Sepsis
Dr Alex Archer
Additional Learning Resources
Case Study
Read the clinical scenario then have a go answering the questions. Click the questions for an example answer.
Clinical Scenario:
You are working a busy Saturday evening shift in the ED. The time is 19:30 and all the consultants and registrars are on their meal break or tied up with sick patients. Your consultant says to you, “Can you please see the new CAT 2 patient and start their management?”.
The patient is a 48 year old female presenting with cough and fever. She has a history of breast cancer and has had chemotherapy 6 days ago. She looks unwell. Her vital signs are:
GCS 15, Temp 39.8, HR 134, BP 84/46, RR 28, Sats 87%
1) What is your clinical assessment and most likely diagnosis?
- This patient has sepsis and is also at high risk of febrile neutropenia.
- The cough and low oxygen saturations indicate that the likely source is pneumonia. However, consider all other possible sources too during your clinical assessment. Also remember that many oncology patients also have PICC lines or other intravascular ports; consider any foreign indwelling device as a potential source.
- She is also at high risk of septic shock if her BP does not improve or deteriorates with treatment.
2) What is your initial management?
Remember the Sepsis Six!
- Deliver oxygen to keep sats 94%
- Lactate (VBG)
- Blood Cultures when inserting your IV cannula. You may need to take separate cultures from the PICC line/other port if line sepsis is suspected or source of infection is not apparent.
- Broad spectrum IV antibiotics. Tazocin (Piperacillin + Tazobactam) 4.5G as per St Vincent’s Febrile Neutropaenia guideline. Refer to guideline in the case of penicillin allergy. If line sepsis is suspected or the patient is deteriorating, the regime may need to be altered. Seek senior advice!
- IV Fluid therapy: In this patient I would start with 1 litre IV crystalloid STAT (0.9% NaCl or Hartmann’s). Then reassess clinically and with repeat lactate.
- Ask the nurses to commence fluid balance charts, including urine output.
Get senior input ASAP! Make sure you let your consultant know that this patient is very sick and has likely septic shock and is immunosuppressed.
3) What other ED investigations are appropriate?
- FBC, U&Es, LFTs, CRP, Troponin, lipase, COAGs
- Serial serum lactates (VBGs)
- CXR
- ECG
- Influenza & COVID-19 swabs
- Other cultures if appropriate: urine, sputum & wounds
4) What is the likely disposition?
- Inpatient admission under oncology
- If hypotension persists, ICU admission for vasopressor support may be necessary (Don’t worry! These higher end decisions will be made at the ED Consultant or Registrar level. You definitely will not be expected to do this on your own. Just remember to let us know if you recognise a deteriorating patient.)