A 63-year-old man with a 40-pack per year smoking history undergoes a low anterior resection for rectal cancer and on postoperative day 5 develops a fever, new infiltrate on chest x-ray, and leukocytosis. He is transferred to the ICU for treatment of his pneumonia because of clinical deterioration. Which of the following is a sign of early sepsis?

It is impoant to identify and treat occult or early sepsis before it progresses to septic shock and the associated complications of multiple organ failure. An immunocompromised host may not manifest some of the more typical signs and symptoms of infection, such as elevated temperature and white cell count; this forces the clinician to focus on more subtle signs and symptoms. Early sepsis is a physiologically hyperdynamic, hypermetabolic state representing a surge of catecholamines, coisol, and other stress-related hormones. Changing mental status, tachypnea that leads to respiratory alkalosis, and flushed skin are often the earliest manifestations of sepsis. Intermittent hypotension requiring increased fluid resuscitation to maintain adequate urine output is characteristic of occult sepsis. Hyperglycemia and insulin resistance during sepsis are typical in diabetic as well as nondiabetic patients. This relates to the gluconeogenic state of the stress response. The cardiovascular response to early sepsis is characterized by an increased cardiac output, decreased systemic vascular resistance, and decreased peripheral utilization of oxygen, which yields a decreased aeriovenous oxygen difference.