Just ask ‘could this be sepsis?’

Definition of sepsis

Sepsis has recently been defined by international consensus as a life-threatening organ dysfunction due to a deregulated host response to infection.¹ This is associated with a high rate of mortality and has been reported to claim an estimated 44,000 lives each year.²

The infection may have started anywhere in a patient's body and can be widespread. Although sepsis may be secondary to odontogenic, mucosal or salivary gland infections,³ sepsis can also occur following chest or urinary tract infections, or simple skin injuries like cuts and bites. A high index of suspicion should therefore be adopted in certain groups of patients, including those over 75 years of age, the immunocompromised, the pregnant and those with recent surgical interventions (Table 1).

Undiagnosed and untreated sepsis can lead to septic shock which is defined as a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock are associated with hospital mortality rates of greater than 40%. Adult patients with suspected infection can be identified as being more likely to have poor outcomes typical of sepsis if they have at least two of the following clinical criteria:

For patients with septic shock, for every hour that appropriate antibiotic administration is delayed, there is an 8% increase in mortality.^4,5

Apart from life-threatening odontogenic sepsis, head and neck fascial space infection can lead to airway obliteration, systemic inflammatory response syndrome (SIRS), cavernous sinus thrombosis and mediastinitis. Past medical history (eg diabetes, recent surgical interventions), past dental history (eg recent extractions or restorative dentistry), and drug history such as immunosuppressant medications, are helpful information to assess the severity of sepsis.

Media coverage and public health campaigns

In December 2015, NHS England published a wide-ranging sepsis action plan to help diagnose and raise awareness in the early prevention, recognition, diagnosis and treatment of sepsis, as well as raising awareness of the condition amongst the public.⁶ The report has a strong focus on ensuring that professionals, including general dental practitioners, are educated about sepsis and trained in identifying the condition promptly. More recently, NICE has published a clinical guideline and accompanying set of tools and resources to improve the recognition and management of sepsis.⁷

Sepsis has the potential to present with non-specific symptoms and it may be poorly recognized. The Parliamentary and Health Service Ombudsman report, entitled ‘A Time to Act’, called upon the NHS and Department of Health to act rapidly to reduce unnecessary deaths from sepsis.⁸ The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report ‘Just say Sepsis’ describes the quality of care delivered in general medical practice. Scope for improvement was found in almost 39% of cases.⁹ Mainstream media outlets have publicized such cases where diagnosis and subsequent treatment has been delayed, leading to potentially avoidable mortality.

Assessing vital signs and non-specific symptoms

NICE guidelines place particular emphasis on those that may have non-specific, poorly localized presentations. Extra care should be taken if the patient cannot provide a good history, for example, people with English as a second language or people with communication problems. This can be particularly relevant in inner cities where there is a higher proportion of immigrants; there may be a mistrust of western medicine and reliance upon their traditional medical beliefs.¹⁰Table 2 gives examples of how signs and symptoms of sepsis may be described in lay terms.¹¹

Assessing vital signs should not delay urgent referral to medical teams if sepsis is suspected, however, assessing a patient's physiological parameters forms an important part of the updated NICE guidance. The following parameters are defined by the Royal College of Physicians initiative National Early Warning Score (NEWS) for adult patients.¹² Vital signs are different for babies and small children; there should be a high index of suspicion for young patients presenting systemically unwell.^7,13 The acronym ‘PASTOR’ can be used to aid memory for Pulse, Alertness/Consciousness level, Systolic blood pressure, Temperature, Oxygen saturation and Respiration rate.

Systolic blood pressure

This should routinely be between 111 mm/hg and 219 mm/hg. Although an elevated blood pressure (hypertension) is an important risk factor for cardiovascular disease, it is a low or falling systolic blood pressure (hypotension) that is most significant in the context of potential sepsis. It is important to note that some people have a naturally low systolic blood pressure (Figure 1). This might be suspected if the patient is well and all other physiological parameters are normal, or confirmed by reference to previous records of blood pressure. Hypertension is given less weighting in the context of acute-illness assessment.

Temperature

The temperature of a patient is easily measured with a tympanic ear device readily available in most dental practices (Figure 2a). A single use oral temperature probe is a useful alternative device to measure temperature (Figure 2b). A normal temperature should lie between 35.5 and 37.5 degrees Centigrade. Both pyrexia and hypothermia should be considered in assessment of the acutely unwell patient; this reflects the fact that the extremes of temperature are sensitive markers of acute-illness severity and physiological disturbance.

Screening for sepsis

The recent NICE guidelines are designed to inform all healthcare professionals working in primary, secondary and tertiary settings. They cover the recognition, diagnosis and early management of sepsis for all populations; this is particularly prudent for dentists who routinely manage patients of all age groups. Vital signs are different in babies and small children;^7,13 parents are often best placed to notice non-specific changes such as malaise and altered mental state (Table 2). It is not uncommon for patients with infection, whether odontogenic or non-odontogenic, to seek routine dental treatment while avoiding general medical practice. The awareness and early detection of potential sepsis could save lives.

General dental practitioners are well trained in assessing and diagnosing patients with potential dento-alveolar infections. The new guidelines place particular emphasis on the reports of family and carers that may have noted acute behavioural disturbances, or any reports of altered breathing and respiration rates. Patients can be assessed for ‘Red Flags’ if there is a suspected infection. Vital signs and physiological parameters are very important but the new guidelines place particular emphasis on identifying patients that may not be exhibiting signs of physiological disturbances. Although general dental practitioners are trained to assess and diagnose patients with potential dento-alveolar infections, some of the above-mentioned vital signs are often not assessed due to lack of equipment and the latest guidelines. Continuing professional training should therefore include the diagnosis and management of sepsis.

The introduction of an improved set of ‘Red Flag’ or high risk sepsis criteria will be discussed, together with a second group of ‘moderate to high risk criteria’ which can be termed ‘Amber Flag’ sepsis criteria. Amber Flag patients carry a lower risk but still warrant close assessment. The reliance on laboratory tests seen in earlier pathways is removed. Thus strategies to identify sepsis in primary care and urgent care settings are now similar to strategies in secondary care.

Specific ‘Red Flag’ signs occurring with odontogenic infection include moderate to severe trismus, facial and neck swelling, dysphagia (difficulty in swallowing), dysphonia (difficulty breathing), malaise, pyrexia and earlier failed antibiotic therapy. Although most dental infection can be managed with root canal treatment, extraction and antibiotic therapy, some can develop into spreading infection and sepsis (Figure 3). Ludwig's angina is a rapidly spreading cellulitis involving at least three fascial spaces and can lead to a compromised airway with high rates of mortality.³

Any patient with presumed sepsis who has one or more Red Flag sepsis criteria should be assumed to have sepsis or septic shock and immediately transferred to hospital. Patients who have no Red Flag sepsis criteria should immediately be screened for Amber Flag sepsis (Table 3).

Although a GDP may not be as well equipped as colleagues in general medical practice, the awareness and knowledge of Red Flag signs are helpful in communicating the available clinical signs, such as altered mental state and respiratory rate.¹⁴ When organizing a hospital transfer, the call should include direct reference to the acuity of the condition, terms such as ‘Red Flag Sepsis’ should be universally understood. If the call is made in the presence of patients or their relatives, it may be preferable to state that the patient has suspected sepsis and give vital sign observations. Where resources permit, general practitioners should initiate oxygen therapy to maintain target saturations of 94% or higher.

Conclusion

Members of the dental profession have a responsibility to recognize and appropriately escalate the treatment of the deteriorating patient, especially those with potential odontogenic causes. Prompt medical treatment with an antibiotic regimen and surgical management of eradication of the source by incisional drainage of an abscess and removal of poor prognosis teeth are essential. It is vitally important to help raise awareness of sepsis and undertake continuing professional development in this area in order to avoid potentially life-threatening consequences due to undiagnosed and untreated sepsis.