Management of Hypothermia in Sepsis
Patients with hypothermia (temperature ≤36°C) and sepsis should be actively rewarmed to normothermia while simultaneously receiving aggressive sepsis management according to established protocols. 1, 2
Initial Assessment and Management
Fluid Resuscitation
- Administer at least 30 mL/kg of crystalloid fluids intravenously within the first 3 hours 2
- Continue fluid administration as long as hemodynamic parameters improve 2
- Use dynamic variables (pulse pressure variation, stroke volume variation) to guide further fluid administration 2
- Consider albumin for patients requiring substantial amounts of crystalloids 2
Hemodynamic Support
- Target a mean arterial pressure (MAP) of ≥65 mmHg 1, 2
- Use norepinephrine as the first-choice vasopressor if the patient remains hypotensive despite fluid resuscitation 1, 2
- Consider adding vasopressin (up to 0.03 U/min) to increase MAP or decrease norepinephrine dose 2
- Consider hydrocortisone (200 mg/day) in patients with persistent hypotensive shock 1, 2
Antimicrobial Therapy
- Obtain blood cultures before starting antibiotics (if no substantial delay) 2
- Administer broad-spectrum antibiotics within 1 hour of sepsis recognition 2
- Select antibiotics with high likelihood to be active against suspected pathogens 2
Specific Management of Hypothermia in Sepsis
Understanding Hypothermia in Sepsis
- Hypothermia (temperature ≤36°C) in sepsis is often transient and self-limiting 3
- Most hypothermic episodes resolve within a median of 6 hours without specific intervention 3
- However, hypothermia can worsen tissue perfusion and coagulation abnormalities 4
Rewarming Strategy
- Use passive external rewarming methods (warm blankets, increasing ambient temperature)
- Consider active external rewarming for temperatures <35.5°C
- Monitor core temperature continuously during rewarming
- Avoid aggressive rewarming which may cause vasodilation and worsen hypotension
Monitoring During Rewarming
- Closely monitor hemodynamic parameters as rewarming may cause vasodilation 2
- Assess for signs of improved tissue perfusion:
- Capillary refill time
- Skin mottling
- Warm and dry extremities
- Mental status
- Urine output >0.5 mL/kg/hour 2
Special Considerations
Coagulation Management
- Monitor coagulation parameters closely as hypothermia can worsen coagulopathy 4
- Mild hypothermia may actually improve functional coagulopathy in some septic patients 4
- Consider platelet transfusion for counts <100,000/μL if active bleeding is present 1
Respiratory Support
- Apply oxygen to achieve oxygen saturation >90% 2
- Place patients in semi-recumbent position (head of bed raised to 30-45°) 2
- Consider mechanical ventilation with lung-protective strategies if respiratory distress develops 1
Avoid Induced Hypothermia
- Despite some historical studies suggesting benefit 5, more recent evidence indicates that therapeutic hypothermia is associated with poor outcomes in sepsis 6
- A randomized controlled trial of induced hypothermia in bacterial meningitis was stopped prematurely due to excess mortality 1
Pitfalls and Caveats
Do not delay antimicrobial therapy while waiting for temperature normalization - administer antibiotics within 1 hour of sepsis recognition 2
Do not assume hypothermia indicates imminent death - research shows hypothermia in sepsis is often transient and self-limiting 3
Avoid excessive fluid administration in patients with signs of fluid overload (rales, hepatomegaly) 1
Do not induce hypothermia as a therapeutic strategy in sepsis despite some historical studies suggesting benefit 1, 6
Do not neglect source control - identify and control the source of infection as rapidly as possible 2