What is the initial management for septic shock in geriatric patients with severe left ventricular (LV) dysfunction?

Management of Septic Shock in Geriatric Patients with Severe LV Dysfunction

In geriatric patients with severe left ventricular dysfunction and septic shock, initial management should include cautious fluid resuscitation with crystalloids, early initiation of norepinephrine as the first-line vasopressor, and addition of dobutamine for ongoing signs of hypoperfusion despite adequate fluid resuscitation and blood pressure control. 1, 2

Initial Resuscitation

• Begin with crystalloid fluid resuscitation, but consider a modified approach from the standard 30 mL/kg recommendation due to the patient's severe LV dysfunction 1
• Use smaller fluid boluses (e.g., 250-500 mL) with frequent reassessment of hemodynamic parameters to avoid fluid overload which can worsen cardiac function 1, 2
• Consider earlier initiation of vasopressors to maintain tissue perfusion while limiting excessive fluid administration 1
• Target a mean arterial pressure (MAP) of 65 mmHg as the initial goal 3
• Use dynamic measures of fluid responsiveness (such as pulse pressure variation or stroke volume variation) rather than static measures when available to guide additional fluid administration 3
• Monitor for signs of fluid overload including pulmonary crackles, increased jugular venous pressure, and worsening respiratory function 4

Vasopressor and Inotropic Support

• Initiate norepinephrine as the first-choice vasopressor if the patient remains hypotensive despite initial fluid resuscitation 3, 1
• Add dobutamine infusion when there is evidence of myocardial dysfunction (as in these patients with severe LV dysfunction) with elevated cardiac filling pressures and low cardiac output, or ongoing signs of hypoperfusion despite adequate fluid resuscitation and MAP 3
• Consider adding epinephrine as a second vasopressor if needed to maintain adequate blood pressure 3, 5
• Epinephrine dosing for septic shock should start at 0.05 mcg/kg/min and can be titrated up to 2 mcg/kg/min to achieve the desired MAP 5
• Avoid dopamine except in highly selected circumstances due to increased risk of arrhythmias, particularly in elderly patients 3

Antimicrobial Therapy and Source Control

• Administer broad-spectrum antimicrobials within the first hour of recognition of septic shock 3, 1
• Obtain appropriate cultures before starting antimicrobials if this does not significantly delay therapy 1
• Identify and address any potential source of infection requiring intervention as rapidly as possible, ideally within 12 hours of diagnosis 1
• Remove any intravascular access devices promptly if they are a possible source of infection 1

Ongoing Monitoring and Reassessment

• Continuously monitor vital signs including heart rate, blood pressure, respiratory rate, and oxygen saturation 4
• Assess for signs of adequate tissue perfusion including improved mental status, urine output, and peripheral perfusion 4
• Consider guiding resuscitation to normalize lactate levels as a marker of tissue hypoperfusion 3
• Monitor cardiac function with echocardiography to assess response to therapy and guide further management 6
• Consider early continuous renal replacement therapy (CRRT) in patients with severe LV dysfunction and hemodynamic instability, as it has been associated with improved survival outcomes 7

Special Considerations for Geriatric Patients with LV Dysfunction

• Be aware that LV diastolic dysfunction is highly prevalent in elderly patients and may be associated with increased mortality in septic shock 6
• Recognize that elderly patients with LV dysfunction are at higher risk for volume overload and pulmonary edema with aggressive fluid resuscitation 1
• Consider a more conservative fluid strategy with earlier vasopressor initiation to maintain adequate perfusion while minimizing the risk of fluid overload 1, 8
• Carefully monitor for adverse effects of vasopressors, including tachyarrhythmias, myocardial ischemia, and tissue hypoperfusion 3

Common Pitfalls and Caveats

• Avoid excessive fluid administration which can worsen cardiac function and lead to pulmonary edema in patients with severe LV dysfunction 1, 2
• Do not delay antimicrobial administration; if vascular access is difficult, consider intraosseous access or intramuscular administration of appropriate antibiotics 1
• Avoid relying solely on static measures like central venous pressure to guide fluid therapy, especially in patients with cardiac dysfunction 3, 2
• Be cautious with vasopressor dosing in elderly patients who may be more sensitive to their effects and at higher risk for adverse events 3
• Recognize that hydroxyethyl starch solutions should be avoided due to increased risk of acute kidney injury and mortality 3, 9