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 otherwi se,
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
9
HHE 2018 | hospitalhealthcare.com