Systemic Inflammatory Response Syndrome Workup

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

Approach Considerations

Laboratory tests to consider include the following:

  • Blood cultures
  • Urinalysis and culture
  • Cardiac enzymes
  • Amylase
  • Lipase spinal fluid
  • Liver profiles

In order to completely evaluate for systemic inflammatory response syndrome (SIRS), a minimum of a complete blood count (CBC) with differential to evaluate for leukocytosis or leukopenia is required. Routine screenings often also include a basic metabolic profile. Other laboratory tests should be individualized based on patient history and physical examination findings.

Interleukin-6

Patients who meet SIRS criteria and have increased IL-6 levels (>300 pg/mL) have been shown to be at increased risk for complications such as pneumonia, multiple organ dysfunction syndrome (MODS), and death.[12]

Lactate

Blood lactate assessments are often performed in critically ill patients. These are felt to be indicators of anaerobic metabolism associated with tissue dysoxia. levels are commonly elevated from increased peripheral intraorgan production, reduced hepatic uptake, and reduced renal elimination. Based on numerous studies, lactate levels correlate strongly with mortality.

Imaging studies

No diagnostic imaging studies exist for SIRS. The selection of imaging studies depends on the etiology that required ICU and hospital admission.

Special concerns

Patients at the extremes of age, patients with immunosuppression, and patients with diabetes may present with sepsis or other complications of infection without meeting SIRS criteria.

Pregnant patients require intensive evaluation because of the presence of 2 patients, as well as the propensity of uncontrolled inflammation to lead to preterm labor.

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Procalcitonin

A significant amount of research has evaluated the use of acute-phase reactants to help differentiate infectious from noninfectious causes of systemic inflammatory response syndrome (SIRS).[13]

In an observational, prospective study in a pediatric ICU, Arkader et al showed that procalcitonin (PCT) was able to differentiate between infectious and noninfectious SIRS, while C-reactive protein (CRP) was not.[14]

Selberg et al reviewed procalcitonin (PCT) and C-reactive protein (CRP), in addition to looking at IL-6 and the protein complement C3a, and showed that PCT, IL-6, and C3a were more reliable in distinguishing infectious from noninfectious causes.[15]

A study by Balci et al confirmed that PCT is a better indicator of early septic complications than CRP is in complex populations, such as patients with multiple trauma.[16]

Caution must be used in interpreting PCT results in elderly patients. Lai et al demonstrated that PCT is useful in predicting bacteremia in elderly patients but was not an independent marker for local infections.[17]

PCT is becoming increasingly available to physicians as a point-of-care test. Currently, availability of this assay will vary by medical center.

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Leptin

Leptin, a hormone generated by adipocytes that acts centrally on the hypothalamus to regulate body weight and energy expenditure, is an emerging marker that correlates well with serum IL-6 and TNF-alpha levels. Using serum leptin levels with a cutoff of 38µg/L, researchers have been able to differentiate sepsis from noninfectious SIRS with a sensitivity of 91.2% and a specificity of 85%. This test is not yet readily available for clinical practice in the United States.[18, 19]

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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

References

  1. [Guideline] Bone RC, Balk RA, Cerra FB. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101:1644-1655. [Medline].

  2. Fung YL, Fraser JF, Wood P, Minchinton RM, Silliman CC. The systemic inflammatory response syndrome induces functional changes and relative hyporesponsiveness in neutrophils. J Crit Care. Dec 2008;23(4):542-9. [Medline].

  3. Dremsizov T, Gilles C, Kellum JA. Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course?. Chest. 2006;129:965-978.

  4. Thoeni RF. The revised atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology. Mar 2012;262(3):751-64. [Medline].

  5. Rangel-Fausto MS, Pittet D, Costigan M. The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. JAMA. 1995;273:117-123. [Medline].

  6. Pittet D, Rangel-Fausto MS, Li N. Systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock: incidence, morbidities and outcomes in surgical ICU patients. Int Care Med. 1995;21:302-309.

  7. Heffner AC, Horton JM, Marchick MR, Jones AE. Etiology of illness in patients with severe sepsis admitted to the hospital from the emergency department. Clin Infect Dis. Mar 15 2010;50(6):814-20. [Medline].

  8. Comstedt P, Storgaard M, Lassen AT. The Systemic Inflammatory Response Syndrome (SIRS) in acutely hospitalised medical patients: a cohort study. Scand J Trauma Resusc Emerg Med. Dec 27 2009;17(1):67. [Medline]. [Full Text].

  9. Angus DC, Linde-Zwirble WT, Lidicker J. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303-1310. [Medline].

  10. Shapiro N, Howell MD, Bates DW. The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection. Ann Emerg Med. 2006;48:583-590.

  11. Sinning JM, Scheer AC, Adenauer V, Ghanem A, Hammerstingl C, Schueler R, et al. Systemic inflammatory response syndrome predicts increased mortality in patients after transcatheter aortic valve implantation. Eur Heart J. January 2012;pending:1-10. [Medline]. [Full Text].

  12. Lai CC, Chen SY, Wang CY, Wang JY, Su CP, Liao CH, et al. Diagnostic value of procalcitonin for bacterial infection in elderly patients in the emergency department. J Am Geriatr Soc. Mar 2010;58(3):518-22. [Medline].

  13. Hoeboer SH, Alberts E, van den Hul I, Tacx AN, Debets-Ossenkopp YJ, Groeneveld AB. Old and new biomarkers for predicting high and low risk microbial infection in critically ill patients with new onset fever: A case for procalcitonin. J Infect. Jan 8 2012;[Medline].

  14. Arkader R, Troster EJ, Lopes MR. Procalcitonin does discriminate between sepsis and systemic inflammatory response syndrome. Arch Dis Child. 2006;91:117-120.

  15. Selberg O, Hecker H, Martin M. Discrimination of sepsis and systemic inflammatory response syndrome by determination of circulating plasma concentration of procalcitonin, protein complement 3a and interleukin-6. Crit Care Med. 2000;28:2793-2798.

  16. Balci C, Sivaci R, Akbulut G, Karabekir HS. Procalcitonin levels as an early marker in patients with multiple trauma under intensive care. J Int Med Res. Nov-Dec 2009;37(6):1709-17. [Medline].

  17. Giannoudis PV, Harwood PJ, Loughenbury P, Van Griensven M, Krettek C, Pape HC. Correlation between IL-6 levels and the systemic inflammatory response score: can an IL-6 cutoff predict a SIRS state?. J Trauma. Sep 2008;65(3):646-52. [Medline].

  18. Bracho-Riquelme RL, Reyes-Romero MA. Leptin in sepsis: a well-suited biomarker in critically ill patients?. Crit Care. 2010;14(2):138. [Medline].

  19. Yousef AA, Amr YM, Suliman GA. The diagnostic value of serum leptin monitoring and its correlation with tumor necrosis factor-alpha in critically ill patients: a prospective observational study. Crit Care. 2010;14(2):R33. [Medline].

  20. [Guideline] Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med. Jan 2008;34(1):17-60. [Medline].

  21. Annane D, Bellissant E, Bollaert PE, Briegel J, Confalonieri M, De Gaudio R, et al. Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review. JAMA. Jun 10 2009;301(22):2362-75. [Medline].

  22. Jeschke MG, Klein D, Herndon DN. Insulin therapy improves systemic inflammatory reaction to severe trauma. Ann Surg. 2004;239:553-560.

  23. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004;79:992-1000. [Medline].

  24. Van den Berghe G, Wilmer A, Hermans G. Intensive insulin therapy in the medical ICU. N Eng J Med. 2006;354:449-61. [Medline].

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