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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.
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Does this patient have sepsis?
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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 ...