What caused the hypothermia?

[AlphaPig]

60+ yr old female patient admitted for hyperkalemia/ARF/UTI 6 days ago is stable on my floor. Multiple co-morbidities including DM, hypothyroid, past ARF, CHF, CVA x 2, COPD, RA and a new 2 cm mass in her lungs found this admission. Pt is 60 but looks 80. Multiple immune disorder markers are found in her blood (all of those funky labs I can't remember right now) and they are hoping to treat the auto-immune disorder to help the kidneys rather than resort to dialysis.

Ok. Patient's baseline is AAOX3 with poor short term memory. She is on O2 2L NC with sats 95-97. BP and HR stable. Afebrile. Poor appetite and frequent c/o nausea. Slightly elevated WBCs and elevated but stable BUN/Cr (sorry, don't remember exact numbers). Overall, her daily CBC and BMP looked ok for her.

Around 11, patient changed - she became more lethargic and slight slurring of speech. She kept saying "I feel so. . strange". BS 118, vitals WNL, did full assessment and mentioned it to the MD who was on the floor who saw her but he dismissed it saying she was probably just tired. Also, I noticed her legs were edematous so I told the nephrologist (who happened to be standing right there, too) and he ordered some Lasix.

She slept for a couple of hours and when she woke up she looked. . .sick. Vitals still fine except. . .I can't get a temperature. I try two thermometers. I try oral and axillary. Won't read. So, I get a rectal and her temp is 93.8. I'm like !?!?!??!?!?!?!??!!?

Get the MD back in the room (that got his attention) and a bunch of orders (blood cultures, urine culture, chest xray, ABGs) When I ask MD why the low temp, he shrugs. I ask if it could be sepsis, he really doesn't know.

At this point, I called a rapid response (because patient was looking really crappy) so they came and took over and I didn't get to see all of the ABG results, but I did see she had critical acidosis and low Pa02 (couldn't see numbers or anything else)

So, they want to put her on a thermal bipap thing (which I didn't know exists) so off she goes to ICU.

And here I sit trying to make sense of it all. What would make her temperature go so low?

I'm sorry I don't have better data - it was a long day and I don't remember all of the details.

Thank you - interested in your feedback. I've never had a patient with a low temperature before so I am curious about it. I've been doing some research on-line and I seem to be going in circles with it all.

[SwansonRN]

Sepsis and hypothyroid? Or maybe she has adrenal insufficiency or something weird going on with her pituitary gland. Sounds like a pretty sick lady.

[kp1987]

I have no clue but I along with yourself would really like to know.

[NightNurseRN13]

I don't know either, but just more proof that when a patient tells you "something isn't right", you LISTEN!

[Esme12, ASN, BSN, RN]

Sepsis, hypothyroid, adrenal insufficiency from stress/sepsis. Did I mention Sepsis?

I'd need labs, ABG's what autoimmune disorders they discovered to really make a good guesstimate....Sepsis/SIRS

SIRS....

SIRS was first described by Dr. William R. Nelson, of the University of Toronto, in a presentation to the Nordic Micro Circulation meeting in Geilo, Norway in February 1983. There was intent to encourage a definition which dealt with the multiple (rather than a single) etiologies associated with organ dysfunction and failure following a hypotensive shock episode. The active pathways leading to such pathophysiology may include fibrin deposition, platelet aggregation, coagulopathies and leukocyte liposomal release. The implication of such a definition suggests that recognition of the activation of one such pathway is often indicative of that additional pathophysiologic processes are also active and that these pathways are synergistically destructive. The clinical condition may lead to renal failure, respiratory distress syndrome, central nervous system dysfunction and possible gastrointestinal bleeding.

Criteria for SIRS were established in 1992 as part of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. The conference concluded that the manifestations of SIRS include, but are not limited to:

• Body temperature less than 36°C(96.8°F) or greater than 38°C(100.4°F)
  
• Heart rate greater than 90 beats per minute
  
• Tachypnea (high respiratory rate), with greater than 20 breaths per minute; or, an arterial partial pressure of carbon dioxide less than 4.3 kPa (32 mmHg)
  
• leukocytes less than 4000 cells/mm³ (4 x 10⁹ cells/L) or greater than 12,000 cells/mm³ (12 x 10⁹ cells/L); or the presence of greater than 10% immature neutrophils (band forms) band forms greater than 3% is called bandemia or a "left-shift."
  

SIRS can be diagnosed when two or more of these criteria are present

medscape requires registration but it is free.

[h=3]Systemic Inflammatory Response Syndrome - Medscape Reference[/h]

[nrsang97, BSN, RN]

Sounds septic to me. Even with the low temp. Esme gave you a lot of great info. My first thought was sepsis.

[xoemmylouox, ASN, RN]

I'm sure it was sepsis, maybe thyroid dysfunction in addition? Poor lady.

[weirdscience]

I thought I remembered learning that a low temp in the elderly often DOES mean sepsis...am I crazy? Not that 60 is elderly, but w/those comorbidities...

[AlphaPig]

I guess I'm so used to sepsis presenting with tachycardia, low BP, elevated WBCs, elevated temp. . .she had none of those. But I know that a low temp CAN be sepsis, too. Maybe with all of her other issues it presented with the low temperature.

She may have been 60, but her body was that of an 80 years old.

I noticed that when she got to ICU, they drew a bunch of thyroid labs so maybe they were thinking along those lines, too (I always look to see what orders they put in when the pt is taken to ICU to help me with my thinking)

[AlphaPig]

If I see her MD will ask about her and see if they found out what was going on.

[classicdame, MSN, EdD]

maybe talk to someone on the RRT or her current nurse? This could be a good learning experience for you. Of course, you will need to avoid the HIPAA gods to learn anything.

[psu_213, BSN, RN]

I know you probably don't have access to this, but a lactate level would also be helpful...the "critical" acidosis could be d/t elevated lactate (although, given the pt's COPD, it could be a respiratory acidosis).