Management of Suspected Sepsis in Adults (16+): NHS Emergency Department Briefing

Executive Summary

This briefing document synthesizes the NICE NG253 (2025) guidelines for the recognition, assessment, and early management of suspected sepsis in individuals aged 16 and over. The central shift in practice is the mandatory use of the National Early Warning Score 2 (NEWS2) for risk stratification in acute hospital settings, ambulances, and acute mental health facilities.

Critical Takeaways:

• Risk Stratification: NEWS2 scores define risk levels: High Risk (\ge7), Moderate Risk (5–6), Low Risk (1–4), and Very Low Risk (0).
• The "Red Flag" Single Parameter: A score of 3 in any single NEWS2 parameter requires an urgent high-priority review by an FY2 or above to determine if the patient is at higher risk than the total score suggests.
• Antibiotic Timelines:
  • High Risk: Within 1 hour of NEWS2 calculation.
  • Moderate Risk: Within 3 hours (allowing time for diagnostic refinement).
  • Low Risk: Within 6 hours.
• Fluid Resuscitation: Initial bolus is now 250 ml (reduced from 500 ml) of isotonic crystalloid, with reassessment after every bolus up to a 1,000 ml limit.
• Peripheral Vasopressors: Now recognized for initial management of hypotension/shock if fluids fail, following consultation with critical care.

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1. Definition and Classification

• Sepsis: A life-threatening organ dysfunction caused by a dysregulated host response to infection [1].
• Suspected Sepsis: Individuals who may have sepsis and require immediate face-to-face assessment and potential urgent intervention [1].

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2. Epidemiology and Aetiology

Incidence and Demographics

The source notes a lack of robust UK-based epidemiological studies, marking this as a priority for future research. However, it identifies specific groups at higher risk:

• Age: People aged 75 or over.
• Ethnicity: People from ethnic minority backgrounds.
• Vulnerable Populations: Individuals experiencing homelessness, living in deprived areas, or those with communication challenges (learning disabilities, neurodiversity, or non-English speakers) [1].

Aetiology and Predisposing Factors

Sepsis is triggered by infection, which may be non-specific or non-localised. Key predisposing factors include:

• Medical Treatment: Impaired immune function (illness or drugs like steroids), chemotherapy within the last 30 days (Neutropenic Sepsis), or repeated antibiotic use.
• Physical Factors: Indwelling catheters, breaches in skin integrity (cuts, burns, infections), and surgery or invasive procedures within the past 6 weeks.
• Comorbidities: Frailty, multimorbidities, or severe chronic conditions [1].

Risk Stratification and Prognosis

Prognosis is tied to the risk of severe illness or death, stratified by NEWS2 in the ED:

• High Risk: NEWS2 \ge 7.
• Moderate Risk: NEWS2 5–6.
• Low Risk: NEWS2 1–4.
• Very Low Risk: NEWS2 0.
• Note: Clinical concern (e.g., ashen appearance, cyanosis) can escalate a patient to a higher risk category regardless of the NEWS2 score [1].

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3. Clinically Relevant Anatomy

While sepsis is a systemic host response, clinical assessment must focus on anatomical sources of infection:

• Respiratory: Lungs (pneumonia).
• Abdomen/Pelvis: Potential for abscesses or perforations requiring surgical or radiological drainage.
• Skin/Soft Tissue: Surgical sites, catheter entry points, and general skin integrity.
• Central Nervous System: Meningeal involvement [1].

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4. Clinical Assessment: ABCDE Approach

Airway (A)

• Assess for patency. Note: Severe sepsis may lead to a decreased level of consciousness (Disability) which compromises the airway.

Breathing (B)

• Respiratory Rate: \ge 25 bpm is a high-risk criterion in community settings; NEWS2 captures this in hospital.
• Oxygen Saturation (SpO2): Maintain 94–98% (88–92% in chronic hypercapnic respiratory failure).
• Caution: Pulse oximeters may overestimate SpO2 in patients with dark skin or indicate poor peripheral circulation if a reading is difficult to obtain [1].

Circulation (C)

• Blood Pressure: Systolic BP \le 90 mmHg or >40 mmHg below normal.
• Heart Rate: >130 bpm. Note: Beta-blockers may mask tachycardia, and older people may develop new arrhythmias instead of simple tachycardia.
• Lactate: >2 mmol/L indicates hypoperfusion.
• Urine Output: Ask about urination in the last 18 hours. For catheterized patients, <0.5 ml/kg/hour is critical [1].

Disability (D)

• Level of Consciousness: Assess for new-onset altered mental state or behaviour.
• Cognitive Function: Changes may be subtle in older people or those with learning disabilities/dementia (irritability or functional decline) [1].

Exposure (E)

• Skin: Check for mottled/ashen appearance, cyanosis (lips/tongue), or non-blanching petechial/purpuric rashes (meningococcal signs).
• Temperature: <36^\circ\text{C} (hypothermia) or high fever. Do not rely on fever alone; older/frail/cancer patients may not mount a pyrexic response.
• Source Check: Examine surgical sites, wounds, and indwelling devices [1].

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5. Key Investigations and Interpretation

Investigation	Rationale and Interpretation
Venous Blood Gas	Measure Lactate and glucose. Lactate >2 mmol/L suggests hypoperfusion.
Blood Cultures	Must be taken before the first dose of antibiotics.
Blood Tests	FBC, CRP, U&Es, Creatinine, LFTs, and Clotting Screen.
Microbiology	Tailor swabs/samples (urine, sputum) to the suspected source.
Imaging	Chest X-ray and urinalysis for all; consider CT Abdomen/Pelvis if the source is occult [1].

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6. Treatment and Evidence-Based Management

Antibiotic Therapy

• Time Zero: Defined as the first NEWS2 score calculated in the ED or upon ward deterioration.
• High Risk (NEWS2 \ge 7): Give broad-spectrum IV antibiotics within 1 hour.
• Moderate Risk (NEWS2 5–6): Review by FY2+ within 1 hour. Antibiotics may be deferred for up to 3 hours to allow for diagnostic refinement, but do not delay once the decision is made.
• Low Risk (NEWS2 1–4): Assessment by FY2+. Antibiotics can be deferred for up to 6 hours [1].
• Choice: Use local formulary. For suspected community-acquired sepsis in those aged 16–18, use Ceftriaxone (80 mg/kg, max 4 g) [1].

Fluid Resuscitation

• Indication: High-risk patients or moderate-risk patients with evidence of hypoperfusion (Lactate >2 or AKI).
• Type: Isotonic electrolyte crystalloid (e.g., Hartmann’s or 0.9% Saline).
• Volume: Initial bolus of 250 ml over 10–15 minutes.
• Limit: Repeat up to a total of 1,000 ml. If no improvement, seek senior clinical advice [1].

Vasopressors

• If hypotension persists despite fluid resuscitation, discuss starting vasopressors with critical care or a senior clinical decision-maker.
• Peripheral Administration: Can be used if central access is unavailable. Ensure the line is visible and monitor for extravasation [1].

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7. Complications and Management

Complication	Timeframe	Management Strategy
Extravasation	Immediate (during vasopressor use)	Monitor peripheral line visibility; follow local policy for vasopressor concentration [1].
Fluid Overload	Immediate to Delayed	Reassess after every 250 ml bolus; seek senior advice after 1,000 ml total fluid [1].
Organ Failure	Immediate	Refer to critical care if no response to interventions within 1 hour [1].
Antibiotic Toxicity/Resistance	Delayed	Narrow spectrum as soon as sensitivities are available [1].

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8. Learning Aids: The Sepsis NEWS2 Framework

Mnemonic: "S.E.P.S.I.S. NEWS"

• Single parameter of 3 = Urgent Review.
• Elevated NEWS2 \ge 7 = Antibiotics in 1 Hour.
• Peripheral Vasopressors = Discuss with ICU.
• Step-wise Fluids = 250 ml Boluses.
• Identify Source = Cultures before Abx.
• Senior Decision Maker = ST3+ for Adults; ST4+ for under 18s [1].

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9. Changes from Previous NICE Guidance (NG51)

• Risk Stratification: Replaced previous "High/Moderate/Low" criteria tables with NEWS2 score bands.
• Fluid Bolus: Reduced initial volume from 500 ml to 250 ml to prevent over-resuscitation and promote frequent reassessment.
• Antibiotic Window: Introduced a more nuanced 1-3-6 hour approach based on NEWS2 risk level to balance urgency with antimicrobial stewardship.
• Vasopressors: Explicitly allows for discussion of peripheral vasopressors in early management [1].

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References

1. National Institute for Health and Care Excellence (NICE). Suspected sepsis in people aged 16 or over: recognition, assessment and early management [NG253]. London: NICE; 2025. Available from: www.nice.org.uk/guidance/ng253

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Example EPIC EHR Documentation Structure

Suspected Sepsis Assessment (Age 16+)

Risk Stratification (NEWS2)

• [ ] NEWS2 Score: _____
• [ ] Single Parameter Score of 3 present? [Yes/No]
  • If Yes, indicate parameter: [RR/SpO2/O2/Systolic BP/HR/Temp/Consciousness]
• [ ] Risk Level: [High (\ge7)/Moderate (5–6)/Low (1–4)/Very Low (0)]

Clinical Red Flags (Check all that apply)

• [ ] Mottled/Ashen Appearance
• [ ] Cyanosis (Skin/Lips/Tongue)
• [ ] Non-blanching Rash
• [ ] Neutropenic Risk (Chemo in last 30 days)

Source Assessment

• Suspected Source: [Resp/UTI/Abdo/Skin/CNS/Unknown]
• [ ] Blood Cultures Sent (Prior to Abx)
• [ ] Lactate Result: _____ mmol/L

Interventions

• [ ] IV Antibiotics Ordered (Target: 1hr High, 3hr Mod)
• [ ] IV Fluid Bolus: [250 ml Crystalloid]
• [ ] Oxygen therapy initiated (Target 94-98% or 88-92%)

Medical Decision Making (MDM)

• Diagnosis: Suspected Sepsis secondary to [Suspected Source].
• Risk Determination: Patient categorized as [Risk Level] based on NEWS2 of [Score]. [Include justification if risk escalated due to clinical concern].
• Escalation:
  • [ ] Senior Clinical Decision Maker Informed (Name: ________)
  • [ ] Consultant Informed (if High Risk/No improvement)
  • [ ] Critical Care Consultation (if vasopressors/fluid refractory)
• Plan: Monitor NEWS2 every [30 min/1 hr/4-6 hrs]. Reassess after [Volume] fluids. Source control via [Intervention] discussed with [Surgical/Radiology Team].

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