Sepsis in the ElderlyDafydd Loughran

Learning goals• Identify and define sepsis

• Discussion on particular considerations in elderly

• Sepsis management

Which of the following are sepsis?

• 85 year old man with a long term catheter admitted confused with foul smelling urine. Temp 37.7, HR 99, BP 90/50, RR 30, WBC 9. Urine output 400ml in the last 24 hours.

• 78 year old lady admitted with cough and chest pain. HR 91, RR 18, BP 100/60, Temp 35.8, WBC 3.5.

• 90 year old lady admitted from home due to pyrexia and unable to give history. Temp 38.4, HR 100, BP 110/78, RR 18.

• 82 year old man admitted with RUQ pain becoming progressively drowsy despite aggressive management for last 24 hours. HR 102, BP 83/50, Temp 38.9, RR 26, WBC 14

Definitions (American college of chest physicians and society of critical care medicine)

Systemic Inflammatory Response Syndrome2 or more of:

Temperature <36 or >38HR >90

RR >20, or PCO2 <4.3, or need for mechanical supportWBC <4 or >12

Severe Sepsis =Sepsis + Evidence of organ dysfunction or hypoperfusion

e.g. confusion, Low urine output, high lactate

Septic Shock = Severe sepsis + hypotension despite fluid

resuscitation

Sepsis = SIRS + presumed or confirmed infection

Which of the following are sepsis?

• 85 year old man with a long term catheter admitted confused with foul smelling urine. Temp 37.7, HR 99, BP 90/50, RR 30, WBC 9. Urine output 400ml in the last 24 hours.

• 78 year old lady admitted with cough and chest pain. HR 91, RR 18, BP 100/60, Temp 35.8, WBC 3.5.

• 90 year old lady admitted from home due to pyrexia and unable to give history. Temp 38.4, HR 100, BP 110/78, RR 18.

• 82 year old man admitted with RUQ pain becoming progressively drowsy despite aggressive management for last 24 hours. HR 102, BP 83/50, Temp 38.9, RR 26, WBC 14

Is sepsis in the elderly an important problem?

Is sepsis in the elderly an important problem?

• 60% of cases of severe sepsis occur in those over 651.

• This subsection of the population is rapidly increasing.

• 60% of all days in ITU were patients >65 (all causes)1.

• Significant mortality and morbidity: overall mortality for severe sepsis is 28.6%, in those >85yrs is 38.4%2.

• Commonest cause of death in non coronary AICU3.

• Crucially however there is evidence that many in this age category respond well to selected interventions if started in a timely fashion.

1. Girard et al. Insights into severe sepsis in older patients: from epidemiology to evidence based management. Clinical infectious diseases 4(5):719-727.

2. Angus et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Critical care medicine. 2001;29:1303-1310.

3. Kumar and Clark, 7th edition

Increasing incidence over last 20 years for more than

1 reason• Ageing population

• Increased life expectancy for patients with a range of chronic conditions

• Immunosuppressive drug use

• Increased use of indwelling catheters and mechanical devices

• Mechanical ventilation

• Widespread antibiotic use?

Considerations in the Elderly

• Atypical presentation – confusion, falls, weakness, & poor symptom recall

• Atypical SIRS response – due to comorbidities, age or medications eg beta-blockers

• Obtaining samples (eg urine & sputum samples) in timely manner can be tricky – need good communication and co-operation with nursing staff

• Consider likely organisms – catheters, lines, ventilators

• Directed fluid management

• Discussion of appropriateness of escalation – particularly HDU/ITU, anticipating possible deteriorations out-of-hours, and documenting plan clearly.

Sepsis ManagementSepsis Six (within 1st hour)

by Global Sepsis Alliance

1. High flow O2

2. Blood Cultures

3. Give broad spectrum antibiotics

4. IV fluid challenges

5. Measure lactate and haemoglobin

6. Accurate urine output measurement

Surviving Sepsis Bundle by Society of Critical Care Medicine

Within 3 hours:

Within 6 hours:

1. Lactate2. Blood cultures

3. Broad spectrum antibiotics

4. Vasopressors if needed to maintain MAP>65

5. If persistent hypotension despite fluid resuscitation then

measure CVP and central venous sats

6. Re-measure lactate

Aim to simplify the initial care of a patient with sepsis

Use your antibiotic guidelines!

In summary…

• SIRS ☞ Sepsis ☞ Severe Sepsis ☞ Septic Shock

• Often good clinical response in elderly if timely management

• High vigilance due to atypical presentations

• Discuss escalation early

• Follow Sepsis Six & Surviving Sepsis Bundles

• Use your antibiotic guidelines