Management of Sepsis in Critically ill Elderly Patients Homework Help

What is Sepsis?

Sepsis occurs as a result of the immune system’s extreme response to an infection. when a person gas sepsis, their immune system may injure their organs and tissues which can be a threat to their life.

Sepsis can occur as the body tries to fight off an infection in the urinary tract, skin, lungs, and other parts of the body. Sepsis is mostly caused by a bacterial infection in the blood known as septicemia.  Sepsis is often confused with septicemia although the two are different.

Recovery from Sepsis

1. Mild sepsis recovery – complete recovery from mild sepsis is usually quicker. The average period it takes to recover from mild sepsis is 3 to 10 days. However, the period it takes to recover from mild sepsis depends on how the patient responds to the appropriate treatment given including medications.
2. Severe sepsis recovery – a person with severe sepsis needs immediate treatment. They should be put in the critical care area for one month or more. It is very much possible to recover from severe sepsis. However, recovery from severe sepsis may take a longer time compared to mild sepsis. Many people regain their normal health after severe sepsis without any residual dysfunctions. The period it takes to recover from sepsis varies from one patient to another. The time it takes to recover depends on the number of organs affected by the infection and the degree of organ dysfunction.
3. Post-sepsis syndrome – post-sepsis syndrome is the combination of short-term or long-term physical problems and cognitive problems. More than half of the elderly patients who survive sepsis experience post-sepsis syndrome.

Difficulties that come with post-sepsis syndrome include psychological, physical, and mental issues. Mental issues may include the inability to do arithmetical calculations. Physical issues include weaker muscle strength, chest pains, and bloated limbs whereas psychological issues include memory loss and anxiety.

Recovery from post-sepsis syndrome

Patients who recover from post-sepsis syndrome should be provided with rehabilitation facilities to help them go back to their normal lives. The average period of recovery from post-sepsis syndrome is around 2 years or more.

Recovery at the hospital – treatment of post-sepsis syndrome starts at the hospital. It is initiated by a physiotherapist. A physiotherapist mostly helps the patient to regain their ability to carry out simple daily activities on their own. They can help them with activities like:

1. doing physical exercises to help them regain their muscle strength
2. bathing, dressing, and walking

Recovery at home

After being discharged from the hospital, the patient will require detailed care at home in addition to regular reviews with their healthcare provider. In addition,

1. they need to interact with family and friends to avoid depression
2. together with their caregiver, they set small targets to achieve daily tasks

• they need to take complete rest and build up their strength while slowly increasing their activities because they feel tired and weak.

1. they should have a balanced diet. Those with a poor appetite can consider small meals and supplemental nutrition drinks.

Sepsis in Elderly Patients

Elderly patients are at more risk of sepsis because of:

• often have reduced immunity
• older people often have conditions like diabetes.
• older people have a higher risk of malnutrition
• older people have reduced immunity

Most cases of sepsis are a result of infection of the respiratory tract such as pneumonia and urinary tract infections. Covid -19 has been identified as an emerging risk factor for sepsis in older adults.

It is more difficult to identify early signs of sepsis in older adults. This is the reason why sepsis progresses more rapidly in older adults compared to young people. Older people above the age of 65 years are more likely to be hospitalized with sepsis than those below 60 years. A large number of people above 6o years are likely to develop sepsis while in intensive care.

Once an elderly patient recovers from sepsis, they are at increased risk of developing:

• organ damage
• chronic pain and fatigue
• post-traumatic stress disorder
• a repeat infection

It is important to recognize symptoms of sepsis in elderly patients early enough for prompt treatment. It is important to take the necessary steps to prevent the development of sepsis whenever possible.

Symptoms of Sepsis

If an elderly patient with an infection starts to develop the following symptoms, they should be taken to the hospital immediately:

1. difficulty breathing
2. fever, chills, and shivering
3. extreme pain or discomfort
4. redness and swelling around a wound
5. clammy or sweaty skin
6. a rapid pulse tachycardia

Symptoms of severe sepsis include:

1. low urine volume
2. low blood pressure
3. a feeling of doom or sudden fear of death
4. faintness or dizziness
5. slurred speech
6. pale, discolored, or mottled skin
7. nausea, vomiting, and diarrhea
8. severe pain and general discomfort
9. loss of consciousness
10. skin that feels unusually cold or warm like a fever
11. shortness of breath
12. confusion, reduced alertness, and other changes in the mental state of the person
13. cool, pale skin at the extremities

Sepsis may progress to cause septic shock. When a person gets into septic shock, their blood pressure falls dangerously low hence oxygen does not get to the organs of the body. Like older adults, children too are at a higher risk of developing sepsis and are likely to have severe symptoms. However, it is more difficult to spot sepsis in younger children and older adults.

Risk factors for Sepsis in Elderly people

There are several risk factors for sepsis in elderly people. These factors are poor performance status, malnutrition, exposure to instrumentation and procedures, comorbid illnesses, institutionalization, and immunosenescence.

Compared to younger patients, patients above 75 years of age have higher rates of comorbidities. Patients above 65 years are twice as likely to have a comorbid medical condition compared to younger patients.

Management of these conditions requires instrumentation such as the use of tracheotomies, central venous catheters, and urinary catheters. Instrumentation interferes with the natural barriers of a person’s innate immunity and may create a pathway for infections.

A large number of elderly patients are admitted to long-term care facilities where the resistance of bacterial flora is higher compared to the environment outside these care facilities.

Malnutrition is common in elderly patients due to functional limitation, inactivity, poor or restricted diet, poor mobility, polypharmacy, depression, poor dentition, chronic disease, and dementia.

It is important for hospitals and long-term care facilities to put in place infection-control programs to help prevent and identify antimicrobial resistance and outbreak of infections. Elderly patients are more exposed to infections therefore strategies for controlling infections are important for the prevention of sepsis.

Diagnosis of Sepsis

When a person with symptoms of sepsis goes to see the doctor, the doctor usually orders tests to determine the severity of the infections and to diagnose sepsis. One of the commonly done tests is the blood test. A blood test is done to check for:

1. clotting problems
2. decreased amount of oxygen
3. infection
4. abnormal kidney or liver function
5. an electrolyte imbalance

Additional tests may be ordered depending on the results of the blood test and the symptoms of the patient. Additional tests that can be ordered include:

1. a wound secretion test to check an open wound for any infection
2. a mucus secretion test to identify germs that may cause an infection
3. a urine test to check for bacteria in the urine

If the above tests do not help the doctor to make a diagnosis, he or she may order an internal view of the body using the following:

1. CT scans to view infections in the bowel area, pancreas, or appendix.
2. MRI scans to identify infections in the soft tissues.
3. Chest x-rays to examine the lungs
4. Ultrasounds to view infections in the ovaries or the gallbladder.

Sepsis criteria

The severity of sepsis can be determined using two sets of criteria. Systematic inflammatory response syndrome is one of the sets of criteria used. Systematic inflammatory response syndrome is defined by two or more of the criteria below:

1. an abnormality in the white blood cell count
2. a heart rate higher than 90 beats per minute
3. a respiratory rate higher than 20 breaths per minute or arterial carbon dioxide tension of fewer than 32 millimeters of mercury.
4. a fever of more than 38 degrees centigrade or less than 36 degrees centigrade.

Another criterion is the quick sequential organ failure assessment. Quick essential organ failure assessment uses the results of the following criteria:

1. low blood pressure with a systolic blood pressure of less than 100 mmHg
2. Glasgow coma scale score of 14 or less to help determine a person’s level of consciousness
3. high respiratory rate of more than 22 breaths per minute

Most doctors prefer quick sequential organ failure assessment because it does not require laboratory tests like systematic inflammatory response syndrome. The doctor can use results from either of these tests to decide on the best course of treatment.

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Management of Sepsis in Older Patients

The surviving sepsis campaign guidelines outline important recommendations for the treatment of severe sepsis and septic shock. However, the implementation of these strategies is different in younger and older patients.

1. Source control and antibiotics – to effectively manage sepsis, the doctor needs to control the source of the infection and administer antibiotics early enough. These are key to the management of sepsis.

However, there is not much evidence to support this argument because of the lack of trials in this area. However, the importance of these two elements should not be dismissed.

It is important to carry out studies aimed at identifying the source of the infection as soon as possible. Once the source is identified, it is important to take measures to control the source of the infection.

Examples of the source of infections that can be controlled are the lungs, necrotic skin, empyema or abscesses, infected catheters, and infected devices.  Once sepsis has been identified, it is very important to put the patient on empirical antibody therapy within 1 hour.

Empirical antibiotic therapy should be started after samples from suspected sites of infection and the blood have been collected for culture. If the initial antibiotic therapy is inadequate, it will lead to poor outcomes.

Initial antibiotic therapy should have a broad spectrum such that it fights all the probable pathogens.  The use of antimicrobial agents in older patients with sepsis is similar to that in younger patients.

Several factors increase the likelihood of repeated antimicrobial exposure. These factors include repeated hospitalizations, high prevalence of intra-abdominal and soft tissues infections, immunocompromised, comorbid illnesses, and repeated hospitalizations.

The standard approach to the treatment of causative organisms in elderly patients should involve rapid reduction of treatment to monotherapy. In addition, it is necessary to reduce pharmacodynamics and pharmacokinetics of antibiotics used in older patients with sepsis due to their reduced lean body mass, reduced renal function, and shock-induced hepatic blood flow.

Elderly patients are at higher risk of suffering from adverse effects of antibiotics and is therefore important for healthcare providers to familiarize themselves with possible effects and to monitor them carefully.

In severe sepsis, metabolic parameters change rapidly and this complicates dosing. It is important to carefully monitor therapeutic drugs that are used to treat severe sepsis in elderly patients.

2. Aggressive resuscitation – initial resuscitation should begin early in patients with septic shock or severe sepsis. The goal of early resuscitation is to maintain adequate tissue perfusion.

Early aggressive resuscitation improves the survival rate of elderly patients.

Excess fluid accumulation is common in elderly patients therefore it is important to take care to avoid this situation. Under-resuscitation is common in patients with severe sepsis due to increased capacity of the vasculature.

During initial resuscitation, it is important to use liberal amounts of intravenous fluid.

3. Steroids – patients with refractory shock should be treated with a replacement dose of hydrocortisone. Treatment using hydrocortisone and fludrocortisone improves mortality rates for patients with relative adrenal insufficiency.

Appropriate dosing and caution are highly recommended. There is a lot of controversy surrounding the use of steroids in the management of sepsis in elderly patients. This is because steroids can result in immunosuppression, poor healing of wounds, mononeuropathy, and poor glucose control.

The use of steroids is mostly beneficial in patients with relative adrenal insufficiency.

4. Transfusion strategies – where there are no tissues hypoperfusion or coronary artery disease or active hemorrhage, strategies for red blood cells transfusion should be approached conservatively. In patients where transfusion is done conservatively, the outcomes are improved.
5. Mechanical ventilation – a great number of people with severe sepsis need mechanical ventilation. A lung-protective ventilation strategy results in a significant reduction in the mortality rate in patients with acute respiratory distress syndrome or acute lung injury.

For patients above 70 years, low tidal volume ventilation reduces the risk of mortality. Elderly patients on mechanical ventilation should have their heads raised to minimize the risk of pneumonia associated with the risk of the ventilator. Weaning from the ventilator should be done using a strategy that avoids unnecessary delay in extubation.

6. Sedatives and analgesics – critically ill elderly patients who develop sepsis experience pain, anxiety, and delirium. The duration of mechanical ventilation can be reduced by using sedation that is standardized, using a sedation goal, or interrupting sedatives daily.

The duration of mechanical ventilation can be reduced by using intermittent bolus instead of continuous infusion.

7. Miscellaneous issues – there are other important aspects of the management of sepsis in elderly patients that should not be ignored. An example of such aspects is
8. prophylaxis for deep vein thrombosis using low molecular weight heparin, low molecular weight heparin, and low dose unfractionated heparin.
9. tight glucose control

• H2-receptor blockers to prevent stress ulcers.

Elderly patients usually develop hyperglycemia which may affect their antimicrobial defense mechanism and may worsen sepsis. Intensive insulin therapy that is focused on maintaining normal blood glucose levels reduces the mortality rate.

8. End-of-life planning – when handling elderly patients with severe sepsis, it is good that the doctors and healthcare providers prepare and be equipped to offer quality end-of-life care. In some cases of elderly patients with severe sepsis, it might be in the best interest of the patient to withdraw or withhold support.

Life-sustaining treatment is limited with advanced age. However, the justification for limiting life-sustaining -treatment is futile. Such decisions are made based on complex interactions of decision-making between the family and the patient. It also involves communication between patients and their families and the medical team.

In situations where it is difficult to decide, the hospital ethics team should assist in achieving a resolution to controversial decisions on life-sustaining treatments that are potentially unhelpful.

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Conclusion

Despite the increasing number of deaths associated with sepsis in critically ill elderly patients, many elderly patients tend to respond well to management strategies and evidence-based diagnostic strategies we have discussed above.

Research on other treatments specific to sepsis is still going on. There is a need for more studies to investigate issues like post-discharge survival and health-related quality of life in elderly patients who have had severe sepsis.

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