Fever in the ICU AA

8/6/2019 Fever in the ICU AA

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Fever in the ICU

Dr Parvez khan


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Introduction


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Fever is a common problem in the ICU

ICU patients have several underlying

medical/surgical conditions

ICU patients undergo many invasivediagnostic and therapeutic procedures

Could be due to infectious and non-infectious causes

Objective is to review a rationalapproach to the management of fever

in ICU patients

Introduction


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Fever is a co-ordinated neuroendocrine, autonomic and behavioralresponse that is adaptive, and an

essential part of the acute-phaseresponse to immune stimulus or tissueinjury

Co-ordinated by the hypothalamus

Neural input from peripheralthermoreceptors

Humoral cues from inflammation or

infection

What is fever?


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Enhances parameters of immune function

Improves antibody production

Activates T-cells

Produces cytokines

Enhances neutrophil and macrophagefunction

Benefits of fever


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Hot baths for treatment of syphilis

Positive correlation between maximum

temperature on the day of bacteremia andsurvival

In children with chicken pox, treatment withacetaminophen increased time to crusting of

skin lesions

Benefits of fever - translated?


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Increased cardiac output

Increased oxygen consumption

Increased carbon-di-oxide production

Increased basal metabolic rate

The downside of fever


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Poorer neurological outcomes in patients withstroke and traumatic brain injury who manifesttemperature

Fever poorly tolerated in patients with reducedcardio-respiratory reserve

Maternal fever cause of fetal malformations as

well as spontaneous abortions

The downside of fever-translated


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How to measure temperature in thecritically ill patient?


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Peripheral temperaturemeasurements

Measured in the outer 1.6 mm of skin ormucus membranes

Considered unreliable as influenced byenvironmental temperatures, mouthbreathing etc.

Examples oral temperature, axillary, skintemperature

Core temperature measurements Not influenced by external factors

More accurately reflects temperature in theinternal organs

Examples pulmonary, rectal, esophageal,urinary, tympanic

Measurement of temperature


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Optimal sitePulmonary but invasive, need

equipment

AlternativesTympanic easy but can be off by even

2O

Urinary good alternative

Rectal uncomfortable

Oesophageal

Measurement of temperature


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When do we say fever in the ICUpatient?


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Normal temperature

98.2O F (36.8OC)

Diurnal variations of temperature withevening rise up to 100O F (37.8O C)

What is normal?


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Society of Critical Care Medicine(SCCM) and Infectious diseases

society of America recommendinvestigations in the ICU iftemperature is above

101O F (38.3OC)

So when do we get worried in the

ICU?


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Approach to fever in the ICU


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What are the causes of fever inICU

How do I act when I am see atemperature spike?

What investigations do I send?

How do I treat the fever?

Approach to fever in ICU


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Patient whocomes in with afebrile illness

Cause of fever needto be ascertained

Approach to fever

Patient in the ICU

develops fever

What is causing this

fever?


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Patient with anobvious focus ofinfection

Where is the focus?

Patient presenting to ICU with

fever

Acute un-differentiated

fever


fever?


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Community acquired pneumonia

Acute CNS infection

Urinary tract infection

Abdominal focus of infection

Wound infection / Pus collections

Trauma with infection

The obvious focus


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And why do they come to theICU

Ventilatory support respiratoryfailure pneumonia

Hemodynamic support shock

Renal replacement therapy renalfailure, severe acidosis

Monitoring, Neurological dysfunction,

Hematologic

The obvious focus


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Patients

presentingwith afebrileillness

Approach to fever

Patient developing feverin the ICU

Is there a focusof infection?

Acute undifferentiated

fever


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Where no specific focus identified

Look for specific clues to guide inthe diagnosis

Acute undifferentiated fever


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Fever with thrombocytopenia

Fever with hepato-renaldysfunction

Fever with pulmonary renalsyndrome

Fever with altered sensorium

Acute undifferentiated fever


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Malaria (notably falciparum)

Dengue

Leptospirosis

Rickettsial infections

Viral fevers



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Fever with hepato-renaldysfunction

Malaria (falciparum)

Leptospirosis

Scrub typhus

Fulminant hepatic failure withhepatorenal

Fever with hepato-renal dysfunction


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Fever with pulmonary-renaldysfunction

Malaria (falciparum)

Leptospirosis

Scrub typhus

Hantavirus infectionSevere legionella / pneumococcal

pneumonia

Fever with pulmonary-renal dysfunction


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Malaria cerebral malaria

Encephalitis

Meningitis

Typhoid fever

Septic encephalopathyBrain abscess



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Patients

presentingwith febrileillness

Approach to fever

Patient developing feverin the ICU



fever


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Infectious

causes

Where is thefocus?

Patient developing fever in the ICU

Non-infective causes


fever?


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Ventilator associated pneumonia

Catheter related blood stream

infections

Urosepsis

Intra-abdominal infections

Sinus infections Diarrhoea

Infectious causes of fever whilst in ICU


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Fungal infections includingcandidemia

Surgical wound infections

Acalculous cholecystitis

Endocarditis

Meningitis

Infectious causes of fever whilst in ICU


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Non-infectious causes of fever in ICU


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Patients

presentingwith febrileillness

Summary of approach to fever in ICU

Patient developing fever

in the ICU



fever

InfectiveCauses Non-infectiveCauses


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What are the causes of fever inICU

How do I act when I see atemperature spike?

Approach to fever in ICU


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How do I act when there is a temperature spike?


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One temperature spike

Should I beworried?

YES In an

immunocompromisedpatient

If hemodynamicinstability

Decreasing UOP Increasing lactate Worsening conscious

state Falling platelet counts Worsening

coagulopathy

NO Small spike No hemodynamic

instability Carefully examine

clinically for an obvious


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What investigations to send?


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Bloods counts, procalcitonin

Imaging CXR, Scans asindicated (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 send?


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Assess if lines are old and ifthere is any evidence of line

sepsis - re-site line if indicated

Change urinary catheter

May need NG change if sinusinfection suspected



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Do not forget about non-infectivecauses

Acute Lung injury/ARDS, Aspiration

Deep venous thrombosis,thrombophlebitis

Drug feverDecubitus ulceration



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Common Causes of Drug Fever

Antibiotics

Sleep

medications Antiepileptics

Stool Softeners

Diuretics

Antihypertensives

Antidepressants Antiarrhythmics

NSAIDs


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Rare Causes of Drug Fever

Digoxin

Steroids

Diphenhydramine

Aspirin

Vitamins

Aminoglycosides

Tetracyclines

Erythromycins

Chloramphenicol

Vancomycin

Imipenim

Quinolones


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How do I treat the fever?


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Difficult question

Do I use antipyretics?

When to administer or change

antibiotics?

How do I treat?


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Do I use antipyretics?

Yes in patients with Neurologicaldisorders

Poor cardio- respiratory reserve

How do I treat?


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When to administer or changeantibiotics?

Generally in an unstable patient choose to treat with broad spectrumantibiotics and pull back depending oncultures & clinical response

How do I treat?


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Summarizing


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Enumerated causesof fever in the ICU

Useful to have asystematicapproach to fever

Investigate & treatappropriately

Recap


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THANK U

Fever in the ICU AA

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