Systemic Inflammatory Response Syndrome Clinical Presentation

  • Author: Steven D Burdette, MD, FIDSA; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Apr 11, 2012
 

History

Despite having a relatively common physiologic pathway, systemic inflammatory response syndrome (SIRS) has numerous triggers, and patients may present in various manners. The clinician's history should be focused around the chief symptom, with a pertinent review of systems being performed. Patients should be questioned regarding constitutional symptoms of fever, chills, and night sweats. This may help to differentiate infectious from noninfectious etiologies. The timing of symptom onset may also guide a differential diagnosis toward an infectious, traumatic, ischemic, or inflammatory etiology.

Pain, especially when it can be localized, may guide a physician in differential diagnosis and necessary evaluation. Although providing a differential for pain in the various body parts is beyond the scope of this article, a physician should carefully obtain information on the duration, location, radiation, quality, and exacerbating factors associated with the pain to help establish a thorough differential diagnosis.

In patients for whom a diagnosis cannot be made based on initial history, a complete review of systems is indicated to try an undercover potential diagnosis.

Patients' medications should be reviewed. Medication side effects or pharmacologic properties may either induce or mask SIRS (ie, beta blockers prevent tachycardia). Recent changes in medications should be addressed to rule out drug-drug interactions or a new side effect. Allergy information should be gathered and the specifics of the reaction should be obtained.

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Physical Examination

A focused physical examination based on a patient's symptoms is adequate in most situations. Under certain circumstances, if no obvious etiology is obtained during the history or laboratory evaluation, a complete physical examination may be indicated. Patients who cannot provide any history should also undergo a complete physical examination, including a rectal examination, to rule out an abscess or gastrointestinal bleeding.

Three of the 4 criteria for SIRS are based on the following vital signs:

  • Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
  • Heart rate of more than 90 beats per minute
  • Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32mm Hg
  • Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature [band] forms)

Careful review of initial vital signs is an integral component to making the diagnosis. Repeating the review of vital signs periodically during the initial evaluation period is necessary, as multiple factors (eg, stress, anxiety, exertion of walking to the examination room) may lead to a false diagnosis of SIRS.

Key points associated with physical examination are as follows:

  • Extreme of ages (both young and old) may not manifest as typical criteria for SIRS; therefore, clinical suspicion may be required to diagnosis a serious illness (either infectious or noninfectious)
  • Patients receiving a beta blocker or a calcium channel blocker are likely unable to elevate their heart rate and, therefore, tachycardia may not be present
  • Although blood pressure is not one of the 4 criteria for SIRS, it is still an important marker; if the blood pressure is low, the establishment of intravenous access and fluid resuscitation is of utmost importance; frank hypotension associated with SIRS is uncommon unless the patient is septic or severely dehydrated (hypotension may lead to the patient being admitted or transferred to a higher acuity unit)
  • Respiratory rate is the most sensitive marker of the severity of illness
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Contributor Information and Disclosures
Author

Steven D Burdette, MD, FIDSA  Associate Professor of Medicine, Program Director, Infectious Diseases Fellowship, Wright State University, Boonshoft School of Medicine; Infectious Disease Advisor to Transplant Program, Miami Valley Hospital; Medical Director of Infectious Diseases, Green Memorial Hospital

Steven D Burdette, MD, FIDSA is a member of the following medical societies: Alpha Omega Alpha, American Society for Microbiology, American Society of Transplantation, Infectious Diseases Society of America, and Transplantation Society

Disclosure: Cubist Honoraria Speaking and teaching; Genentech Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Optimer Honoraria Speaking and teaching

Coauthor(s)

Miguel A Parilo, MD, FACP  Associate Clinical Professor of Medicine, Department of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, The Bull Family Diabetes Center

Disclosure: Sanofi-Aventis Honoraria Speaking and teaching; Amylin Honoraria Speaking and teaching

Lewis J Kaplan, MD, FACS, FCCM, FCCP  Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine

Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, and Surgical Infection Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Klaus-Dieter Lessnau, MD, FCCP  Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Joseph F John Jr, MD, FACP, FIDSA, FSHEA  Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM  Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine

Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, European Society of Intensive Care Medicine, Shock Society, and Society of Critical Care Medicine

Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

Additional Contributors

Heatherlee Bailey, MD Assistant Program Director, Assistant Professor, Department of Emergency Medicine, Division of Critical Care, Medical College of Pennsylvania Hahnemann University

Heatherlee Bailey, MD is a member of the following medical societies: American Academy of Emergency Medicine, Association for Surgical Education, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Joseph F John Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Venn diagram showing overlap of infection, bacteremia, sepsis, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction.
 
 
 
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