From the Guidelines
Febrile hypotension is primarily caused by severe infections leading to sepsis, where pathogens trigger an overwhelming systemic inflammatory response. The most common causes include bacterial infections such as pneumonia, urinary tract infections, intra-abdominal infections, and skin/soft tissue infections. Gram-negative bacteria like E. coli, Klebsiella, and Pseudomonas are frequent culprits, though gram-positive organisms like Staphylococcus and Streptococcus can also cause this condition 1. Viral infections (particularly in immunocompromised patients), fungal infections, and parasitic diseases may lead to febrile hypotension in certain populations.
The pathophysiology involves vasodilation from inflammatory mediators, increased vascular permeability causing fluid shifts, myocardial depression, and endothelial damage. This creates a state of distributive shock where blood pressure drops despite fever. Management requires prompt identification of the source, early administration of broad-spectrum antibiotics, fluid resuscitation, and vasopressors like norepinephrine if fluids don't restore blood pressure.
Some key points to consider in the management of febrile hypotension include:
- Prompt identification of the source of infection
- Early administration of broad-spectrum antibiotics, such as piperacillin-tazobactam or meropenem
- Fluid resuscitation, typically with crystalloids at 30ml/kg within the first 3 hours
- Use of vasopressors, such as norepinephrine, if fluids do not restore blood pressure
- Source control through drainage or debridement, depending on the infection site 1.
It's worth noting that the management of febrile hypotension may vary depending on the underlying cause and the patient's individual circumstances. However, the principles of prompt identification and treatment of the underlying infection, fluid resuscitation, and use of vasopressors as needed remain key components of management.
From the Research
Causes of Febrile Hypotension
The causes of febrile hypotension can be complex and multifaceted. Some possible causes include:
- Septic shock, which is a common condition associated with hypotension and organ dysfunction 2
- Adrenal insufficiency, which can occur in patients with septic shock and is associated with higher rates of refractory hypotension and mortality 3
- Peripheral glucocorticoid resistance, which can occur in patients with septic shock and can be assessed at bedside using skin tests 3
- Orthostatic hypotension, which can occur in children with acute febrile illness and is associated with symptoms such as lightheadedness, dizziness, fatigue, and weakness 4
- Vasopressor-resistant septic shock, which can occur in patients with septic shock and is associated with higher mortality rates 5, 6
Underlying Mechanisms
The underlying mechanisms of febrile hypotension can involve:
- Cytokine release, which produces a systemic inflammatory state 5
- Vasopressor resistance, which can occur in patients with septic shock and is associated with higher mortality rates 5, 6
- Adrenal insufficiency, which can occur in patients with septic shock and is associated with higher rates of refractory hypotension and mortality 3
- Peripheral glucocorticoid resistance, which can occur in patients with septic shock and can be assessed at bedside using skin tests 3
Clinical Implications
The clinical implications of febrile hypotension can include:
- Increased risk of mortality, particularly in patients with septic shock 2, 5, 6
- Increased risk of organ dysfunction, particularly in patients with septic shock 2
- Need for prompt treatment, including fluid resuscitation and vasopressor therapy 2, 5, 6
- Need for careful monitoring, including blood pressure and organ function 2, 5, 6