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v70 - updated 28th June 2017

Visual summary How to assess risk and identify Evidence level

NICE sepsis guidance

appropriate level of monitoring and Based on the opinion of the guideline development committee,
management for suspected sepsis supported by generally very low quality evidence

Person with possible infection

Infection +/- Fever Feeling unwell

Young children
Think: High People with sepsis may Pay particular ?
temperature have non-specific, attention to concerns Different first language
Could this could be non-localising Take particular care if
be sepsis? expressed by the person
present presentations, such as and family/carer there are communication People with
or absent feeling very unwell barriers to overcome communication problems

Assessment Age 75+ Age under 1 Pregnant Pregnant in last 6 weeks

Assess people with suspected infection to identify: Frail with complex comorbidities Particularly if:
Gestational diabetes Diabetes
Likely source Indicators of clinical concern: Risk factors Within last Required invasive procedure
Surgery 6 weeks such as caesarean section
of infection Behaviour Circulation Respiration for sepsis Invasive procedure Forceps delivery
Removal of retained
Impaired immunity products of conception
Indwelling lines or catheters Prolonged rupture of membranes
Intravenous drug users
Close contact with someone with
Sepsis not suspected Suspected sepsis Any breach of skin integrity:
group A streptococcal infection

Cuts Burns Blisters Have continued bleeding or

No clinical cause for concern No risk factors an offensive vaginal discharge
Stratify risk of severe illness Skin infections
and death from sepsis
Use clinical judgment to treat the person

Detailed risk assessment H High risk M Moderate to high risk

In hospital
Age (years) Under 1 1–2 3–4 5 6–7 8–11 12+ and adults
H Weak, high-pitched or continuous cry H Objective evidence of new mental state
H Appears ill to a healthcare professional M History from patient,
H Does not wake or, if roused, does not stay awake
friend or relative of altered
behaviour / mental state
In primary care
H No response to social cues M Deterioration of functional H M M
M Parent or carer concern that child is behaving differently from usual ability

M Decreased activity M Impaired immune system 1+ 2+ 1 No high or

M M Not behaving normally M Trauma, surgery or high risk moderate moderate moderate to
Behaviour Not responding normally to social cues
procedure in last 6 weeks criteria to high risk to high risk high risk
and M No smile
history met criteria met criteria met criteria met
M Wakes only with prolonged stimulation
M Poor feeding 1+ 1+ No high or
moderate to
high risk moderate
Breaths per minute (resting rate)
criteria to high risk high risk
H 60+
criteria met Review by Clinical
60 H 50+ met criteria met Clinician
senior clinical assessment
M 50–59 H 40+ review and
40 M 40–49 H 29+ decision maker3
H 27+ H 25+ H 25+ consider
M 35–39
blood tests Manage
20 M 24–28 M 24–26 M 22–24 M 21–24 Give IV4
Age under 18 according
H Grunting antibiotics Within
Breathing H New requirement of oxygen with immunity to clinical
H without 1 hour
Apnoea 0.4+ FiO2 to maintain compromised judgment
saturation above 92% delay
H Oxygen saturation 90% or less in air
or 88% in known COPD1
M Oxygen saturation 92% or less in air
M Nasal flaring
Pre-alert Can definitive Perform tests Escalate to high risk
M Crackles in the chest secondary condition be Lactate
Heart rate (beats per minute) care diagnosed and Blood culture
170 H 160+ treated? Clinician and
Full blood count
H 150+ results review
150 M 150–159 H 140+ Clotting screen
M 140–149 H 130+ H 131+ No Yes C-reactive protein Within 1 hour
130 M 130–139 H 120+ U/E and creatinine
M 120–129 H 115+
Blood gas
110 M 110–119 M 105–114 M 91–130 Lactate
90 Send to Treat definitive <2 2+
Circulation H Less than 60 beats per minute H Systolic BP2 90 mmHg or less emergency condition and/or Lactate (mmol/L)
or 40+ mmHg below normal department provide information
M Capillary refill time 3+ seconds <2 2–4 4+ Assessed as having AKI5
M Cold hands / feet M Systolic BP2 91–100 mmHg to safety net
Consider Give IV4 fluid No Yes
M Leg pain M Pregnant: 100–130 BPM IV4 fluids bolus injection
M New onset arrythmia
Discuss with consultant
Only consider giving antibiotics if
H Colour of skin / lips / tongue is mottled or ashen or blue Refer to Definitive condition identified?
transfer time will be greater than 1 hour critical
H Non-blanching rash care
No Yes
H Reduced skin turgor M Signs of infection
Increased redness
M Pallor of skin, lips or tongue
Swelling or discharge Repeat structured
at surgical site Manage
Chronic obstructive pulmonary disease Carry out
Skin Breakdown of wound assessment definitive
Blood pressure observations
condition /
Continuously in At least infection
NICE provides the following examples of senior clinical decision hourly
H Under 36°C M Under 36°C emergency
makers in the UK: department
H 38+ °C Under 3 months of age
Temperature M 39+ °C For adults For under 18s or every 30 min
Review by senior Within
Consultant to 3 hours
3—6 months of age CT3 or ST3 or Advanced nurse Paediatric clinical decision maker3
H Not passed urine in 18 hours practitioner ST4 or above attend if patient
M Reduced urine output M Not passed urine in the does not improve Consider antibiotics
Urine last 12–18 hours 4
Acute Kidney Injury

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