Management of sepsis and septic shock in critically ill patients transferred by a dedicated transport team in the West of Scotland

Over 500 critically ill patients are transferred by the dedicated transport team known as the 'Shock Team' each year in the West of Scotland. With the advent of international guidelines for the management of severe sepsis and septic shock, there are now criteria by which the management of these conditions can be assessed [1]. We undertook a prospective audit over a 3-month period to determine what proportion of the patients transferred have these conditions and to determine how management conforms to the guidelines.

Patients were deemed to have sepsis if they had suspicion of infection and two or more of the following: T >38°C or < 36°C; WCC < 4 or >12 × 10³/mm³; HR >90/min; RR >20/min; SBP <90 mmHg or MAP <65 mmHg or needing a vasopressor. We adapted sepsis resuscitation bundles derived from the guidelines [2] and devised a data collection form with relation to the following: serum lactate measurement; blood cultures prior to antibiotics; antibiotics given within 3 hours; MAP <65 mmHg and management with a minimum 20 ml/kg fluid challenge, vaso-pressors, and CVP monitoring; achievement of MAP ≥ 65 mmHg; measurement of central venous oxygen saturation (ScvO₂). Data were collected for every patient transferred during June, July, and August 2005.

Data were collected for 82 patients. Forty-five patients (55%, 95% CI 44–66%) met criteria for sepsis. Of these, eight patients had blood cultures prior to antibiotics (18%, 95% CI 8–32%), and in 23 (51%, 95% CI 35–66%) this information was not available or unclear. Similarly, 24 patients (53%, 95% CI 28–68%) had antibiotics within the time window, and in 17 (38%, 95% CI 24–54%) this was unclear. Twenty-eight (62%, 95% CI 47–76%) patients had circulatory failure with 19 of these (68%, 95% CI 48–84%) requiring more than a fluid challenge alone. MAP ≥ 65 mmHg was achieved in 43 patients (96%, 95% CI 85–100%). Two patients with sepsis had serum lactate measured (4%, 95% CI 0.5–15%). One patient of the 19 who had not responded to a fluid challenge had ScvO₂ measurement (5%, 95% CI 0–26%).

A significant number of critically ill patients with sepsis and septic shock are transferred each year. Many have circulatory failure and this is managed consistently with fluids, vasopressor and CVP targeting. Documentation and communication of blood culture withdrawal and antibiotic therapy may be poor. Serum lactate and ScvO₂ measurement may not yet be part of routine management of patients with sepsis transported in the West of Scotland.