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Sepsis and the Frail ElderPATHOPHYSIOLOGY, TREATMENT, NURSING CARE AND LONG-TERM EFFECTS

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Learning Objectives:

Define sepsis as it relates to the elderly population

Achieve an understanding of the etiology of sepsis in the elderly

Discuss treatment options

Be able to implement evidence-based nursing care of the elderly patient

who presents with sepsis

Gain insight into the long-term effects of surviving sepsis:

Quality of life (QOL) implications

What can we do to improve outcomes?

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What is Sepsis?

Sepsis is defined as a life-threatening organ dysfunction caused by adysregulated host response to infection and/or super antigen [leading to]profound circulatory, cellular and metabolic abnormalities [which]unchecked cause multisystem organ failure and death

Chamberlain, (2016); Girard, Opal & Ely, (2005).

Sepsis in the elderly population is associated with a higher morbidity andmortality rate peaking at 38.4 % in patients aged >/= 85 years old. Elderlypatients constitute 2/3 of the patients admitted to hospital with sepsis andpatients aged >/= 65 years old account for 40-50% of all bacteremiacases with an overall fatality rate of 40-60%

Destarac & Ely, (2002).

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Etiology of Sepsis in the ElderlyPopulation

Most commonly bacterial

Related to respiratory, urinary, abdominal and skin infections

Elders are more susceptible related to chronic conditions, comorbidities,decreased immune response, malnutrition, dementia, medicationregimens, decreased mobility and functional status, residence in long-term care facilities and repeated hospitalizations, repeated exposure toantibiotic therapy, prosthetic devices, and prior colonization by gram-negative multi-drug resistant organisms

Destarac & Ely, (2002); Girard et al., (2005); Lange, (2012); Nasa et al., (2012).

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Bacterial causes of Sepsis

Gram-negative Bacteria

Escheria coli (urinary/peritoneal)

Klebsiella pneumoniae(urinary/respiratory)

Enterobactor (urinary)

Pseudomonas aeruginosa(pneumonia/skin)

Proteus (urinary)

Bacteroides fragilis (peritoneal)

Chamberlain, (2016).

Gram-positive Bacteria

Streptococcus pneumonia(pneumonia/meningitis)

Streptococcus pyogenes (ski

Staphylococcus aureus/ Metresistant staphylococcus auretissue/pneumonia/urinary)

Enterococcus (urinary)

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Treatment of Sepsis and Septic Shockin the Elderly

Timely diagnosis is KEY. The threshold for immediate treatment should belowered in this susceptible and vulnerable population

Elders often present with infection atypically: hypothermia, CONFUSION,delirium, falls, weakness, anorexia and urinary incontinence

Most likely sources of infection are PNEUMONIA and URINARY INFECTIONS

Obtain pan cultures, lactic acid level, CBCD, BMP, chest xray, start empiricbroad spectrum antibiotic coverage

Begin supportive care: cardiac and respiratory monitoring, fluid resuscitation,vasoactive drug therapy, electrolyte repletion, pain control, supplementaloxygen and/or intubation, invasive line placement and foley catheter as wellas renal replacement therapy may be necessary

Chamberlain, (2016); Destarac & Ely, (2002); Girard et al., (2005); Nasa et al., (2012).

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Evidence-based Nursing Care of theSeptic Elder

Ideally, the goals of providing nursing care to the critically-ill older adultinclude restoring physiologic stability, preventing complications, maintainingcomfort and safety, and preserving or preventing decline in pre-illnessfunctional ability and quality of life

The development of a patient-centered, multidisciplinary plan of care whichtakes each body system and the implications of pre-existing conditions intoconsideration is key in achieving best outcomes in this fragile population

The nurse must be familiar with age-related changes and their implications tothe patient: coordination of care with pharmacists, respiratory, physical andoccupational therapists, pharmacists, case management, social workers andthe patients family members and care-givers assure that best-practice careinterventions are implemented at each stage of sickness and recovery.

Botlz, et al., (2012)

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Evidence-based Nursing Care of theSeptic Elder, Body Systems

NeurologicalAssess pain and sedation needs

Review medications and side effects

Monitor for delirium/change in mental status

Provide for assistive-communication devices

Advocate for family presence

Encourage early mobilization and line/tube removal

CardiacMonitor electrocardiogram for changes

Check cardiac enzymes every 8 hours x2to assess for cardiac damage

Provide vasoactive support as needed

Assess central venous pressure to ensurefor adequate hydration/avoid fluidoverload

RespiratoryPlace continuous pulse oximetr

Check arterial blood gas to assacidosis/oxygenation requirem

Elevate HOB to 30 degrees to daspiration

Utilize ICU pulmonary bed settin

If ventilated, initiate VAP preveadvocate for spontaneous awatrials.

Mobilize ASAP!

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Evidence-based Nursing Care of theSeptic Elder, Body Systems, cont.

GastrointestinalAssess nutritional and electrolyte status

Initiate supplemental feedings and electrolytereplacement if indicated

Initiate stress ulcer prophylaxis

Implement bowel regimen

Monitor for gastrointestinal bleeding

Achieve glycemic control

Initiate aspiration precautions

GenitourinaryAssess urinary output every hour

Assess renal function andcreatinine clearance both atbaseline and as effected by illnessand medications in hospital

Ensure patency and cleanliness ofurinary catheters

Discontinue foley catheter ASAP

SkinPerform comprehensivevery 2-4 hours assessmpreexisting and develo

Implement continuousmodules, repositioning

Monitor invasive lines/Iinfiltration/infection/ski

Encourage early mobi

Use Braden Scale

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Evidence-based Nursing Care of theSeptic Elder, Body Systems, cont.

Immune:

Assess efficacy of antibiotic therapy

Monitor for anemia, transfuse if patients he

actively bleeing or shows cardiac demand

Monitor and support thermoregulation

Maintain infection control and preventative

Re-panculture for temperatures >101.5 or d

Consider infectious disease MD consult in cteam management

Boltz et al., (2012); Lange, (2012).

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Long-Term Effects ofSepsis in the ElderlyPrior focus has been on decreasing short-termmortality during hospitalizationlittle attention has

been given to the post-ICU course and the

chronic issues that confront patients in the monthsto years following an ICU stay

Volk & Grassi, (2009).

Quality of Life (QOL) issues abound followingsurvival of a sepsis-related admission, most arerelated to cognitive decline and substantial

worsening in trajectoryin those patients with

better baseline functioning

Iwashyana et al., (2010).

The odds of acquiring moderate to severe

cognitive impairment were 3.3 times higherfollowing an episode of sepsis, with an additionalmean increase of 1.5 new functional limitationsper person among those with no or mildpreexisting functional limitations

Iwashyana et al., (2012).

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What can we DO to Help?

Sepsis-specificplans of care

Better sedation practices

Earlier cognitive/physical therapypractices

More aggressive vaccination practicesRecognition of atypical sepsispresentation in elderly patients

FOCUS ON LIMITING DEFICITSASSOCIATED WITH SEPSIS

Management ofChronic Disease

Outpatient care must improvemanagement of chronicconditions: Patient-centeredmodels of care which arecommunity-based

This will lead to lesshospitalizations, community andnosocomial-acquired infections

Improve baseline wellness andQOL

Involve palliative care practicesfor those with severe illness

End-of-LifeDiscussions

Initiate discussion of Qpreferences EARLY

Elderly patients are opdiscussions.. Often it is medical team who limof openness in discussrelated to end-of-life c

This is a 2020 Health Cit relates to palliative acare initiatives

Gerard et al., (2005); Iwas(2012); Volk & Grassi, (2009

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Sepsis 2016

Develop and Initiate bundle: hard order sets and associated protocols willimprove timely treatment and therefore improve outcomes!

Multidisciplinary approach: promotes compliance through a team approach

Education: Physician, Nurse and Pharmacy Leaders can enact change inpractice!

Eliminate barriers to change through unit-based champions- Mentoring iskey!

Change the culture throughout the organization to recognize sepsis as anemergency and mobilize resourcescreate an environment to allow forefficient care and eliminate delays in treatment

Health Research & Educational Trust, (2016).

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Sepsis 2016, continued

New criteria:

Temperature 38 degrees Celsius

Heart rate >90 beats per minute

Respiratory rate >20 per minute

PaC02 32mmHg

White blood cell count 12,000 and/or >10%bandemia

If Lactic Acid level is >4 this is now defined as severe sepsis

If persistent hypotension along with signs of end-organ damage this is nowseptic shock

Health Research & Educational Trust, (2016).

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Sepsis is diagnosed in over one million patientseach year in the United Statestreatment cost

resulted in an estimated $20.3 billion making itthe most expensive condition treated in 2011,with a mortality rate of 28 to 50%

HEALTH RESEARCH AND EDUCATIONAL TRUST, (2016).

An aggressive and multidisciplinary approach must be implemented uponpresentation and reevaluated daily in order to achieve best-care practice awell as the provision of patient-centered, evidence-based care; we canimprove on current practices in order to ensure for better future outcomes.

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In Conclusion..

Sepsis and Septic Shock are multifactorial in etiology, treatment optionsand long-term effects.

Quality of life both during and post-hospitalization needs to be broughtinto treatment discussions sooner rather than later in order to achievemore patient-centered outcomes.

As practitioners, it is up to us to recognize sepsis and to incorporatediscussions of patient-centered care into health care discussions withpatients and family.

THANK YOU COLLEAGUES FOR SHARING YOUR KNOWLEDGE, THOUGHTSAND YOURSELVES THESE LAST WEEKS, I HAVE LEARNED FROM YOU ALL.

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REFERENCES

Boltz, M., Capezuti, E., Fulmer.,T. & Zwicker, D. (2012). Evidence-based geriatric nursing

protocols for best practice. A. OMeara (Ed.). New York, NY: Springer Publishing

Company.

Chamberlain, N. R. (2016). Sepsis and septic shock. Retrieved from

https://www.atsu.edu/faculty/chamberlain/website/lectures/lecture/sepsis2007.htm

Destarac, L. A. & Ely, E. W. (2002). Sepsis in older patients: An emerging concern in critical

care. Advances in Sepsis 2 (1). Retrieved from

http://advancesinsepsis.com/pdfs/934.pdf

Girard, T. D., Opal, S. M. & Ely, E. W. (2005). Insights into severe sepsis in older patients:

From epidemiology to evidence-based management. Clinical Infectious Diseases 40 (5),

719-727. doi: 10.1086/427876

Health Research and Educational Trust. (2016). Severe sepsis and septic shock change

package:2016. Retrieved from

http://www.hret-hen.org/topics/sepsis/HRETHEN_ChangePackage_Sepsis.pdf

Iwashyana, T. J., Ely, E. W., Smith, D. M. & Langa, K. M. (2010). Long-term cognitive

impairment and functional disability among survivors of severe sepsis. Journal of

American Medicine 304 (16), 1787-1794. doi: 10.1001/jama.2010.1553.

https://www.atsu.edu/faculty/chamberlain/website/lectures/lecture/sepsis2007.htmhttp://advancesinsepsis.com/pdfs/934.pdfhttp://advancesinsepsis.com/pdfs/934.pdfhttps://www.atsu.edu/faculty/chamberlain/website/lectures/lecture/sepsis2007.htm

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References, continued

Lange, J. W. (2012). The nurses role in promoting optimal health of older adults: Thriving in

the wisdom years. Philadelphia, PA: F. A. Davis Company.

Martin, G. S., Mannino, D. M. & Moss, M. (2006). The effect of age on the development and

outcome of adult sepsis. American Journal of Critical Care Medicine 34 (1), 15-21.

Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16374151

Nasa, P., Juneja, D. & Singh, O. (2012). Severe sepsis and septic shock in the elderly: An

overview. World Journal of Critical Care Medicine 1 (1), 23-30.

doi: 10.5492/wjccm.v1.i1.23

Opal, S. M., Girard, T. D. & Ely, E. W. (2005). The immunopathogenesis of sepsis in elderly

patients. Clinical Infectious Diseases 41 (7), 504-512. Retrieved from

http://cid.oxfordjournals.org/content/41/Supplement_7/S504.full.pdf

Volk, B. & Grassi, F. (2009). Treatment of the post-ICU patient in an outpatient setting.

American Family Physician 79 (6), 459-464. Retrieved from

http://www.aafp.org/afp/2009/0315/p459.html

http://www.ncbi.nlm.nih.gov/pubmed/16374151http://cid.oxfordjournals.org/content/41/Supplement_7/S504.full.pdfhttp://www.aafp.org/afp/2009/0315/p459.htmlhttp://www.aafp.org/afp/2009/0315/p459.htmlhttp://cid.oxfordjournals.org/content/41/Supplement_7/S504.full.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/16374151