulance Western Australia Ltd © Copyright 2020, All Rights Reserved

Privacy Policy | Copyright Statement & Disclaimer