Caring for a patient with suspected sepsis is a challenging nursing role.

Early recognition
and appropriate management of a patient with sepsis saves lives. Nurses play a
fundamental role in detecting changes in physiological observations that could indicate
the onset of sepsis. Additionally, an awareness of the pathophysiology of sepsis allows
the nurse to better understand how rapid intervention prevents the onset of septic
shock. Furthermore, knowledge and use of clinical guidelines and sepsis screening tools
are established methods to help reduce patient mortality. Nurse familiarity with 'red
flag' criteria for sepsis and thorough completion of early warning scores facilitate earlier
recognition and time critical intervention. Delivery of the 'sepsis six' within 1 hour of
suspected sepsis saves lives.

Keywords: Early identification and management; Nursing management of sepsis; Sepsis;

Sepsis six; Septic shock.

As the first line of defense for patients with sepsis, your early
recognition of the signs and ability to deliver timely, effective care
can mean the difference between life and death.
Keep up with the latest developments in sepsis treatment with this
timely selection of AACN resources, intended to help you deliver the
best evidence-based care for patients with sepsis

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S
epsis can be dened as a life-
threatening organ
dysfunction that is caused by a
dysregulated host
response to infection (Singer et al,
2016). Despite
notable improvements in our
understanding of
the pathophysiology of sepsis,
innovations in
haemodynamic monitoring and
methods of resuscitation, as
well as pharmacological and surgical
interventions, it remains
one of the major causes of morbidity
and mortality in critically
ill patients. The global incidence of
this clinical syndrome
has been placed at 30 million patients
each year with up to
6million deaths. In the UK, this
translates to 200 000 cases,
70% of which arise in the community
and an estimated 52 000
deaths (Daniels and Nutbeam,
2019:9). The annual economic
burden may be as high as £2 billion
and this may rise to
£15.6 billion if the long-ter m e ects
on survivors is taken
into account (Daniels and Nutbeam,
2019:10). Despite the
signicant morbidity, mortality and
economic costs associated
with sepsis, 10 000 deaths are
thought to be preventable and
the care improved in 2 out of 3
patients (NHS England,
2015). It is generally agreed that the
crux of improving
Recognitio
n and
manageme
nt
of sepsis:
the nurse’s
role
Greg Bleakley and Mark
Cole
outcomes associated with sepsis is
its early identi cation,
coupled with prompt diagnostic
testing, antimicrobial therapy
and haemodynamic resuscitation
(Wentowski et al, 2018).
In essence, it is vital to recognise and
act before signicant
organ failure has occurred. Early
appropriate management
saves lives. Delay costs lives. Sepsis
is life-threatening and
time-critical (Daniels and Nutbeam,
2019:53).
Early appropriate management,
however, is not without
challenges. Sepsis recognition and
management often takes
place in busy healthcare settings and it
can be dicult at rst
presentation to distinguish between
sepsis and severe infection.
Moreover, sepsis has a highly complex
set of pathophysiological
pathways. It is not so much an illness
as a syndrome that can
manifest itself through a number of
nonspecic symptoms
(Berg and Gerlach, 2018). A plethora
of health professionals
will come in contact with sepsis but it
is nurses who take an
inimitable position because of the
constant interaction they
have with patients.
The thrust of sepsis guidance is its
proactive management.
That is, ‘think sepsis’ if a patient
presents with signs and
symptoms that indicate possible
infection. However, the Sepsis
Manual (Daniels and Nutbeam, 2019)
highlights the challenge
in dierentiating between ‘infection’
and ‘sepsis’. Infection is
dened as:
‘The invasion of a normally sterile
cavity
by organisms, or inammation
caused by
organisms in parts of the body which
are not
normally sterile.’
Daniels and Nutbeam, 2019: 26
and sepsis as:
‘A deterioration in the Sequential
Organ Failure
Assessment score of 2 points.’
Daniels and Nutbeam, 2019: 26
The quick Sequential Organ Failure
Assessment (qSOFA) score
is a prompt bedside assessment for
patients with suspected infection;
qSOFA is considered positive if the
patient has at least two of
the following clinical criteria (Daniels
and Nutbeam, 2019:16):
■
Low blood pressure (systolic blood
pressure below 100 mmHg)
■ High respiratory rate above 22
breaths per minute (bpm)
■ Reduced conscious level (Glasgow
Coma Scale below 15).
This article will provide a brief
overview of the
pathophysiology of sepsis and septic
shock. It will then outline
high risk groups, the importance of
early warning scores and
ABSTRACT
Caring for a patient with suspected sepsis
is a challenging nursing
role. Early recognition and appropriate
management of a patient with
sepsis saves lives. Nurses play a
fundamental role in detecting changes
in physiological observations that could
indicate the onset of sepsis.
Additionally, an awareness of the
pathophysiology of sepsis allows the
nurse to better understand how rapid
intervention prevents the onset of
septic shock. Furthermore, knowledge
and use of clinical guidelines and
sepsis screening tools are established
methods to help reduce patient
mortality. Nurse familiarity with ‘red
ag’ criteria for sepsis and thorough
completion of early warning scores
facilitate earlier recognition and time
critical intervention. Delivery of the
‘sepsis six’ within 1 hour of suspected
sepsis saves lives.
Key words: Sepsis ■ Septic shock ■ Early
identication and
management ■ Nursing management of
sepsis ■ Sepsis six
Greg Bleakley, Lecturer in Adult Nursing,
University of
Manchester, g.bleakley@manchester.ac.uk
Mark Cole, Senior Lecturer in Nursing,
University of Manchester
Accepted for publication: June 2020
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British Journal of Nursin g, 2020, Vol 29, No 21
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Table 1. Mediator molecules, cytokines
and their functions
Mediator molecules Function
Nitric oxide Nitric oxide causes and maintains
vasodilation. This helps to
make capillaries more permeable (‘leaky’)
Bradykinin Bradykinin is responsible for the
pain at the site of
inammation and is also involved in
vasodilatation, making
capillaries more permeable. This permits white
blood cells to
pass through and ght infective agents
Complement proteins These act directly to
neutralise pathogens, mobilise white
blood cells and amplify the immune response
Thrombin Thrombin helps clot formation by
turning brinogen into
brin and is involved in nitric oxide
production. During
sepsis, activation of extrinsic coagulation
pathways
increases coagulation. The pro-coagulation state
can lead
to the formation of microvascular emboli and
cause organ
dysfunction
Interleukins These are a complex group of
proteins that help white blood
cells to function, attract them to the area and
modulate
inammation—some cause inammation,
some damp it down
Tumour necrosis factor Tumour necrosis factor
is a pro-inammatory cytokine
Source: Sepsis Manual (Daniels and Nutbeam,
2019:43)
red ags to aid a structured
assessment and a prompt diagnosis.
Finally, it will introduce the Sepsis six
care bundle and highlight
how it has been shown to improve
patient mortality.
Pathophysiology of sepsis
Sepsis occurs when infective
pathogens trigger a localised
inflammatory reaction that
stimulates a wider systemic
inflammatory response (SIR).
Physiologically, a bacterial
pathogen enters the body and resident
macrophages initiate a
localised inammatory response
(Stearns-Kurosawa et al, 2011;
Porth, 2015). Receptors in the lining
of blood vessels detect
infective agents on the cell wall of
pathogens. The response
from the host immune system is to
inltrate the local area
with macrophages, leukocytes and
neutrophils. Macrophages
are specialised cells linked to the
detection, phagocytosis and
destruction of pathogens. Essentially,
macrophage cells ingest
(phagocytose) infective bacteria and
create a series of pro-
inammatory cytokines which
stimulate a SIR. In a similar
way, leukocytes are white blood cells
connected to pathogen
recognition and destruction.
Neutrophils are among the rst
specialist white blood cells to migrate
to the site of infection and
destroy invading micro-organisms
(Gotts and Matthay, 2016).
Interestingly, some forms of cancer
treatments can suppress
the ability of bone marrow to respond
to infection. People
receiving chemotherapy and health
professionals providing care
need to be aware of the risk of
neutropenic sepsis. Neutropenic
sepsis is an overwhelming infection
that aects people with a
low neutrophil count and is a
potentially fatal complication of
anticancer treatment (National
Institute for Health and Care
Excellence (NICE), 2012).
Infective agents can give rise to
sepsis via a number of
sources. These include: skin and joint
infection, meningitis,
respiratory tract (lungs), endocarditis,
urinary tract infection
(UTI) and healthcare device-related
infection. Sometimes
there may be a clinical suspicion of
infection, but the source
is unknown. Clinically, such patients
may have a history of
pyrexia (fever), diaphoresis or appear
ushed. The Sepsis Manual
reports that a ‘clinical suspicion of an
infection is all that’s
needed’ to trigger further
investigations to exclude sepsis
(Daniels and Nutbeam, 2019:20).
The systemic immune response is
characterised by the
mobilising of white blood cells
(neutrophils and monocytes) to
the site of injured tissue to destroy
pathogens. The proliferation
of white blood cells due to the SIR is
referred to as leukocytosis
(Porth, 2015). Although increases in
white cell count attempt
to destroy the invasive pathogens,
they can harm the cells that
line blood vessels (endothelium).
Critically, damage to the
endothelium enhances vascular
permeability causing capillaries
to become ‘leaky’ (Daniels and
Nutbeam, 2019:20). Damaged
endothelial cells produce excesses of
nitric oxide and other
cytokines, which in turn, act as an
eective vasodilator and
key determinant in developing sepsis
(Porth, 2015). Updated
evidence from the Third International
Consensus Denitions
for Sepsis and Septic Shock (Sepsis-
3) suggests abandoning
use of host inammatory response
syndrome criteria (systemic
inammatory response syndrome
(SIRS)) in the identication
of sepsis and, furthermore, eliminate
the term ‘severe sepsis’
from existing terminology. This is
particularly signicant when
discussing the progression of sepsis
through to septic shock
(Singer et al, 2016). Table 1
highlights the molecules and
cytokines that are released during the
SIRS phase.
Septic shock
Septic shock is a life-threatening
clinical emergency that occurs
when the blood pressure drops to
dangerously low level following
an infection. This haemodynamic
instability contributes to
organ dysfunction due to decreased
delivery of oxygen to cells
(Thompson et al, 2019).
Inammatory mediators (cytokines)
cause arterial and venous dilation.
Consequently, venous return
is impaired, which stimulates a state of
septic cardiomyopathy
and hypotension (Gyawali et al,
2019). Furthermore, septic
shock has been described as:
‘The subset of sepsis in which
underlying
circulatory and cellular or metabolic
abnormalities are profound enough to
increase
mortality substantially.’
Singer et al, 2016
First, intravascular uid loss
caused by endothelial cell
damage results in the movement of
 uid into interstitial
spaces. Consequently, the
intravascular fluid loss from
increased vascular permeability
causes decreased perfusion
of cells and tissue. Second, this
hypoperfused state restricts
oxygen delivery to cells, thus
evoking anaerobic respiration.
Physiologically, anaerobic respiration
produces increased levels
of lactic acid. Increased serum
lactate levels accelerate under
hypotensive conditions and
anaerobic glycolysis (breaking
down glucose) (Lee and An, 2016).
Lactate clearance normally
occurs by the liver and kidneys but is
inhibited during critical
illness. Increasing levels of serum
lactate causes lactic acidosis
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which, in turn, restricts cardiac
function. At a cellular level,
circulating cytokines cause
depression of cardiac myocytes
and aects their mitochondrial
function (Gyawali et al, 2019).
Essentially, septic shock happens
when there is insu cient
cardiac output to maintain
metabolism because of sepsis
(Lee and An, 2016).
Finally, the diagnosis of septic shock
requires the presence
of three elements:
■ Sepsis
■ Hypotension requiring vasoactive
drugs to maintain mean
arterial pressure (MAP) above 65
mmHg
■ A serum lactate level above 2
mmol/L despite intravenous
uid replacement (Sepsis-3, Singer et
al, 2016) (Table 2).
At-risk groups
Sepsis is a time-critical medical
emergency that, unless treated
quickly, can progress to severe sepsis,
multi-organ failure, septic
shock and ultimately death (NHS
England, 2015). Successful
management relies on the nurse to have
a high index of suspicion
when faced with a patient who is
deteriorating or one that is
failing to improve. ‘Think sepsis’ has
entered healthcare language
and the nurse should combine this
approach with a knowledge
of at-risk groups and their own
clinical acumen, to achieve
sound clinical outcomes (Daniels and
Nutbeam, 2019:15).
NICE guidelines identify a number of
at-risk groups who
are at higher risk of acquiring sepsis.
These include elderly frail
people (aged over 75 years old), and
the very young (under
1years old). Individuals who have
an impaired immune system
due to illness, drugs or invasive
devices, for example, those
undergoing chemotherapy, people
with diabetes, on long-term
steroids, with breeches in skin and
those with an indwelling
device. Pregnant women who have
any of the above, had a
dicult labour, a termination of
pregnancy, or miscarriage in
the preceding 6 weeks; and neonates
who are preterm, or where
there has been a recent history of
infection in mother or baby,
are also at risk (NICE, 2016).
Early warning scores
If an understanding of at-risk groups
is the rst stage, the
second is for nurses to use a structured
set of observations to
help quantify potential acute illness.
Moreover, in the context
of infection, they should use a tool
that prompts them to
actively look for organ dysfunction
and facilitate a prompt and
appropriate clinical response (Daniels
and Nutbeam, 2019:15).
In an observational study Churpek et
al (2017) found that the
National Early Warning Score
(NEWS) was the most accurate
tool for predicting in-hospital
mortality, and intensive care
unit (ICU) transfer in non-ICU
patients, where there was a
suspicion of infection. NEWS is an
early warning score that
was rst produced in 2012 and
updated in 2017 to NEWS 2
(Royal College of Physicians (RCP),
2017). It calculates a score
from a series of physiological
observations (Table 3), the higher
the score the more severe a patient’s
condition.
A score of 5 or more reects medium
clinical risk, and a score
of 7 or more high clinical risk, and key
thresholds for potential,
acute serious clinical deterioration, and
the need for an urgent
clinical response (RCP, 2017). This is
echoed by the UK Sepsis
Trust, which states that a screen for
sepsis should be triggered
when a patient has a combined NEW
score of 5 or more, when
one of the aforementioned risk factors
is present, or when the
nurse is unduly worried. This should
also include an immediate
check for any red ags (Daniels and
Nutbeam, 2019:23).
‘Red ag’ sepsis (Table 4) was a term
rst used by the UK
Sepsis Trust, NHS England and several
of the royal colleges. It was
developed in 2015 as part of a
pragmatic operational solution, for
use at the bedside, in patients who do
not full the cr iteria for
severe sepsis on physiological or near-
patient assessment alone.
It is not seen as a formal ‘diagnosis’,
but a set of criteria that can
be measured rapidly. If a patient
identies one or more red ags
the nurse should assume the patient has
sepsis and has a degree
of organ dysfunction (Daniels and
Nutbeam, 2019:22).
Table 2. Clinical criteria for diagnosing
sepsis and septic shock
Current guidelines and
terminology
Sepsis Septic shock
2015 clinical criteria Suspected or documented
infection and an acute
increase of ≥2 sequential
organ failure assessment
(SOFA) score (a proxy for
organ dysfunction)
Sepsis and vasopressor
therapy needed to elevate
Mean Arterial Pressure
(MAP) ≥65 mmHg and
lactate >2 mmol/L (18
mg/dL) despite adequate
uid resuscitation
Source: adapted from Singer et al, 2016
Table 3. Items in the National Early
Warning Score (NEWS) 2
Respiration rate Pulse rate
Oxygen saturation Level of consciousness or
new confusion
Systolic blood pressure Temperature
Source: Royal College of Physicians, 2017
Table 4. ‘Red ag’ criteria indicating a
high risk of deterioration
Responds only to voice or pain/
unresponsive
Needs oxygen to keep SpO2 ≥ 92%
Acute confusional state Non-blanching rash,
mottled/ashen/
cyanotic
Systolic BP ≤ 90 mmHg (or drop >40
from normal)
Not passed urine in last 18 hours/
UO <0.5 ml/kg/hour
Heart rate >130 per minute Lactate ≥ 2mmol / l
Respiratory rate ≥25 per minute Recent
chemotherapy
BP=blood pressure; SpO2=oxygen saturation;
UO=urinary output
Source: Daniels and Nutbeam, 2019:23
Table 5. Sepsis six
Give oxygen to keep SATS above 94% Give a
uid challenge
Take blood cultures Measure lactate
Give IV antibiotics Measure urine output
Source: UK Sepsis Trust, 2020
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The sepsis six

Once sepsis is suspected the key
immediate interventions that
increase survival are described in a
care bundle termed the sepsis
six (Table 5). Care bundles were
introduced by the Institute for
Healthcare Improvement and were
founded on the idea that
if you group together a small number
of evidence-informed
practices, and then perform these
collectively, reliably and
continuously, it will improve patient
outcomes (Lavallée et
al, 2017). The sepsis six was
specically designed to facilitate
early intervention in a busy hospital
and pre-hospital setting
(Kumar et al, 2015). Developed in
2015 by The UK Sepsis Trust
and revised in 2019, it consists of
three diagnostic and three
therapeutic steps (UK Sepsis Trust,
2020). The crucial point is
that these need to be delivered within
1 hour to control the
source of infection, restore circulation
and promote oxygen
delivery. In one study, the e ective
delivery of the sepsis six
reduced the relative risk of death by
46.6% (Daniels et al, 2011).
If these gures were extrapolated to
the NHS as a whole, 80%
compliance would save an estimated
15 000 lives each year.
It is important to note that primary
care settings have a
dierent pre-hospital sepsis screening
tool and action tool. If
the NEWS score is above 3 and/or the
patient looks sick then
sepsis should be considered.
Signicantly, the prehospital sepsis
screening tool advises practitioners to
arrange immediate transfer
of the patient to a ‘designated
destination’ and ‘communicate
likelihood of sepsis at handover’
(Daniels and Nutbeam, 2019: 29).
Conclusion
Sepsis remains a signicant
healthcare challenge and economic
burden. This article has explained how
a sound understanding
of the pathophysiology of sepsis can
equip the nurse with the
knowledge needed to ensure prompt
action and save lives.
Nurses are the health professional
that has greatest contact
with high-risk patients. As such, they
are uniquely placed to use
clinical guidelines and make a rapid
detection of the syndrome
and then activate appropriate
interventions. In particular, the
integration of early warning scores is a
proven template that
can ‘track and trigger’ clinical
deterioration and ensure patient
safety and timely intervention.BJN
Declaration of interest: none
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