46,000 people die in the UK from this condition ever year (NHS: Sepsis overview 2016). Sepsis claims more lives than lung cancer, and more than bowel, breast and prostate cancer combined.
NICE has produced useful guidance on the recognition, diagnosis and management of sepsis in multiple age ranges and settings. Here we will be focusing on adults aged 12 and over in the community setting, but I recommend reading and becoming familiar with the guidance which bests fits your scope of practice.
But first, let’s go back to basics. What is sepsis?
The term gets used a lot these days as the NHS pushes to create a culture of early diagnosis and therefore more favourable patient outcomes.
But do we really know what it is?
Remember those immunology lectures and classes? Where we learnt how the body’s immune system can react inappropriately and disproportionately to an allergen it wrongly perceives as a threat and sometimes, in the extreme, it leads to anaphylactic shock? Well you could use that metaphor to crudely describe sepsis as well.
However, with sepsis the body is responding to an infection, most commonly infections of the lungs, urinary tract, abdomen and pelvis, but it can be anywhere and from any infectious agent (Bacteria, Fungal, Viral). Usually, once an infection has occurred, the body will react, sending immune cells and inflammatory chemicals to the site, causing inflammation, the key here is locally. One of the bodies chief tactics is to keep the infection localised and so manageable. That inflammation causes the characteristic erythema, oedema, heat and tenderness associated with localised infection. However, as with the allergy metaphor, under certain circumstances the bodies response can be inappropriate and disproportionate.
In sepsis, that inflammation spreads throughout the whole body. This wide spread inflammation leads to impaired blood flow and altered coagulation in the vasculature. Restricting tissue nutrient and oxygen availability. Which can lead to organ damage.
Put simply, Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.
In severe cases Septic shock can manifest. Due to the impairment of blood flow and loss of plasma volume, hypovolaemia can occur which results in a rapid drop in blood pressure. This quickly and severely decreases organ perfusion and can lead to multi-organ failure.
Who is at risk?
As said before, sepsis can occur from any infection or wounds, with any infectious agent. However, as with most diseases, some people are more at risk. The young (<1yr), elderly (75yrs +) and frail are among those. Similarly, those with other co-morbidities, pregnancy or pregnant within the last six weeks, recent surgery, cuts, burns, blisters, skin infection impaired immune function and a history of previous sepsis are also at higher risk.
What should we be looking out for?
One of the most important questions to consider is ‘Could this be sepsis?’ It sounds simple, or even obvious, but starting with this intention will guide your thinking process and hopefully guide your decisions to a safe outcome.
No matter what setting you work in, having that question in mind and being aware of the signs allows you to make a real impact in reducing sepsis deaths.
It’s about early detection but restraining from overzealous diagnosis.
The NEWS – National Early Warning Score (Royal College of Physicians 2012) is an excellent and simple way to assess if a patient should be suspected of having sepsis. But it is also used to assess the severity of acute illness in general.
According to the NEWS, a patient is assigned a score, one for each of the seven physiological parameters listed in the table below. The scores range from 1-3 depending on the distance from the normal physiological value. Then the scores are added together to get the full NEW-score. In this way, the higher the score, the more acutely ill the patient is.
Regarding sepsis specifically, the guidance recommends that a patient suspected/at high risk of/with a known infection and whom scores 5 or more in total requires urgent assessment and management by a team competent in managing sepsis
Furthermore, if there is evidence of an infection and the patient scores 3 in one single parameter we should urgently consider sepsis.
In summary, the RCP 2012 NEWS guidance suggests:
A total score of 5 or more or a single parameter score of 3 → THINK SEPSIS.
BMJ NICE Sepsis Visual Infographic (pdf version)
But not all settings have access to such physiological parameters.
So, what can Community Pharmacists do to help?
Simply put: Detect high risk patients and make the correct referrals.
Objective evidence of altered mental state, tachypnoea, tachycardia, Hypotension, feverish, hot or cold to the touch, mottled or ashen appearance, cyanosis, decreased frequency of urination and extended capillary refill time (NG51).
These are all parameters that should be accessible to MOST community pharmacists and are a simple way to quickly assess a patient you might suspect of having sepsis.
Correct referral is then key. Depending on the patient and severity of there parameters, arranging a blue light transfer with a 999 call stating “This could be Sepsis” would be the most suitable option as any red flag sepsis must have the Sepsis 6 protocol done within the first hour following recognition of sepsis.
Make sure if the patient does not have any red flag symptoms present but still looks unwell that you safety net with the appropriate advice for the patient to seek further help or call 999 should they deteriorate further.
Whichever you choose, I would suggest personally following this referral up to ensure continuity of care as well as public confidence in community pharmacy. But also, any information you can provide to the next healthcare professional would be hugely appreciated.
Take home message
Matthew J Burgoyne MPharm
NHS: Sepsis overview. Updated 24/02/2016. https://www.nhs.uk/conditions/sepsis/
NICE guidance (NG51): Sepsis: recognition, diagnosis and early management. Updated September 2017. https://www.nice.org.uk/guidance/NG51/chapter/Recommendations#identifying-people-with-suspected-sepsis
Royal College of Physicians. National Early Warning Score (NEWS): Standardising the assessment of acute-illness severity in the NHS. Report of a working party. London: RCP, 2012.
NEWS e-learning: https://newslms.ocbmedia.com/login
BMJ: Suspected sepsis: summary of NICE guidance. Updated August 2017. https://www.bmj.com/content/354/bmj.i4030
The UK Sepsis Trust: The Sepsis Manual 4th edition (2017-18)