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2023/10/15 Management of Sepsis in the Elderly Patient
- Prof. Richard Phillip Dellinger
- Professor of Medicine and Distinguished Scholar, Senior Critical Care Faculty
- Cooper University Hospital, Camden NJ, USA
Biography：
Dr. R. Phillip Dellinger is Professor of Medicine and Distinguished Scholar at Cooper Medical School of Rowan University (CMSRU) and Senior Critical Care Faculty, Cooper University Health (CUH), Camden NJ USA. He is Adjunct Professor, Department of Pulmonary Medicine, the University of Texas MD Anderson Cancer Center, Houston Texas USA. Dr. Dellinger has authored over 300 journal articles and book chapters as well as edited over 30 books and journal issues in the fields of critical care medicine and lung disease. He was inducted as a Master Fellow in the College of Critical Care Medicine (SCCM) in 2012 and is a Past President of the SCCM. He was the 15th recipient of the SCCM Lifetime Achievement Award in 2015. He received the New Jersey Hospital Association Lifetime Achievement Award in 2021. He was the lead author of the 2004, 2008 and 2012 Surviving Sepsis Campaign (SSC) International Guidelines on the Management of Severe Sepsis and Septic Shock, senior author on the 2016 SSC guidelines and committee member and masthead author on the 2021 SSC guidelines.
Dr. R. Phillip Dellinger is Professor of Medicine and Distinguished Scholar at Cooper Medical School of Rowan University (CMSRU) and Senior Critical Care Faculty, Cooper University Health (CUH), Camden NJ USA. He is Adjunct Professor, Department of Pulmonary Medicine, the University of Texas MD Anderson Cancer Center, Houston Texas USA. Dr. Dellinger has authored over 300 journal articles and book chapters as well as edited over 30 books and journal issues in the fields of critical care medicine and lung disease. He was inducted as a Master Fellow in the College of Critical Care Medicine (SCCM) in 2012 and is a Past President of the SCCM. He was the 15th recipient of the SCCM Lifetime Achievement Award in 2015. He received the New Jersey Hospital Association Lifetime Achievement Award in 2021. He was the lead author of the 2004, 2008 and 2012 Surviving Sepsis Campaign (SSC) International Guidelines on the Management of Severe Sepsis and Septic Shock, senior author on the 2016 SSC guidelines and committee member and masthead author on the 2021 SSC guidelines.
Abstract：
Management of Sepsis in the Elderly Patient
Elderly patients are often defined as age ≥ 65 years old (yo). More than 60% of sepsis (infection induced organ dysfunction) is diagnosed in this patient group. Elderly patients have both an increased risk of developing infection and once infected are more likely to become septic. Once septic there is an increased chance of mortality. As to treatment considerations, despite similar pathophysiologic changes that have caused hypotension and high lactate, baseline comorbidities of compensated heart failure and chronic renal insufficiency are more likely. Therefore, the aggressiveness of fluid administration needs to be tempered based on these likelihoods and smaller fluid boluses delivered sequentially while monitoring oxygenation, but nevertheless targeting a similar overall total fluid delivery.
The ideal mean arterial pressure (MAP) target in septic shock is controversial. The Asfar et al. study enrolled all age adult patients with septic shock with randomization to a norepinephrine achieved MAP target of 65-70 mm Hg versus 80-85 mm Hg. (1) There was no difference in outcome. However, a subset analysis from a different smaller study found better outcomes in patients ≥70 yo with a lower as opposed to a higher MAP target and a subsequent randomized trial in patients ≥65 yo, although not showing statistical significance, had better survival with a 60-65 mm Hg target. (2,3) The Surviving Sepsis Campaign recommends a target of 65 mm Hg as opposed to higher targets for all septic shock patients, independent of age.(4) As to source control, one study that reported increased survival with early source control for community acquired sepsis did not demonstrate clinical outcome benefit in patients 55 years old and older. (5)
1. Asfar et al. NEJM (2014) 370:17
2. Lamontagne et al. Intensive Care Med (2016) 42:542
3. Lamontagne et al. JAMA (2020) 323:938
4. Surviving Sepsis Campaign Guidelines Critical Care Med (2021)49:e1063
5. Reitz et al. JAMA Surg (2022) 157:817
Management of Sepsis in the Elderly Patient
Elderly patients are often defined as age ≥ 65 years old (yo). More than 60% of sepsis (infection induced organ dysfunction) is diagnosed in this patient group. Elderly patients have both an increased risk of developing infection and once infected are more likely to become septic. Once septic there is an increased chance of mortality. As to treatment considerations, despite similar pathophysiologic changes that have caused hypotension and high lactate, baseline comorbidities of compensated heart failure and chronic renal insufficiency are more likely. Therefore, the aggressiveness of fluid administration needs to be tempered based on these likelihoods and smaller fluid boluses delivered sequentially while monitoring oxygenation, but nevertheless targeting a similar overall total fluid delivery.
The ideal mean arterial pressure (MAP) target in septic shock is controversial. The Asfar et al. study enrolled all age adult patients with septic shock with randomization to a norepinephrine achieved MAP target of 65-70 mm Hg versus 80-85 mm Hg. (1) There was no difference in outcome. However, a subset analysis from a different smaller study found better outcomes in patients ≥70 yo with a lower as opposed to a higher MAP target and a subsequent randomized trial in patients ≥65 yo, although not showing statistical significance, had better survival with a 60-65 mm Hg target. (2,3) The Surviving Sepsis Campaign recommends a target of 65 mm Hg as opposed to higher targets for all septic shock patients, independent of age.(4) As to source control, one study that reported increased survival with early source control for community acquired sepsis did not demonstrate clinical outcome benefit in patients 55 years old and older. (5)
1. Asfar et al. NEJM (2014) 370:17
2. Lamontagne et al. Intensive Care Med (2016) 42:542
3. Lamontagne et al. JAMA (2020) 323:938
4. Surviving Sepsis Campaign Guidelines Critical Care Med (2021)49:e1063
5. Reitz et al. JAMA Surg (2022) 157:817