4.1 Sepsis Recognition, NCG No. 26 & the Sepsis 6 Bundle

Sepsis Recognition, NCG No. 26 & the Sepsis 6 Bundle

Know which guideline is current. Ireland's sepsis guideline is NCEC National Clinical Guideline No. 26, Sepsis Management for Adults (including maternity). Version 1 was published in September 2021; Version 2, a rapid update, followed in August 2025. The older National Clinical Guideline No. 6 (Sepsis Management, 2014) has been formally retired by the Department of Health. RCSI's own reading list points candidates at NCG No. 26 Version 2 and at the September 2025 HSE Sepsis Screening Tool for Adults, noting that from 24 January 2026 it is only that September 2025 screening tool that will be used at the OSCEs until further notice. Quoting the retired 2014 guideline, or a bundle timing it contained, is a dated answer.

Sepsis is a time-critical emergency, and in Irish acute hospitals the nurse is usually the person who recognises it first: the INEWS chart triggers the thought, the screening tool structures it, and the bundle delivers the response.

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1. Pathophysiology: Sepsis and Septic Shock

NCG No. 26 adopts the international Sepsis-3 definitions:

• Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. The host response moves from a controlled local defence to generalised systemic inflammation; endothelial activation produces capillary leak, microvascular thrombosis, vasodilation and impaired tissue oxygen extraction.
• Septic shock: a subset of sepsis with circulatory and cellular or metabolic abnormalities profound enough to substantially increase mortality. Clinically, it is persistent hypotension requiring vasopressors to maintain a mean arterial pressure of at least 65 mmHg, together with a serum lactate above 2 mmol/L despite adequate fluid resuscitation.

Infection (bacterial, viral, fungal)
       |
       v
Dysregulated host immune cascade (TNF-alpha, IL-1, IL-6)
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       v
Endothelial injury + systemic vasodilation + microcirculatory thrombosis
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       v
Tissue hypoperfusion + cellular dysoxia (anaerobic metabolism -> lactate rises)
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       v
Multi-organ dysfunction -> septic shock

SIRS Has Not Disappeared

Moving to Sepsis-3 removed the systemic inflammatory response syndrome (SIRS) criteria from the definition of sepsis, but NCG No. 26 is explicit that SIRS has not gone away. SIRS is over-sensitive - it captures self-limiting infections and non-infective insults - which is why it no longer defines sepsis, but it remains a useful description of the inflammatory response. For an adult non-pregnant patient, SIRS is present when two or more of the following are met:

• heart rate above 90 beats/min
• respiratory rate above 20 breaths/min
• temperature above 38.3 degrees C or below 36 degrees C
• white cell count above 12 or below 4 x 10^9/L, or normal with more than 10% immature forms
• bedside glucose above 7.7 mmol/L in the absence of diabetes mellitus

The maternity criteria are modified (for example heart rate 100 or above, temperature above 38 or below 36 degrees C, white cell count above 16.9 or below 4 x 10^9/L, altered mental status, fetal heart rate above 160 bpm) and the changes must be sustained rather than transient.

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2. Recognition: From INEWS to the Screening Tool

Recognition in Irish practice is a two-step process, and candidates are expected to know both steps.

Step 1 - the trigger. On the INEWS V2 Escalation and Response Protocol, an aggregate score of 4 to 6 carries the standing instruction THINK SEPSIS and the action screen for sepsis. An aggregate of 7 or more is an emergency response requiring immediate Registrar review with the Consultant informed, while a score of 3 in any single parameter or a score of 2 for a heart rate of 40 or below requires the SHO to review immediately - and a patient that unwell with a suspected infection needs screening too. The INEWS guideline itself states that a sepsis screening and decision-support tool should be used for the identification of, escalation for and response to sepsis.

Step 2 - the screen. Use the HSE Sepsis Screening Tool for Adults (a separate maternity tool exists for pregnant and recently pregnant women). These are described in NCG No. 26 as living forms that are periodically updated by the HSE National Clinical Programme for Sepsis, so always work from the current version. For the OSCE, that means the September 2025 adult screening tool.

Who Deteriorates Quietly

Some patients decompensate without the textbook picture, and the screen must be applied with a lower threshold:

• Older adults, who may be normothermic or hypothermic and present with new delirium, lethargy or a fall rather than fever.
• Immunocompromised patients - chemotherapy and neutropenic sepsis, transplant recipients, long-term corticosteroids, advanced HIV.
• Post-operative and post-procedural patients, especially after abdominal surgery, orthopaedic implants or urinary tract instrumentation.
• Patients with indwelling devices - central venous catheters, PICCs, urinary catheters, tracheostomies, peritoneal dialysis catheters.
• Pregnant and postpartum women, assessed with IMEWS (NCG No. 4) rather than INEWS; the physiological changes of pregnancy mask early shock.
• Patients with chronic organ failure - end-stage renal disease, cirrhosis, heart failure, diabetes.

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3. The Sepsis 6 Bundle

Sepsis 6 is the bundle name used in NCG No. 26. It was developed by the UK Sepsis Trust as a practical way to deliver the Surviving Sepsis Campaign hour-1 bundle, and it is structured as Take 3 and Give 3. The maternity variant, Sepsis 6 + 1, adds assessment of fetal wellbeing: resuscitating the mother resuscitates the baby, but the uteroplacental circulation is not autoregulated, so maternal circulatory insufficiency can present as fetal distress.

The 2025 Change: Antimicrobial Timing Is No Longer One Number

This is the highest-yield update in the guideline and the point most likely to separate a current answer from a dated one. Version 2 replaced the single hour-1 rule with two recommendations graded by how certain the diagnosis is:

The stated purpose of the split is to keep rapid treatment for those who need antibiotics urgently while reducing unnecessary antibiotic exposure in those who may not have sepsis at all. It is an antimicrobial stewardship measure as much as a safety measure - NCG No. 26 explicitly discusses the unintended consequences of Sepsis 6, including patients started inappropriately on antimicrobials and empiric therapy never reviewed at 24 to 48 hours under the Start Smart, Then Focus approach.

The other recommendations stay familiar: obtain routine microbiological cultures including blood before starting antimicrobials if this causes no substantial delay; use empiric broad-spectrum therapy covering all likely pathogens; optimise dosing on pharmacokinetic and pharmacodynamic principles; and narrow therapy once the organism and sensitivities are known.

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4. Fluid Resuscitation and Haemodynamic Monitoring

Fluid restores perfusion, but fluid overload increases mortality, prolongs ventilation and lengthens ICU stay. Give it as a series of assessed challenges, not as a single prescription.

• Fluid choice: crystalloid rather than colloid; balanced crystalloids (such as Hartmann's or compound sodium lactate) are suggested over 0.9% sodium chloride, which in large volumes produces hyperchloraemic acidosis. Crystalloids are suggested over gelatins.
• Technique: give a defined bolus rapidly, then reassess before the next one.
• Reassess after every bolus:
  • mean arterial pressure, targeting at least 65 mmHg (MAP is approximately (systolic + 2 x diastolic) / 3)
  • heart rate - a falling rate suggests improving stroke volume
  • capillary refill time (normal under 2 seconds) and peripheral perfusion
  • urine output
  • lung bases: stop the bolus and call the medical team if the respiratory rate climbs, saturations fall, or bilateral basal crackles appear.
• Recheck lactate to judge whether perfusion is actually improving.

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5. Escalation

Failure to respond to initial treatment is itself a trigger. The INEWS protocol states that at a score of 4 to 6, if there is no response to treatment within 1 hour, contact the Registrar and/or ANP service, consider continuous monitoring and consider transfer to a higher level of care. Escalate using ISBAR.

Call for critical care review when you see:

• Refractory hypotension - systolic BP below 90 mmHg or MAP below 65 mmHg despite adequate crystalloid resuscitation, indicating a likely need for vasopressors and central access.
• Severe or non-clearing hyperlactataemia - lactate above 4 mmol/L, or a lactate that is not falling on repeat.
• Persistent oliguria below 0.5 mL/kg/hour despite fluid loading.
• Respiratory failure or exhaustion - worsening hypoxaemia or a rising respiratory rate requiring advanced support.
• Falling conscious level - a drop in GCS or progression through the ACVPU scale.

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6. OSCE Points

1. Say which tool you are using. "I am completing the HSE Sepsis Screening Tool for Adults" is a scorable statement; "I am worried about sepsis" is not.
2. Blood culture technique. Disinfect the venepuncture site with 2% chlorhexidine in 70% isopropyl alcohol and let it dry fully; clean the bottle septa with separate swabs; inoculate to the volume the bottles require. Take cultures before antimicrobials only if that causes no substantial delay.
3. State the timing rule correctly. For possible septic shock or a high likelihood of sepsis, antimicrobials immediately and ideally within 1 hour. For possible sepsis without shock, a time-limited rapid work-up and antimicrobials within 3 hours if concern persists.
4. Do the urine output arithmetic aloud. For a 70 kg patient, the minimum acceptable output is 70 x 0.5 = 35 mL/hour.
5. Re-score and document. Repeat the full observation set and recalculate INEWS at the frequency the tier demands - 1-hourly at a score of 4 to 6, half-hourly or continuous in an emergency response.