Should I warm up a hypothermic septic patient?

Management of Hypothermia in Septic Patients

Hypothermic septic patients should be actively rewarmed to a target temperature of at least 36°C to reduce mortality and improve outcomes. 1, 2

Understanding Hypothermia in Sepsis

• Hypothermia in sepsis is classified as mild (34-36°C), moderate (32-34°C), or severe (<32°C) and is associated with increased mortality, particularly when temperature falls below 32°C 3, 1
• While hypothermia was once thought to be purely detrimental, recent evidence suggests it may be a transient, self-limiting response in sepsis rather than a terminal event 4
• Despite this natural course, untreated hypothermia in sepsis is still associated with poor outcomes and higher mortality rates 5

Assessment and Monitoring

• Temperature should be monitored continuously using core temperature measurements (esophageal thermometer, bladder catheter in non-anuric patients, or pulmonary artery catheter) 6
• Axillary and oral temperatures are inadequate for accurate core temperature monitoring, especially during active temperature manipulation 6
• Consider using a secondary source of temperature measurement if using a closed feedback cooling system 6

Rewarming Protocol for Septic Patients

• For mild hypothermia (34-36°C):

  • Remove wet clothing immediately
  • Cover with at least two warm blankets
  • Increase ambient room temperature
  • Apply forced-air warming devices 3, 1

• For moderate hypothermia (32-34°C):

  • Continue all measures for mild hypothermia
  • Administer warmed intravenous fluids
  • Provide humidified, warmed oxygen
  • Consider more aggressive external warming methods 1, 2

• For severe hypothermia (<32°C):

  • Continue all previous measures
  • Consider active internal rewarming methods
  • Consider peritoneal lavage with warmed fluids in extreme cases 1

Fluid Management and Hemodynamic Support

• Keep patients euvolemic to maintain normal hemodynamic parameters 6
• Use crystalloids as the initial fluid of choice for resuscitation 6
• Consider albumin in patients with persistent hypotensive shock despite corrective measures 6
• Target a mean arterial pressure (MAP) of ≥65 mmHg, though this may need to be individualized based on patient characteristics 6
• Use norepinephrine as the initial vasopressor for hypotension after euvolemia is restored 6
• Consider hydrocortisone (200 mg once daily) in patients with persisting hypotensive shock 6

Important Considerations and Potential Complications

• Fluid restriction to reduce cerebral edema is not recommended in septic patients 6
• Monitor for complications during rewarming, including:
  • Coagulopathy (hypothermia impairs coagulation)
  • Cardiac arrhythmias
  • Increased risk of infection (hypothermia decreases immune function) 6, 1
• Cease rewarming after reaching 37°C as higher temperatures are also associated with poor outcomes 3, 2
• Patients with severe sepsis should be managed in a critical care setting in accordance with surviving sepsis guidelines 6

Special Situations

• For patients with traumatic brain injury alongside sepsis, controlled hypothermia (33-35°C) may be beneficial only after bleeding from other sources has been controlled 3
• Induced hypothermia has shown some benefit in septic ARDS patients, with one study showing improved oxygenation and survival, though this is not standard practice 7

Current Practice Patterns

• Most institutions (96%) do not have specific protocols for managing hypothermic sepsis 8
• There is significant variation in rewarming practices regarding temperature thresholds and target temperatures 8
• The most common first-line rewarming method is forced-warm air followed by warm IV fluids 8