Management of the Patient with Suspected Sepsis or Septic Shock: Clinical Recommendations for the Portuguese Prehospital Setting

Abstract

Sepsis is a time-dependent medical emergency associated with high morbidity and mortality. Early recognition and appropriate prehospital management are critical for prognosis. Despite the existence of the Sepsis Fast Track standardized by the Directorate-General of Health (Direção-Geral da Saúde), there has been underreporting of suspected sepsis cases, highlighting the urgent need to review the alert criteria. In addition, Portugal lacked specific guidelines for its activation and management in the pre-hospital setting. Considering these facts, this article aims to produce evidence-based recommendations for the standardization of the recognition and treatment of sepsis and septic shock in the Portuguese pre-hospital context, in line with the latest international guidelines and the operational capabilities of the Integrated Medical Emergency System. This guideline is the result of a comprehensive review of the literature, integrating international consensus and adapting it to the Portuguese context. For that matter, inclusion and exclusion criteria are defined for sepsis alert in the pre-hospital context, prioritizing early identification through suspected infection or changes in temperature and organ dysfunction or clinical indicators of severity, such as NEWS/NEWS2 ≥ 5, Shock Index ≥ 0.7, Mottling ≥ 2, capillary refill time > 2 seconds. Treatment depends on the type of intervention, including oxygen therapy, positioning, and temperature control for basic life support teams; balanced crystalloids, parenteral antipyretics, and early initiation of vasopressor support for differentiated teams, subject to certain assumptions for immediate life support teams. Empirical antibiotic therapy is also recommended in cases of septic shock handled by teams with a physician, namely Emergency Medical and Resuscitation Vehicles and Emergency Helicopter Service. The article also standardizes both clinical records and alert activation via the iTeams® platform and manual registries. This first national guideline for sepsis in the pre-hospital setting establishes uniform, evidence-based procedures for early recognition and treatment in this context, contributing to improved clinical outcomes, optimization of resources, and strengthened inter-hospital coordination within the sepsis fast track.