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so I Carl, I can't hear you with the other people. Come. Can you hear me now? I Okay, that's also excellent. Thank you. Me? So I'm I'm just going to have it. Give a brief talk today on geriatrics. Sepsis. So when I review of the talks, we want to have a chat. A bite him. What's abscesses and specific relation to the elderly population? We talk about risk factors that are specific to the answer. The population I then talk about diagnostic challenge is well, then provide a new review of the monitor mint of sepsis. A man conclude with the prognosis. Sorry. So by 2050 the elderly population will like number the young for the first time in history. On this, because of being a shift in the demographic transition with the decrease in birth Rios, a decrease in mortality andan increase in life expectancy. The incidents of sepsis in the elderly is increasing on dust. Part of my work for this past intention, I was surprised to see that up to two thirds off all sexes passions are out tonight on sepsis is the second largest cause of death and Alberni passions and noncardiac. I see you. So what is sepsis? So sepsis is really characterized by four things. It's life threatening. There's organ dysfunction. It's caused by a dysregulated host response to infection. So septic shock, so septic shock is a subset of sepsis on. That would really be the passion to retreat in the any Saturn who have sepsis but also have the BP on septic. Shock is defined as passions that require a visa pressors to meant to Monty and the main arterial pressure off Ritalin. 65 millimeters of mercury on a lot of better than two. So why are elderly patients that increased risk off salicis in the first place? Well, there are three million players. The first one would be a decline and functional status that occurs with aging. The second would be the presence of tumor abilities. Under third is a dysregulated immune system. Um, we'll talk about each of these in turn. So as as individuals age, there's a general decline and functional status on in the first of these you get I'm sarcopenia on sarcopenia is really whenever there is a permanent and irreversible loss of muscle tissue, then that you can also get with and maybe passions. Vicious atrophy. Eight. Where there's a loss of lean muscle mass elderly patients often present with lubie Um, I uncompromised nutritional Steelers. They also have a just cardio pulmonary reserve on this is particularly relevant when it comes to sepsis. Exact it shock for the patients, and the patient's heart isn't able to respond on appropriate way to flee or challenges. So the presence of cooler, better days not only increase the risk of sepsis in elderly patients at the Coumadin, Iti's and salves mean that is often more difficult to treat this abscess in these passions. So and then any given day and and you will frequently come across elderly passions, we could have 23 or, indeed four who morbidities on finally, him. A dysregulated immune system means of us. A meld, really patient is more likely to get sepsis, and it's also last likely to respond well, so elderly patients and their immune system is really dumping. Dying on the academic term, for this is my immunosenescence. This is where elderly people have decreased immune functions. They're there for a increased risk of infection. They have a decreased ability to respond to infection unless is largely being attributed to decrease number and activity off both tea and be sounds, which your key an immune response to infections. Elderly patients are also noted to have to be in a crawling like Lubriderm. Proinflammatory steered really increased levels of TNF Alpha I'll six CRP and overall, this results in a blunted, under laid immune response, meaning overall up in an elderly passion. Their immune response is just regulated. So what are the diagnostic challenge is feast and with a septic patient in their means. So if you ask most people working in an E, and you would say what is the one feature of sepsis generated? It's a temperature for up to 47% of septic geriatric patients that a a Perec sick. They tend to present lee it with a rapid progression. Deceptive shock. A non specific signs of sepsis are more common on these include confusion, decreased appetite, all feet or falls. I'm in confidence. Another area that poses a challenge with geriatric patients is that they can often be more difficult to t and I've most expensive ins, and they may not want to sit still for imaging. This is often the key is whenever they're agitative confused or have delivery. So in the Albany passions and the two there are two million sources off sepsis. First would be respiratory. So in a young well person, you would think signs of respiratory infection would include cough sputum in temperature. But this isn't The key is an elderly patients, the data suggest. Stop the three commonest presentations off respiratory tract infections in the elderly. Patients would be falls weakness on an increased risk for surgery, so they do present slightly differently. The second column is sort of infection would be a urinary tract infection. And in a whale young person who presents with the UTI, we often hear them saying that they pee in with the past year. Um, we're going to the bathroom more often, and they may get up a flight to go to the bathroom. Ever an elderly patient to calmness presentations off urosepsis would be confusion under continents. So in terms of the management of sepsis, use the steps. Six. So off the sex is six oxygen fluids on the biotics liked it. Cultures and urine, I put so we'll take it from in turn, so oxygen, so oxygen is a drug harm can occur from too much. You want to, um, for target saturations of greater than 94% but that's a blast. The patient is a new one to have COPD under a routine ER, and then your target Saturations would be idiot to 92 and it's interesting. Whenever I read through the data about oxygen and sepsis, the dot adult appeared to suggest that evening, really, for target of 93%. And those passions is beneficial. They can suggest that, and they over 92 anybody can be associated with adverse effects. But that hasn't quite been translated into changing clinical practice yet, but it might be one that comes up with feature. So the next one then fluids appropriate fluids decrease mortality in sepsis. And this is particularly the key is and sepsis triple a contention. Really, it's importantly, increase pre loot on increased cardiac, I put, but just a zoo can be out. This convicted somewhat problematic in patients who have aged really a diastolic dysfunction. I ever. In the majority of allergy passions, you commend with sepsis in the loop BP, and you wouldn't be doing any harm with the 2 50 Bullis, and I would probably suggest bulldozing smaller might have cleared for responsiveness would be more helpful than giving too much fluid. So in terms of antibiotics, and you want to always consider your shore showed infection No again. With sepsis times off, the essence and broad spectrum cover can be ideal. Any D if you invite so you don't always. You may not be able to get a history from the patient, the urine that might be available and the patient may be confused. So a start dose of a broad spectrum antibiotic and would be best not kiss and then further down the line, you can tailor the antibiotic to the appropriate source, but you don't want to forget about allergies on where the past it came from. Originally such a community nursing home? Or was it a recent hospital admission? Yeah, and you also want to think of I ain't have antibiotics already been given in the community, and if so, where the effective or not and just I'm considered do dose adjustments based on age, we have a needle function, so locked it, then so black tea. It is independent message. See it in this mortality and sepsis, I ever a gamut. A bit of a caveat with elderly patients were 50% of allergy patients were septic shock. So if you remember back to my earlier and slide talk but sepsis and then septic shock receptive shot was with the passion is hypertensive, a non responsive to fluids on require fees, oppressors 20 and the BP. So these are pretty passions are very, um, well, and but 50% of those passions around really have a lot of lasting 3.9. It's important just to be aware that, you know, uh, analogy on elected that isn't that high could be falsely reassuring and elevated levels of locked. It can also be find if there's recent and be the agonist. Use. Such a so beautiful are becoming seizures, liver future or a skin that got, and I think it's very useful to recognize that laxity. It can be useful in March rings, faults and sepsis, but I wasn't aware off, and it wasn't where, just by the extent which it can measure response. So if you find that we repeat, your VBG underactive is declining, that's a good sign. But they've quantifying that a decrease in locked out of 10% corresponds to a decrease of mortality of about 1%. So culture so cultures could be difficult, particularly the passion this confused or agitated. And but they're very important and they can guide on the breo sex therapy, and they again, it's important that the aseptic non touch technique is used. And but recent Arken data would suggest it. Only 45% of patient's attending you did you have cultures taken within one hour so fluid and sorry you're like, put them so powerful monitoring or fluid, and put my put. It's very important. It is indicative of the organ profusion. And it doesn't mean that you have to insert a catheter and sat in itself. Can increase infection risk. And just documenting on communicating that nursing colleagues that would like the patients ends. Lights to be documented would be very important, and it's important also to monitor progress. So what's the problem exists for another patient sepsis. Well, 50% mortality so and 50% off already patients success will die, and there's often a longer stay in the hospital with increased medical input. They often feel to regain and functional. I comes on discharge. They're likely not be as good as they wear before they had sepsis. When they're discharged, they also have a new impairments present on. Interestingly, off those discharged from hospital, only 45% actually go directly whole, the rast going to stop growing bads care homes or residential ones. So one of the tags with messages. So there's an increased incidence of riveted eight on mortality from sepsis in the elderly. The atypical is typical. Have a lower threshold of a higher index of suspicion with fired, and sex is in the our passions. You want to treat with sepsis six on have a holistic approach regarding produces seasons of care on end of life less You can see they're all the passions and giving us the thumbs up for all the hard work sepsis and calls my eating like you for listening. And I welcome your questions. Thanks so much. So when I spoke with questions, that problem the chart, I didn't ask the question off. Um, was no, you're both the ongoing key. I project with steps us. And if you had to pick one of the of the sex s or targets that you think we could do better on which would it be? And why? What do you think the biggest priority is? And what do you think? The conflict? Mm. Well, I think Doctor would appear to suggest that the thing we're not so good after and the thing that kills is dying every month would be you're in. I put so monitoring here, and I put I think that the reason why that house and it was good as we would hope it's because people wrongly assume that that means that a catheter has to be pleased in order for urine to be monitored. But And as I mentioned, it's really a bite just communicating with your nursing staff and documenting what you want in put a night put because, really, if you think about your sepsis six. If one of them is Lou, it pulls your overall achievement, re it, going to that level. And so by simply monitoring your in, I put on doing that well in cause way, for example, we could increase our achievement of the steps. Six within one are by 30%. Just that one thing that's simply done because that's really a documentation of communication thing, as opposed to something that you're doing to your patient or a blood sample or something that requires even more times is probably a simple step. I think we could probably do that better. I was really hanging. That's great. Thank you. And I think it was a few folks and thanks. They're really appreciate your talks, so I don't think any other questions coming up. And so thanks so much, girl. That was from you on. Let me stop.