Causing the deaths of five people every hour in the UK and more deaths annually worldwide than breast, bowel and prostate cancer combined, sepsis remains one of the few disease processes that can kill a healthy adult in hours.
The five key symptoms are confusion; not passing as much urine as normal; very high or low temperature; uncontrolled shivering and/or sweating; cold or flushed/blotchy arms and legs. When faced with these symptoms, becoming noticeably worse, a set of observations should be taken promptly.
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Four of these indicate SHOCK (end organ dysfunction) due to sepsis. An Early Warning Score chart or Organ Failure Assessment scale facilitates an SBAR (Situation Background Assessment Recommendation) handover summary of a patient’s condition.
The two main clinical pictures of shock in sepsis can overlap:
Warm shock
● skin flushes due to sepsis-induced dilation of small blood vessels
● heart rate increases to maintain increased cardiac output.
● systolic blood pressure may initially rise
● with increasing shock the diastolic blood pressure becomes low, followed by the systolic blood pressure
● untreated, the patient will progress either to cold shock or hypotensive cardiac arrest.
Cold shock
● cardiac output decreases due to sepsis-induced dysfunction of the heart and cardiovascular system
● initial constriction of small blood vessels may cause falsely-reassuring normal blood pressure (clue is in the fast heart rate)
● blood pressure drops
● skin becomes cool, mottled, pale, blotchy and/or clammy.
● untreated, the patient progresses to cardiac arrest due to low cardiac output.
Children, infants and elderly people may have vague, non-specific symptoms of sepsis which can be hard to diagnose but are rapidly progressive, with a high risk of death. Babies and young children can often present in an advanced state of shock. Patients with known recent or current infection (cellulitis, UTI, chest infection) or risk factors due to underlying conditions are particularly vulnerable.
Risk assessment and good basic observations are key to separating sepsis patients from those with a simple infection. If your patient looks seriously ill, consider sepsis and ask for senior expert review. Gut feeling plays a big part.
Health professionals should retain the key symptoms, ensure early diagnosis, effective communication and prompt, simple treatment so that patients’ chances of survival increase.
Dr Colin Begg, Sepsis Research FEAT Trustee and Consultant Paediatric Intensivist at the Royal Hospital for Children in Glasgow