HHE Emergency care supplement 2018 - Page 15

qSOFA (quick Sequential (Sepsis-related) Organ failure Assessment): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mmHg or less, for rapid bedside assessment with higher predictive validity of sepsis than traditional SIRS criteria. Early sepsis-related organ dysfunction was defined as an acute change in total SOFA score ≥ 2 points, because of infection. The National Early Warning score (NEWS) was first produced in 2012 and updated (NEWS2) in December 2017. 5 NHS England and NHS Improvement have endorsed NEWS2, which is based on a simple aggregate scoring system in which a score is allocated to physiological parameters routinely measured in clinical practice – respiratory rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion and temperature. 6 Three of these parameters are same as those of qSOFA and with added parameters from NEWS2, the ability to identify patients at risk of sepsis will be remarkably enhanced. A raised NEWS of 5 or more should trigger immediate escalation of treatment and patients affected treated for sepsis until proven otherwise, as this failure to do so has been shown to be associated with a >threefold increased risk of transfer to the intensive care unit or death. 7 after cardiovascular disease. 6 While these data relate to sepsis resulting from all infection, the most common cause of sepsis in surgical patients is intra-abdominal infection, which accounts for approximately two-thirds of all cases. 8,9 While sepsis might arise from intra-abdominal (or retroperitoneal) infection resulting from upper gastrointestinal, hepato-pancreaticobiliary and small intestinal disease, colonic (including appendicular) perforation predominates. 10 It is sobering to note that Moynihan’s 1920 observations still remain valid, and a significant proportion of hospital-acquired sepsis arises as a direct consequence of complications of abdominal surgery. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) review Just Say Sepsis 11 noted that more than 60% of patients with hospital-acquired sepsis developed their infection as a result of an invasive procedure. 12 Despite advances in management, the development of septic shock in a patient with infection still has considerable negative prognostic implications. Septic shock is associated with an overall hospital mortality of 39% in patients admitted as a surgical emergency and 30% mortality in those admitted for elective surgery. 9 It is therefore imperative to identify sepsis promptly, commence resuscitation and antimicrobial therapy, and achieve rapid source control. Burden of surgical sepsis NHS England have estimated that approximately 120,000 patients develop sepsis each year and more than 37,000 people die as a consequence. Sepsis is the second most common cause of death Initial resuscitation Current clinical guidelines on the management of sepsis, such as those from NHS England, 2 Surviving Sepsis Campaign, 13 the English National qSOFA – respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100mmHg or less, has higher predictive validity of sepsis for rapid bedside assessment Institute for Health and Care Excellence 14 and the Irish National Clinical Effectiveness Committee, 15 all emphasise that sepsis is a medical emergency with a limited window of opportunity for effective intervention. The new sepsis Hour-1 Bundle spells out essential steps that should be undertaken in the first hour of managing a patient with suspected sepsis – this includes measuring blood lactate level, perform blood cultures, administration of intravenous antibiotics, fluids and oxygen and measuring hourly urine output. 16 The Surviving Sepsis Campaign has also introduced Time zero or Time of Presentation (2018), which is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of sepsis to improve compliance and performance. 16 The effect of morbidity and mortality in sepsis has been well documented and adopting sepsis care bundles has been shown to significantly reduce mortality. 17 15 HHE 2018 | hospitalhealthcare.com