A 32-year-old man was admitted to the neurologic intensive care unit (ICU) after presenting to the hospital with complaints of difficulty walking and numbness in the lower extremities. Initial workup supported a diagnosis of Guillain-Barré syndrome. The patient was started on treatment with intravenous immunoglobulin (IVIG) and on day 2 of his ICU stay was intubated and placed on mechanical ventilation because of worsening vital capacity measurements. The patient completed a 5-day course of IVIG treatments. One week after admission the patient remained intubated on mechanical ventilation.
On day 7 of the ICU admission the patient developed a new fever with tachycardia, and increased oxygen requirements on the ventilator. Vital signs were temperature 38.9°C (102.1°F), heart rate 120 bpm, respiratory rate 22 breaths/min, and blood pressure 100/65 mm Hg. Ventilator settings at the time included the following: assist-control mode at a rate of 14 with a set tidal volume of 450 mL, and the fraction of inspired oxygen (FiO2) increased to 60% from 30% to maintain an arterial oxygen saturation (SaO2) greater than or equal to 92%. On examination, the patient has an endotracheal tube and is on mechanical ventilation. Neurologic assessment is as follows: the patient is lethargic but arousable and able to follow simple commands. Strength is decreased in the upper extremities (2/5 bilaterally) and lower extremities (2/5 right, 3/5 left). Cardiac examination shows tachycardia with a regular rate and no gallops, rubs, or murmurs. Lung auscultation reveals coarse breath sounds bilaterally. The abdominal examination is unremarkable. The patient has a left subclavian triple-lumen catheter with mild erythema around the insertion site, which is nontender on palpation, and a urinary Foley catheter. Laboratory data obtained that day were significant for a white blood cell (WBC) count of 17,000/mm3 with 80% neutrophils, a platelet count of 120,000/mm3, a creatinine level of 2.1 mg/dL (increased from 1.1 mg/dL), and an international normalized ratio (INR) of 1.7. A chest radiograph shows a possible infiltrate in the right lower lobe and that the endotracheal tube and central line are in good position.
Does this patient have sepsis?
Sepsis is one of the most important causes of morbidity and mortality in patients admitted to the intensive care unit.1, 2 Early recognition of sepsis has important therapeutic implications, as there are multiple time-sensitive interventions that ultimately have a significant impact on patient outcomes. However, finding a clinically "fool-proof" definition of sepsis has been a challenge, most likely because of the platitude of signs and symptoms associated with the sepsis syndrome. In order to resolve this issue, a consensus conference was convened to create standardized definitions and formulate a blueprint to guide research on sepsis.3 The term systemic inflammatory response syndrome (SIRS) was introduced. SIRS can occur in response to a variety of severe clinical insults and is defined by the presence of two or more of the ...