A 71-year-old is referred with fever, confusion and hypotension but no obvious source of infection. Talk us through your approach.

Question

A 71-year-old man is referred by his GP with three days of malaise and fever. On arrival: temperature 38.8, HR 118, BP 88/52, RR 26, SpO2 94% on air, NEWS2 of 9. Chest is clear, abdomen soft, urine dip negative.

Accepted Answer

This is sepsis with organ dysfunction and no identified source, and the key principle is that I would deliver the Sepsis Six within the first hour while I look for the source rather than before I find it. So in parallel with assessment: high-flow oxygen titrated to target, blood cultures before antibiotics provided that does not delay them, empirical broad-spectrum intravenous antibiotics per local policy, a fluid bolus of balanced crystalloid reassessed clinically, a venous gas with lactate, and monitoring of urine output. Then the source hunt, and this is where the station is won. I would undress him completely, because the commonest missed sources are on the parts of the patient nobody looks at: pressure areas and the sacrum, the perineum and scrotum, the feet and between the toes in a diabetic, and the back. I would examine every joint for a septic arthritis, palpate the spine for a discitis or epidural abscess, look carefully for stigmata of endocarditis and listen for a new murmur, examine the abdomen for a collection and consider a rectal examination, check for meningism, review any indwelling line, catheter or prosthesis, and look in the mouth for a dental source. Investigations would be directed by that examination: cultures, a chest film, urine culture even with a negative dip, and cross-sectional imaging or echocardiography where the examination points that way. I would also keep non-infective mimics in mind — pulmonary embolism, adrenal crisis, a drug reaction, thyroid storm, vasculitis or malignancy — particularly if he does not respond. I would reassess after fluid, and my escalation triggers would be a lactate that remains above 4, hypotension persisting after 30 ml/kg, or a NEWS2 that does not fall, at which point I would involve critical care and my consultant. I would document the source hunt explicitly so the next team does not repeat it.

Undifferentiated Sepsis with an Unclear Source

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