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Fever in the ICU. J V Peter MD, DNB (Med), FRACP, Medical ICU Christian Medical College & Hospital. Introduction. Introduction. Fever is a common problem in the ICU Could be due to infectious and non-infectious causes

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fever in the icu

Fever in the ICU

J V Peter MD, DNB (Med), FRACP, Medical ICU

Christian Medical College & Hospital

introduction3
Introduction
  • Fever is a common problem in the ICU
  • Could be due to infectious and non-infectious causes
  • Objective is to review a rational approach to the management of fever in ICU patients
what is fever
What is fever?
  • Fever is a co-ordinated neuro endocrine, autonomic and behavioral response that is adaptive, and an essential part of the acute-phase response to immune stimulus or tissue injury
  • Co-ordinated by the hypothalamus
      • Neural input from peripheral thermoreceptors
      • Humoral cues from inflammation or infection
benefits of fever
Benefits of fever
  • Enhances parameters of immune function
  • Improves antibody production
  • Activates T-cells
  • Produces cytokines
  • Enhances neutrophil and macrophage function
benefits of fever translated
Benefits of fever - translated?
  • Hot baths for malaria fever for treatment of syphilis
  • Positive correlation between maximum temperature on the day of bacteremia and survival
  • Temperature > 38 °C improved survival in patients with SBP
  • In children with chicken pox, treatment with acetaminophen increased time to crusting of skin lesions
the downside of fever
The downside of fever
  • Increased cardiac output
  • Increased oxygen consumption
  • Increased carbon-di-oxide production
  • Increased basal metabolic rate
the downside of fever translated
The downside of fever-translated
  • Poorer neurological outcomes in patients with stroke and traumatic brain injury who manifest temperature
  • Fever poorly tolerated in patients with reduced cardio-respiratory reserve
  • Maternal fever cause of fetal malformations as well as spontaneous abortions
measurement of temperature
Measurement of temperature
  • Peripheral temperature measurements
        • Measured in the outer 1.6 mm of skin or mucus membranes
        • Considered unreliable as influenced by environmental temperatures, mouth breathing etc.
        • Examples – oral temperature, axillary, skin temperature
  • Core temperature measurements
        • Not influenced by external factors
        • More accurately reflects temperature in the internal organs
        • Examples – pulmonary, rectal, esophageal, urinary, tympanic
measurement of temperature12
Measurement of temperature
  • Optimal site
      • Pulmonary – but invasive, need equipment
  • Alternatives
      • Tympanic – easy but can be off by even 2O
      • Urinary – good alternative
      • Rectal – uncomfortable
      • Oesophageal
what is normal
What is normal?
  • Normal temperature
      • 98.2O F (36.8OC)
      • Diurnal variations of temperature with evening rise up to 100O F (37.8O C)
so when do we get worried in the icu
So when do we get worried in the ICU?
  • Society of Critical Care Medicine (SCCM) and Infectious diseases society of America recommend investigations in the ICU if temperature is above
      • 101O F (38.3OC)
approach to fever in icu
Approach to fever in ICU
  • What are the causes of fever in ICU
  • How do I act when I am see a temperature spike?
  • What investigations do I send?
  • How do I treat the fever?
approach to fever
Approach to fever

Patient who comes in with a febrile illness

Cause of fever need to be ascertained

Patient in the ICU develops fever

What is causing this fever?

patient presenting to icu with fever
Patient presenting to ICU with fever

Patient with an obvious focus of infection

Where is the focus?

Acute un-differentiated fever

What is causing this fever?

the obvious focus
The obvious focus
  • Community acquired pneumonia
  • Acute CNS infection
  • Urinary tract infection
  • Abdominal focus of infection
  • Wound infection / Pus collections
  • Trauma with infection
the obvious focus21
The obvious focus
  • And why do they come to the ICU
      • Ventilatory support – respiratory failure – pneumonia
      • Hemodynamic support – shock
      • Renal replacement therapy – renal failure, severe acidosis
      • Monitoring, Neurological dysfunction, Hematologic
approach to fever22
Approach to fever

Patients presenting with a febrile illness

Patient developing fever in the ICU

Is there a focus of infection?

Acute undifferentiated

fever

acute undifferentiated fever
Acute undifferentiated fever
  • Where no specific focus identified
  • Look for specific clues to guide in the diagnosis
acute undifferentiated fever24
Acute undifferentiated fever
  • Fever with thrombocytopenia
  • Fever with hepato-renal dysfunction
  • Fever with pulmonary renal syndrome
  • Fever with altered sensorium
fever with thrombocytopenia
Fever with thrombocytopenia
  • Fever with thrombocytopenia
      • Malaria (notably falciparum)
      • Dengue
      • Leptospirosis
      • Rickettsial infections
      • Viral fevers
fever with hepato renal dysfunction
Fever with hepato-renal dysfunction
  • Fever with hepato-renal dysfunction
      • Malaria (falciparum)
      • Leptospirosis
      • Scrub typhus
      • Fulminant hepatic failure with hepatorenal
fever with pulmonary renal dysfunction
Fever with pulmonary-renal dysfunction
  • Fever with pulmonary-renal dysfunction
      • Malaria (falciparum)
      • Leptospirosis
      • Scrub typhus
      • Hantavirus infection
      • Severe legionella / pneumococcal pneumonia
fever with altered sensorium
Fever with altered sensorium
  • Fever with altered sensorium
      • Malaria – cerebral malaria
      • Encephalitis
      • Meningitis
      • Typhoid fever
      • Septic encephalopathy
      • Brain abscess
approach to fever29
Approach to fever

Patients presenting with a febrile illness

Patient developing fever in the ICU

Is there a focus of infection?

Acute undifferentiated

fever

patient developing fever in the icu
Patient developing fever in the ICU

Infectious causes

Where is the focus?

Non-infective causes

What is causing this fever?

infectious causes of fever whilst in icu
Infectious causes of fever whilst in ICU
  • Ventilator associated pneumonia
  • Catheter related blood stream infections
  • Urosepsis
  • Intra-abdominal infections
  • Sinus infections
  • Diarrhoea
infectious causes of fever whilst in icu32
Infectious causes of fever whilst in ICU
  • Fungal infections including candidemia
  • Surgical wound infections
  • Acalculous cholecystitis
  • Endocarditis
  • Meningitis
summary of approach to fever in icu
Summary of approach to fever in ICU

Patients presenting with a febrile illness

Patient developing fever in the ICU

Is there a focus of infection?

Infective

Causes

Acute undifferentiated

fever

Non-infective

Causes

approach to fever in icu35
Approach to fever in ICU
  • What are the causes of fever in ICU √
  • How do I act when I am see a temperature spike?
one temperature spike
Should I be worried?

YES

In an immunocompromised patient

If hemodynamic instability

Decreasing UOP

Increasing lactate

Worsening conscious state

Falling platelet counts

Worsening coagulopathy

NO

Small spike

No hemodynamic instability

Carefully examine clinically for an obvious focus of infection

One temperature spike
what investigations should i send
What investigations should I send?
  • Bloods – counts, procalcitonin
  • Imaging – CXR, Scans as indicated (abdomen, sinus, CT brain)
  • Cultures as appropriate – ETA, BAL, Urine, Blood cultures (peripheral and through lines), cultures from pus, wound etc, Stool for clostridium
what investigations should i send40
What investigations should I send?
  • Assess if lines are “old” and if there is any evidence of line sepsis - re-site line if indicated
  • Change urinary catheter
  • May need NG change – if sinus infection suspected
what investigations should i send41
What investigations should I send?
  • Do not forget about non-infective causes
      • Acute Lung injury/ARDS, Aspiration
      • Deep venous thrombosis, thrombophlebitis
      • Drug fever
      • Decubitus ulceration
how do i treat
How do I treat?
  • Difficult question
  • Do I use antipyretics?
  • When to administer or change antibiotics?
how do i treat45
How do I treat?
  • Do I use antipyretics?
      • Yes – in patients with “Neurological disorders”
      • Poor cardio- respiratory reserve
how do i treat46
How do I treat?
  • When to administer or change antibiotics?
      • Generally in an unstable patient – choose to treat with broad spectrum antibiotics and pull back depending on cultures & clinical response
recap
Recap
  • Enumerated causes of fever in the ICU
  • Useful to have a systematic approach to fever
  • Investigate & treat appropriately