Severe Sepsis Case File
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Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J.
Rosh, MD, MS
Case 6
A 73-year-old woman is brought to the emergency department (ED) from an assisted-living facility. The patient
has a history of dementia, hypertension, and type II diabetes mellitus. By report, she has had chills and a
productive cough for several days. In the past 24 hours she has become weaker and does not want to get out of
bed. The physical examination reveals a thin, elderly woman who is somnolent but arousable. Her rectal
temperature is 36.0°C (96.8°F), pulse rate is 118 beats per minute, blood pressure is 84/50 mm Hg, and
respiratory rate is 22 breaths per minute. Her mucous membranes are dry. Her heart is tachycardic but regular.
She has crackles at her right lung base with a scant wheeze. Her abdomen is soft and nontender. The extremities
feel cool and her pulses are rapid and thready. The patient is moving all extremities, without focal deficits.
⯈ What is the most likely diagnosis?
ANSWER TO CASE 6:
Severe Sepsis
Summary: A 73-year-old woman presents from an assisted-living facility with cough, lethargy, and hypotension
of unknown etiology.
Most likely diagnosis: Severe sepsis due to healthcare-associated pneumonia
ANALYSIS
Objectives
1. Learn to recognize the clinical presentations of systemic inflammatory response syndrome
(SIRS)/sepsis and the atypical presentations in children and the elderly.
2. Learn the pathophysiology, systemic effects, and management of sepsis and its common
complications.
3. Become familiar with early goal-directed therapy in the treatment of sepsis and septic shock.
Considerations
This woman appears to be suffering from severe sepsis, a clinical entity on the continuum from systemic
inflammatory response syndrome to septic shock with multiorgan system dysfunction (see below for
definitions). In her case, the etiology is likely pneumonia, an extremely common cause of sepsis in elderly
patients. Sepsis caused by a urinary tract infection (ie, urosepsis) is another important cause of sepsis in this
population.
There are over 750,000 cases of sepsis in the United States each year. Overall mortality is 30% and,
while the mortality rate has been decreasing, the rise in number of cases has led to an increase in
the total number of deaths caused by sepsis: the most recent US figures attribute >215,000 deaths
annually to sepsis. As this woman falls into the classification of septic shock, her risk of death may
be closer to 70%, even with treatment.
The current standard of care for treating sepsis uses an algorithm known as early goal-directed therapy (EGDT),
which has been shown to dramatically improve hemodynamic outcomes and mortality (see below).
Approach To:
Severe Sepsis
DEFINITIONS
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS): At least two of the
following:
Temperature >38°C or <36°C
Heart rate >90 beats per minute
Tachypnea or hyperventilation (respiratory rate >20 breaths per minute or Paco 2 <32 mm Hg)
White blood cell count >12,000 cells/mL or <4000 cells/mL, or >10% bands
SEPSIS: SIRS with an infectious source.
SEVERE SEPSIS: Sepsis in conjunction with at least one sign of organ failure or hypoperfusion,
such as lactic acidosis (lactate ≥4 mmol/L), oliguria (urine output ≤0.5 mL/kg for 1 hour), abrupt
change in mental status, mottled skin or delayed capillary refill, thrombocytopenia (platelets ≤
100,000 cells/mL) or disseminated intravascular coagulation, or acute lung injury/acute respiratory
distress syndrome.
SEPTIC SHOCK: Severe sepsis with hypotension (or requirement of vasoactive agents, eg,
dopamine or norepinephrine) despite adequate fluid resuscitation in the form of a 20- to 40-cc/kg
bolus.
MULTIORGAN DYSFUNCTION SYNDROME (MODS): MODS is the far end of the
spectrum that begins with SIRS. It is defined as dysfunction of two or more organ systems such that
homeostasis cannot be maintained without intervention.
