Sepsis is a significant problem in the elderly population, accounting for 60% of severe sepsis cases and being a leading cause of death in non-coronary intensive care units. While the elderly may present atypically and have an unusual SIRS response, timely management following protocols like Sepsis Six can yield good clinical outcomes. Key considerations include discussing escalation plans early due to potential deterioration, and considering likely infectious sources and appropriate antibiotic treatment.

1. Sepsis in the Elderly
Dafydd Loughran

2. Learning goals
• Identify and define sepsis
• Discussion on particular considerations in
elderly
• Sepsis management

3. 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

4. Definitions (American college of chest physicians and society of critical care medicine)
Systemic Inflammatory Response Syndrome
2 or more of:
Temperature <36 or >38
HR >90
RR >20, or PCO2 <4.3, or need for mechanical support
WBC <4 or >12
Systemic Inflammatory Response Syndrome
2 or more of:
Temperature <36 or >38
HR >90
RR >20, or PCO2 <4.3, or need for mechanical support
WBC <4 or >12
Severe Sepsis =
Sepsis + Evidence of organ dysfunction or hypoperfusion
e.g. confusion, Low urine output, high lactate
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
Septic Shock =
Severe sepsis + hypotension despite fluid resuscitation
Sepsis = SIRS + presumed or confirmed infectionSepsis = SIRS + presumed or confirmed infection

5. 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

6. Is sepsis in the elderly an important problem?

7. 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

8. 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?

9. 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.

10. Sepsis Management
Sepsis 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. Lactate
2. 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

11. Use your antibiotic guidelines!

12. 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