SEPTIC SHOCK

Management of Elderly Patient at Risk

for Shock

The population as a whole is aging: the most

rapidly growing population group consists of
people over 65 years of age. The physiologic
changes associated with aging, coupled with
pathologic and chronic disease states, place
the older individual at increased risk of
developing a state of shock and possibly MODS.

Shock
a condition in which systemic blood
pressure is inadequate to deliver oxygen
and nutrients to support vital organs and
cellular function.

Shock can be classified by

etiology and may be described
as
Hypovolemic

shock
Cardiogenic shock
Circulatory or Distributive shock

SEPTIC SHOCK
Septic

shock is the most common type

of circulatory shock

medical condition as a result of

severe infection and sepsis

Severe

sepsis is a common problem associated

with substantial mortality and a significant
consumption of healthcare resources.

Severe

sepsis is a very common and important

cause of morbidity and mortality in the older
population, and its incidence has increased in the
last 10 years

 Older

persons are more prone to infections due

to the effects of aging, comorbidities, use of
invasive devices, and problems associated with
institutionalization.

The

diagnosis of sepsis in this population can be

difficult, as older patients may have atypical
responses to sepsis and may present with
delirium or falls, thus delaying therapeutic
interventions that may influence their outcome.

 It

is the most common cause of death in

noncoronary intensive care units in the United
States and the 13th leading cause of death in
the U.S. population.

Elderly

patients are at particular risk for sepsis

because of decreased physiologic reserves and
an aging immune system.

RISK FACTORS
Immunosuppression
Extremes

of age (<1 yr and >65 yr)

Malnourishment
Chronic illness
Invasive procedures

CAUSES
When

bacteria or viruses are present in

the bloodstream, the condition is known as
bacteremia or viremia. Sepsis is a
constellation of symptoms secondary to
infection that manifest as disruptions in
heart rate, respiratory rate, temperature
and WBC.

If sepsis worsens to the point of end-organ

dysfunction (renal failure, liver dysfunction,
altered mental status, or heart damage),
then the condition is called severe sepsis.
Once severe sepsis worsens to the point
where blood pressure can no longer be
maintained with intravenous fluids alone,
then the criteria have been met for septic
shock.

CLINICAL MANIFESTATION
Progressive Phase
High

Cardiac Output with systemic vasodilation

Normal

limits of Blood Pressure

Increase
Flushed

in heart rate

skin

Bounding

pulses

Elevated

Respiratory Rate

Normal

or decrease in urine output

Nausea
Vomiting
Diarrhea
Decreased
Subtle

Bowel Sounds

changes in mental status

Confusion

or agitation

CLINICAL MANIFESTATION
Irreversible
Low

Cardiac Output with systemic vasoconstriction

Normal
Drops
Cool

Phase

limits of Blood Pressure

in blood pressure

and pale skin

Normal
Heart

and respiratory rate remains rapid

Patient
MODS

or below normal temperature

no longer produces urine

progressing to failure develops

CLINICAL MANIFESTATION IN OLDER

PATIENTS
Clinical

manifestations of infections in older patients may be

unusual, nonspecific, or absent, and can include weakness,
malaise, delirium, confusion, loss of appetite, falls, or urinary
incontinence

Fever,

a hallmark of infection, can also be blunted or absent

in infected older patients.

Although

body temperature elevations in elderly persons are

an indicator for the presence of serious infections, decreased
body temperature (hypothermia) is a more ominous sign.

Confusion may be the first sign

of infection and sepsis in elderly
patients

 The

septic process can be altered or

modified if it is recognized early, and
adequate supportive care is promptly
initiated. The most important intervention
is to make a rapid diagnosis a difficult
task to achieve given the atypical
presentation of sepsis in the older patient.

 Older

persons often do not present with the

classical signs and symptoms of systemic
inflammatory response

Clinicians

might be misled by such a

presentation, causing a delay in disease
recognition and perhaps jeopardizing the timely
dministration of appropriate therapies and,
therefore, the patients ultimate outcome.

 In

addition, clinicians may be less inclined

to treat older persons aggressively based
solely on their age a decision that may be
inappropriate for a substantial number of
older patients with a minimal burden of
comorbidity and a good premorbid state of
health
and
quality
of
life.

Risk Factors for Older Patients

Performance

status
A number of aging processes lead to poorer performance
status, an independent predictor of mortality;
disuse atrophy from an inactive life-style
sarcopenia from accelerated muscle loss
changes in responsiveness to trophic hormones (growth
hormones, androgens, and estrogens)
neurological alterations
altered cytokine regulation
changes in protein metabolism
changes to dietary intake.

Immune Function
Older

patients are often nutritionally or

immunologically impaired, making them an easy
target for infection and its associated complications.

They

are frequently affected by comorbidities that

require treatment with foreign devices (e.g.
indwelling urinary catheters, gastrostomies,
cystostomies, tracheostomies, peripherally inserted
catheters) that make patients vulnerable to
infections or complications.

Nutrition
One

of the physiological changes of aging

includes a substantial decrease in olfactory
discrimination by age 70; sweet, sour, bitter,
and salty tastes are impaired.

Which

contributes to a decreased enjoyment

of meals, aggravating the anorexia of aging.

An older patients nutritional status can

also be affected by

inactivity
inadequate funds or resources
mobility and transportation issues
social isolation
functional limitations
poor or restricted diets
chronic disease
dementia
depression
poor dentition
polypharmacy
alcohol or substance abuse

Treatment
Primarily Treatment consists of the
following.
Volume

resuscitation

Early

antibiotic administration

Early

goal directed therapy

Rapid

source identification and control.

Support

of major organ dysfunction.

Medical Management
Any potential routes of infection must be
eliminated. Intravenous lines are removed
and reinserted at other body sites.
Antibiotic-coated intravenous central lines
may be placed to decrease the risk of
invasive line-related bacteremia in high-risk
patients, such as the elderly.

If possible, urinary catheters are removed. Any

abscesses are drained and necrotic areas
dbrided.
Fluid replacement must be instituted to correct
the hypovolemia that results from the
incompetent vasculature and inflammatory
response. Crystalloids, colloids, and blood
products may be administered to increase the
intravascular volume.

PHARMACOLOGIC THERAPY

If the infecting organism is unknown, broad-spectrum antibiotic

agents are started until culture and sensitivity reports are
received.
A third-generation cephalosporinplus an aminoglycoside may be
prescribed initially.
This combination works against most gram-negative and some
gram-positive organisms. When culture and sensitivity reports
are available, the antibiotic agent may be changed to one that
is more specific to the infecting organism and less toxic to the
patient.

Recombinant human activated protein C (APC), or

drotrecogin alfa (Xigris), has recently been
demonstrated to reduce mortality in patients with
severe. It has been approved by the U.S. Food and
Drug Administration for treatment of adults with
severe sepsis and resulting acute organ dysfunction
who are at high risk of death.
It acts as an antithrombotic, anti-inflammatory, and
profibrinolytic agent. Its most common serious side
effect is bleeding. Therefore, it is contraindicated in
patients with active internal bleeding, recent
hemorrhagic stroke, intracranial surgery, or head
injury.

NUTRITIONAL THERAPY
Aggressive nutritional supplementation is critical in the
management of septic shock because malnutrition further
impairs the patients resistance to infection.
Nutritional supplementation should be initiated within the
first 24 hours of the onset of shock. Enteral feedings are
preferred to the parenteral route because of the increased
risk of iatrogenic infection associated with intravenous
catheters; however, enteral feedings may not be possible if
decreased perfusion to the gastrointestinal tract reduces
peristalsis and impairs absorption.

 The

elderly patient can overcome shock

states if signs and symptoms are treated
early with aggressive and supportive
therapies. Nurses play an essential role in
assessing and interpreting subtle changes in
the older patients response to illness.

Nursing Management
All

invasive procedures must be carried out with

aseptic technique after careful hand hygiene.

Intravenous

lines, arterial and venous puncture sites,

surgical incisions, traumatic wounds, urinary
catheters, and pressure ulcers are monitored for signs
of infection in all patients.

Monitors

the patients hemodynamic status, fluid

intake and output, and nutritional status.

Daily

weights and close monitoring of serum albumin

levels help determine the patients protein
requirements.

Clinical Case
A 90-year-old retired physician presented to
the emergency department with a 1-day
history of shortness of breath and cough. He
denied chills or fever, but had marked mental
status changes that had begun approximately
36 h earlier.

On examination his vital signs showed:

blood pressure of 98/65 mmHg

heart rate of 70 beats/min (paced)
respiratory rate of 32 breaths/min
temperature of 36.7C.

The patient had rhonchi at the right lung base,

anteriorly and posteriorly, with no dullness to
percussion. His white blood cell count (WBCC) was
11 800 cells/mL, and his renal function showed a
blood
urea nitrogen (BUN) level of 28 mg/dL and
creatinine
level of 1.6 mg/dL. His admission chest X-ray is
shown

The patient was begun on intravenous antibiotics,

including ceftriaxone and levofloxacin, supplemental
oxygen, and aggressive fluid resuscitation. Despite
these interventions, his condition deteriorated
requiring increased oxygen support, his WBCC rose to
23 000 cells/mL, and his BUN and creatinine levels
increased to 42 mg/dL and 2.6 mg/dL, respectively.

All the patients cultures remained negative, and

he completed a 14-day course of intravenous
antibiotics. The patient eventually recovered and
was discharged home following a lengthy stay of
31 days.

As illustrated in this example, older persons often do

not present with the classical signs and symptoms of
systemic inflammatory response. Despite sepsisinduced organ dysfunction, this patient initially had
only one of the classically defined systemic
inflammatory response syndrome criteria
tachypnea. He had no fever, and had not mounted a
tachycardic response, probably because of his preexisting
cardiac
conduction
disease.

He also demonstrated a delayed rise in his WBCC.

Clinicians might be misled by such a presentation,
causing a delay in disease recognition and perhaps
jeopardizing the timely administration of appropriate
therapies and, therefore, the patients ultimate
outcome.

In addition, clinicians may be less

inclined
to
treat
older
persons
aggressively based solely on their age
a decision that may be inappropriate for
a substantial number of older patients
with a minimal burden of comorbidity
and a good premorbid state of health
and
quality
of
life.