Recognising a patient with sepsis can be challenging. Consider sepsis in all patients with acute illness or deterioration who may have an infection.
Importantly, the presentation of sepsis in neonates and children may differ to adults. In children, hypotension is not necessary to diagnose septic shock. In older people, commonly recognised sepsis signs and symptoms are often absent. Older people are more likely to have relative immunosuppression. The presentation is less likely to include a fever, raised white cell count or raised C-reactive protein. In older people, hypothermia, delirium and falls (in frail people) are more likely.
Clinical support tools are available to help detect sepsis early and enable further assessment and escalation, although these tools do not replace clinical judgement. Identify possible sepsis using a structured approach that is consistent with an appropriate decision support tool for the setting, which has been agreed at the local level. Tools will vary according to the patient age, cultural needs and healthcare setting – no single tool will apply to everyone.
For situations where a decision support tool is not available (for example, for neonatal and maternity patients), early assessment and escalation to a clinician with expertise in recognising and managing sepsis are the priority. State or territory-endorsed age-specific observation charts and monitoring tools for children allow recognition of acute deterioration in children.
To determine whether a patient has signs or symptoms of organ dysfunction, take a full set of observations that includes vital signs and other relevant observations appropriate to the patient, including:
- Respiratory rate
- Oxygen saturation
- Heart rate
- Systolic blood pressure
- Altered mentation, behaviour change or delirium
- Poor peripheral perfusion, cool peripheries, delayed capillary refill time or mottled skin
- Blood lactate concentration
- In pregnant women, the vital signs of the fetus measured using cardiotocography (CTG).
Where this will not delay urgent care, test venous blood lactate levels. Capillary lactates may be useful in children. An increased lactate level may indicate a protective or a maladaptive response to shock and can play an important role in screening. Include blood lactate routinely in decision-making for an acutely deteriorating patient or for suspected sepsis. Although assessment of lactate levels is not sufficient for the purpose of diagnosis, it is a relatively simple investigation that can help recognise sepsis, while failure to recognise sepsis can lead to patient harm and potentially death. Point-of-care lactate testing is especially useful in rural or remote settings, including Aboriginal medical services, where critical care cannot be readily accessed.
Maintain a high index of suspicion for patients presenting with risk factors for sepsis or groups who experience higher rates of sepsis, including Aboriginal and Torres Strait Islander peoples. Red flags include:
- Family or carer concern. It is well demonstrated that a high level of family or carer concern warrants investigation – for example, concern for an older relative or for a child or an infant
- If a patient is presenting for acute medical care for a subsequent time, and has signs or symptoms of infection, or has an indwelling medical device
- Clinical deterioration despite treatment
- Recent history of surgery or burns
- Patients undergoing cancer treatment or who may be immunosuppressed.
In primary and community healthcare settings, be aware of the risk factors for sepsis as a time-critical emergency. If you suspect a patient has sepsis, refer the patient to an appropriate hospital as soon as possible.