PowerPoint Presentation

SEPTIC SHOCKManagement of Elderly Patient at Risk for ShockThe 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.

Shocka condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular function.3Shock can be classified by etiology and may be described as

Hypovolemic shockCardiogenic shockCirculatory or Distributive shock

SEPTIC SHOCKSeptic shock is the most common type of circulatory shock

A medical condition as a result of severe infection and sepsisSevere 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 FACTORSImmunosuppressionExtremes of age (65 yr)MalnourishmentChronic illnessInvasive procedures

CAUSESWhen 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.

10If 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.

The most common causative microorganisms of septic shockare the gram-negative bacteria; however, there is also an increasedincidence of gram-positive bacterial infections. Currently, grampositive bacteria are responsible for 50% of bacteremic eventsOther infectious agents such asviruses and funguses also can cause septic shock.

11

When a microorganism invades body tissues, the patient exhibits an immune response. This immune response provokes theactivation of biochemical mediators associated with an inflammatory response and produces a variety of effects leading toshock. Increased capillary permeability, which leads to fluid seeping from the capillaries, and vasodilation are two such effects thatinterrupt the ability of the body to provide adequate perfusion,oxygen, and nutrients to the tissues and cells.

12CLINICAL MANIFESTATIONProgressive Phase

High Cardiac Output with systemic vasodilationNormal limits of Blood PressureIncrease in heart rateFlushed skinBounding pulsesElevated Respiratory Rate

Normal or decrease in urine outputNauseaVomitingDiarrheaDecreased Bowel SoundsSubtle changes in mental statusConfusion or agitation

Septic shock typically occurs in two phases. The first phase, referred to as the hyperdynamic, progressive phase, is characterized by a high cardiac output with systemic vasodilation. The blood pressure may remain within normal limits. The heart rate , flushed skin and bounding pulses.The respiratory rate is elevated. Urinary output may remain at normal levels or decrease. Gastrointestinal status may be compromised as evidenced by nausea, vomiting, diarrhea, or decreased bowel sounds. The patient may exhibit subtle changes in mental status, such as confusion or agitation.

13CLINICAL MANIFESTATIONIrreversible PhaseLow Cardiac Output with systemic vasoconstrictionNormal limits of Blood PressureDrops in blood pressureCool and pale skinNormal or below normal temperatureHeart and respiratory rate remains rapidPatient no longer produces urineMODS progressing to failure develops

The later phase, referred to as the hypodynamic, irreversible phase, is characterized by low cardiac output with vasoconstriction,reflecting the bodys effort to compensate for the hypovolemia caused by the loss of intravascular volume through the capillaries.In this phase, the blood pressure drops and the skin is cool and pale. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. The patient no longer produces urine, and multiple organ dysfunction progressing to failure develops.

14CLINICAL MANIFESTATION IN OLDER PATIENTSClinical 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 PatientsPerformance statusA 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.

Aging is a process associated with numerous risk factorsthat contribute to the increasing incidence of, andmortality from, severe sepsis.

20Immune 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.

The natural barriers of innate immunity are broken, providing increased access for pathogens.

21NutritionOne 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 abuseTreatmentPrimarily Treatment consists of the following.Volume resuscitation Early antibiotic administration Early goal directed therapy Rapid source identification and control. Support of major organ dysfunction.

Current treatment of septic shock involves identifying and eliminating the cause of infection. Specimens of blood, sputum, urine,wound drainage, and invasive catheter tips are collected forculture using aseptic technique.

24Any 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.

Medical ManagementIf 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.

Research efforts show promise for improving the outcomes ofseptic shock. Although past treatments focused on destroying theinfectious organism, emphasis is now on altering the patients immune response to the organism. The cell walls of gram-negativebacteria contain a lipopolysaccharide, an endotoxin released during phagocytosisEndotoxin and/orgram-positive cell wall products interact with inflammatory biochemical mediators, initiating an intense inflammatory responseand systemic effects that lead to shock.

27Recombinant 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.30Nursing ManagementAll 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.

The nurse caring for any patient in any setting must keep in mind the risks of sepsis and the high mortality rate associated with septic shock.31Clinical 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 topercussion. His white blood cell count (WBCC) was11 800 cells/mL, and his renal function showed a bloodurea nitrogen (BUN) level of 28 mg/dL and creatininelevel 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 to23 000 cells/mL, and his BUN and creatinine levelsincreased 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 sepsis-induced 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 pre-existing 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 perhapsjeopardizing the timely administration of appropriatetherapies 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.