Three large scale multi-centre trials into Severe Sepsis and Septic Shock: ProCESS (USA), ARISE(Aus), ProMISe(UK), all showed the same thing. What works is good early resuscitation (Not the fancy stuff from ICU – however, that does have its place later on).

1. Severity

The 2024 NICE guidance has redefined the severity based on NEWS2 scale

  • 7 or more = High risk of severe illness or death from sepsis
  • 5 or 6 = Moderate risk of severe illness or death from sepsis
  • 1 to 4 = Low risk of severe illness or death from sepsis
  • 0 = Very low risk of severe illness or death from sepsis

Considerations – the presence of following increases the NEWS2 based risk:

    • a single parameter contributes 3 points to their NEWS2 score and a medical review has confirmed that they are at high risk
    • mottled or ashen appearance
    • non-blanching petechial or purpuric rash
    • cyanosis of skin, lips or tongue
    • lactate over 2 mmol/litre or evidence of acute kidney injury


2. Antibiotics

Ideally cultures should be taken prior to giving antibiotics. However, obtaining cultures should not delay delivery.

  • High risk – <1hour from calculation of NEWS2
    • Any suspicion of infection prescribe antibiotics immediately
  • Moderate risk – <3hours from calculation of NEWS2
    • You have limited time to perform basic tests if you are clinically uncertain
  • Low risk – <6hours for calculation of NEWS2


3. Fluids

For most need for fluids will be individualised however in;

  • High risk – <1hour  if lactate over 2 mmol/litre or systolic blood pressure (sBP) less than 90 mmHg
  • Septic Shock  – mean BP (MAP) 65 mmHg or less and having a serum lactate level greater than 2 mmol/litre after adequate fluid resuscitation
    • If the patient has required 30ml/kg of fluid to maintain a MAP >65mmHg a decision on Vassopressors must be made


4. Investigations

  • Investigations will be clinically dictated, and should not delay delivery of antibiotics.
  • In High/Moderate risk the following should be carried out;
    • Blood Gas
    • Blood Culture (More Blood = Better pick-up)
    • FBC
    • U&E, CRP, LFT
    • Clotting



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