Introduction
Sepsis often lurks in the shadows until it reaches a critical stage. Medical professionals hold the key to identifying and treating sepsis in its early stages, as delayed intervention can result in dire consequences. This blog post delves into the crucial elements of sepsis, from its identification to treatment, with a special focus on its medico-legal aspects. Additionally, we'll explore the essential work of the Sepsis Trust, NICE guidelines and the NEWS (National Early Warning Score) system.
Defining Sepsis
Sepsis emerges when the body overreacts to an infection, setting off a chain reaction of events. If left untreated, it can lead to multi-organ failure and fatal consequences.
How common is it?
The Sepsis Trust state that there is up to 48,000 deaths per year in the UK.
“Sepsis kills more than breast, bowel and prostate cancer combined “
Recognising Sepsis
Early identification of sepsis is critical. Symptoms of sepsis can initially be subtle, resembling those of milder conditions. Medical professionals must maintain heightened awareness, especially when dealing with patients who have risk factors such as compromised immunity, advanced age, or recent surgeries.
In our experience, those who are very sick with sepsis are not often missed as they are very unwell and usually placed before senior seasoned clinicians. The real risk and challenge is identifying those at the start of their sepsis journey when the symptoms can be more difficult to spot.
Typical symptoms and indicators of sepsis in adults include (but not all):
1. Temperature Changes: Patients may experience a high fever or abnormally low body temperature.
2. Heart Rate Acceleration: Tachycardia is common in sepsis, with the heart rate often exceeding 90 beats per minute.
3. Breathing Rate: Tachypnea, or a respiratory rate above 20 breaths per minute, is another red flag.
4. Blood Pressure Drops: Hypotension is a late sign of severe sepsis or septic shock.
5. Mental Status Changes: Patients may become confused, disoriented, lethargic, or agitated.
6. Breathing Difficulties: As sepsis progresses, respiratory distress may occur, often necessitating mechanical ventilation.
7. Signs of Infection: Localised signs like redness, warmth, swelling, or discharge from an infected wound should raise concerns.
8. Rashes or changes in skin colour/perfusion.
Diagnostic Procedures
Sepsis is diagnosed through a combination of clinical assessment and diagnostic tests, including:
1. Blood Cultures: Identifying the infecting pathogen through blood cultures is vital for tailoring antibiotic treatment.
2. Full Blood Count (FBC): Irregularities in white blood cell, red blood cell, and platelet counts offer diagnostic clues.
3. Serum Lactate Levels: Elevated lactate levels indicate tissue hypoxia, a common feature in sepsis, necessitating prompt intervention.
4. Inflammatory Markers: Measuring inflammatory markers like C-reactive protein (CRP) and procalcitonin can provide additional diagnostic insights.
5. Imaging: X-rays, CT scans, and ultrasounds may be used to pinpoint the source of infection.
There is no one specific test for sepsis. The diagnosis involves the clinician’s skill, expertise and experience. This is particularly important, as younger patients may physiologically compensate, and therefore not have changes in observations until the later stages of sepsis when they may rapidly deteriorate.
Treating Sepsis
The treatment may involve an admission to the intensive care where we support patient’s organ function and treat the sepsis.
The UK healthcare system often refers to the immediate treatment – the Sepsis 6 (Often remembered as 3 in and 3 out). This consists of urgently:-
1. Administering oxygen (In)
2. IV fluid resuscitation (In)
3. Giving broad spectrum IV antibiotics (in)
4. Measuring serum lactate (out)
5. Take Blood cultures (out)
6. Monitoring urine output (out)
The ongoing treatment will be determined by the clinical signs and symptoms but will, most likely include:
1. Continued Intravenous Antibiotics: Swift administration of suitable antibiotics, aligned with local guidance and patient allergies, is crucial after obtaining blood cultures. Culturing allows for effective antibiotics to be administered. Although, we don’t wait for cultures, antibiotics are given and then tailored (if required) following culture results. Evidence has shown that the odds of in-hospital mortality increase by 7% for every hour in delay of antibiotics in patients with septic shock.
2. Continued Fluid Resuscitation: Intravenous crystalloid fluids are administered to maintain a mean arterial pressure (MAP) of 65 mmHg or higher. The fluid helps blood pressure (and therefore organ perfusion) by ‘filling’ the intravascular space.
3. Vasopressors: NICE guidelines recommend initiating vasopressor therapy if there is no response to initial fluid resuscitation or if the patient is in septic shock. If inotropic drugs are needed this usually indicates that the patient needs to be within a critical care unit and being looked after by critically care trained staff.
4. Source Control: The infection's source is identified and promptly managed, sometimes requiring surgical or interventional radiology procedures. If the patient is very unwell it’s likely that many teams of doctors and nurses will be involved such as the microbiologists who are the experts in the identification of infection and its treatment. Most NHS trusts will have a Antimicrobial Guide which can be referred to for guidance.
5. Continuous Reassessment: Patients with sepsis are continuously evaluated to gauge the treatment response and make necessary adjustments. Blood will usually be sampled for lactate amongst many other kinds of tests. The medical and nursing team will closely monitor the condition of the patient and their organ function. This is important as patients can deteriorate quickly.
Medico-Legal Aspects
In cases of sepsis, healthcare providers need to be cognisant of potential medico-legal implications.
These may include:
1. Standard of Care: Healthcare providers must adhere to a specific standard of care in sepsis management. Deviating from this standard could lead to legal repercussions.
2. Informed Consent: Patients and their families should be thoroughly informed about diagnostic and treatment processes and choices, potential risks, and benefits.
3. Communication: Effective communication among healthcare providers is vital for seamless care. Inadequate communication can result in treatment delays, which may have legal ramifications. It is important to be aware of the Trusts escalation policy based on clinical concern or due to increased early warning scores.
4. Medical Records: Accurate and comprehensive documentation is essential. Medical records should accurately reflect the patient's condition, treatment plans, and responses to therapy, reducing the risk of legal issues. It is essential to document when and to which senior colleagues’ concerns are escalated to.
5. Post-Treatment Care: Providing appropriate follow-up care and monitoring after the acute sepsis phase is crucial for minimising complications and legal disputes.
In our experience of acting as expert witnesses in sepsis cases the issue involved is a missed diagnosis. We have found that we have been asked to comment on clinical encounters and asked whether it was breach of duty to have not considered sepsis (and therefore escalated the patient) as a diagnosis. As we have said earlier in this blog post, in our experience these are often patients who are at the start of their sepsis illness when the clinical signs and symptoms may not be as obvious as someone who is seriously unwell.
The NEWS (National Early Warning Score) System in Sepsis
In the UK, the National Early Warning Score (NEWS) system is a pivotal tool in early identification of deteriorating patients, including those with sepsis. The NEWS system is designed to aid healthcare professionals in spotting signs of clinical deterioration and taking timely action.
The system assigns scores to various physiological parameters, including vital signs like heart rate, respiratory rate, blood pressure, temperature, and more. These scores are then combined to generate a cumulative score that indicates the severity of a patient's condition. An elevated NEWS score suggests that a patient may be at risk of deterioration or sepsis. The NEWS system can be a valuable tool for healthcare providers in identifying sepsis at an early stage. Remember that concerns can be escalated based on clinical concern and not just NEWS Scores.
In our expert witness practice, we have been involved in cases where it has been found the NEWS tool was not used correctly and escalation did not occur as per the local policy.
Sepsis in Special Populations
Sepsis can affect individuals of all ages and backgrounds, but it presents unique challenges in special populations. Recognising these challenges is vital for healthcare professionals to provide appropriate care.
1. Sepsis in Children: Sepsis in children, particularly in infants, can be particularly challenging to identify. Pediatric healthcare providers use specific assessment tools and clinical criteria to diagnose sepsis in young patients. Early recognition and treatment are essential to prevent severe outcomes.
2. Sepsis in the Elderly: Elderly individuals are at a higher risk of sepsis due to weakened immune systems and the presence of multiple chronic conditions. Sepsis can present with atypical symptoms in older adults, such as confusion and altered mental status. Healthcare providers should maintain a heightened suspicion for sepsis in this population and be vigilant in early diagnosis.
3. Sepsis in Immunocompromised Patients: Individuals with compromised immune systems, such as those undergoing chemotherapy or organ transplant recipients, are more susceptible to severe infections and sepsis. The challenge lies in identifying sepsis promptly, as their symptoms may differ and be subtle. Timely intervention is critical in this vulnerable group.
4. Sepsis in Pregnant Women: Pregnant women can also develop sepsis, often associated with infections of the genital or urinary tracts. The management of sepsis in pregnancy requires a delicate balance, considering both the health of the mother and the unborn child. Healthcare providers should be well-versed in the specific considerations for this group.
5. Sepsis in Individuals with Preexisting Conditions: Patients with chronic illnesses, such as diabetes or heart disease, may be at an increased risk of sepsis. Sepsis can exacerbate these conditions and vice versa. Understanding the interplay between sepsis and preexisting health issues is crucial for tailored care. Part of the patient’s management in critical illness should be maintaining normal glycaemic control.
Highlighting the unique challenges of sepsis in these special populations underscores the importance of individualised care and specialised training for healthcare professionals. Early recognition and prompt intervention remain the cornerstones of sepsis management, and this is particularly true when dealing with vulnerable groups.
Post-Sepsis Syndrome (PSS)
Post-Sepsis Syndrome is a frequently overlooked consequence of sepsis survival. This condition entails lingering physical, psychological, and cognitive symptoms long after the acute sepsis phase has resolved. Common PSS symptoms include:
- Chronic pain
- Fatigue
- Muscle weakness
- Insomnia
- Anxiety and depression
- Cognitive impairments
- Post Traumatic Stress Disorder (PTSD)
PSS can significantly impact a survivor's quality of life, requiring sustained medical and psychological support. Healthcare providers and patients must be aware of this condition and its long-term effects, ensuring the provision of suitable post-sepsis care.
Supporting Caregivers
Caring for someone who has survived sepsis is a demanding and often emotionally taxing role. Caregivers are instrumental in the recovery journey of sepsis survivors.
Caregivers often find themselves thrust into a demanding role as they help their loved ones recover from the physical and psychological effects of sepsis. Their responsibilities may encompass:
- Assisting with daily activities like bathing, dressing, and eating.
- Administering medications and managing medical equipment.
- Providing emotional support and companionship.
- Advocating for their loved one's needs within the healthcare system.
- Managing the logistics of post-sepsis care, including follow-up appointments and therapy sessions.
Support Resources for Caregivers:
Caregivers don't have to navigate this journey alone. Numerous resources offer guidance, assistance, and emotional support:
1. Support Groups: Joining a support group for caregivers of sepsis survivors can provide a sense of community and a space to share experiences and advice.
2. Educational Materials: Access to information about sepsis recovery can help caregivers better understand the challenges their loved ones are facing. This knowledge empowers them to provide more effective care and emotional support.
3. Respite Care: Caregivers need breaks too. Respite care services offer temporary relief, allowing caregivers to rest and recharge.
4. Professional Counselling: Therapy or counselling services provide caregivers with a safe space to address the emotional challenges they may be experiencing.
5. Financial Assistance: Some organisations offer financial aid to caregivers to help alleviate the burden of medical expenses and caregiving-related costs.
6. Legal and Advocacy Support: Caregivers may also require legal or advocacy support to navigate healthcare systems, insurance, and disability services on behalf of their loved ones.
It's crucial for caregivers to recognise their own needs and seek support when necessary. Supporting caregivers is not only beneficial for their well-being but also enhances the quality of care they can provide to sepsis survivors. The journey of sepsis recovery is one that can be shared, and caregivers deserve acknowledgment and assistance in their invaluable role.
Conclusion
Sepsis needs to be spotted quickly and treatment commenced promptly. Organisations such as NICE and The Sepsis Trust provide exceptional guidance to both clinicians and patients as to what to look for and how to treat sepsis. Sepsis is survivable, the battle can be won but early identification and staff training is crucial.