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Fever in the ICU Fever, Late 1800s ◦Fever is the regulation of body temperature at a higher level ◦Fever dangerous if too high or prolonged ◦Antipyretic drugs should be used only for high fevers or of long duration 5/5/2017 dr .yekefalah-phd of nursing 2 Fever, Late 1800s Antipyretic drugs widely available: aspirin, other salicylates Many physicians advocated reducing fever Fever considered harmful by-product of infection, not host-defense response Why? Perhaps because salicylates are analgesic and antipyretic 5/5/2017 dr .yekefalah-phd of nursing 3 Fever is energetically costly increasing temperature 2-3ºC increases energy consumption 20% 5/5/2017 dr .yekefalah-phd of nursing 4 Mechanism of Protective Effect Enhanced neutrophil migration Increased production of antibacterial substances by neutrophils Increased production of interferon Increased antiviral and antitumor activity of interferon Increased T-cell proliferation 5/5/2017 dr .yekefalah-phd of nursing 5 Nosocomial Fevers Hospital-acquired fevers occur in one-third of all medical inpatients Nosocomial fevers even more common in the ICU 5/5/2017 dr .yekefalah-phd of nursing 6 Fever in the ICU ICU patients have several underlying medical/surgical conditions ICU patients undergo many invasive diagnostic and therapeutic procedures Therefore, fever in ICU patients must be thoroughly and promptly evaluated to discriminate infectious from noninfectious etiologies 5/5/2017 dr .yekefalah-phd of nursing 7 Diagnostic Approach Fever is a non-specific sign seen in inflammatory processes that may be ◦infectious ◦noninfectious, including neoplasm. 5/5/2017 dr .yekefalah-phd of nursing 8 Temp < 102º Acute cholecystitis Acute MI Thrombophlebitis GI bleed Acute pancreatitis Pulmonary embolism or infarct Viral hepatitis Uncomplicated wound infection 5/5/2017 dr .yekefalah-phd of nursing 9 Temp 102º( Helps avoid needless antibiotic therapy) Cholangitis phlebitis Pericarditis Septic pulmonary embolism Pancreatic abscess Non-viral liver disease: drug fever, Complicated wound infection Bowel infarction 5/5/2017 dr .yekefalah-phd of nursing 10 Causes of Fever in the ICU Intravenous-line infections Nosocomial pneumonia Nosocomial sinusitis Intraabdominal infections Urinary catheterassociated bacteriuria Drug fever Post-operative fever Neurosurgical causes 5/5/2017 dr .yekefalah-phd of nursing 11 Systemic Inflammatory Response Syndrome Definition of SIRS ◦T > 38ºC or < 36ºC ◦HR > 90 ◦RR > 20 or pCO2 < 32 ◦WBC > 12 or < 4 5/5/2017 dr .yekefalah-phd of nursing 12 SIRS Often noninfectious etiology found: ◦ Pulmonary embolism ◦ Myocardial infarction ◦ Gastrointestinal bleed ◦ Acute pancreatitis ◦ Cardiopulmonary bypass 5/5/2017 dr .yekefalah-phd of nursing 13 Drug Fever Some 3-7% of fevers on an inpatient medical service are drug reactions History of atopy is a risk factor Patient may have been on the “sensitizing medication” for days to years 5/5/2017 dr .yekefalah-phd of nursing 14 Drug Fever On physical patient looks “inappropriately well” for degree of fever ◦fever usually 102º to 104º ◦relative bradycardia ◦5-10% have rash 5/5/2017 dr .yekefalah-phd of nursing 15 Drug Fever Lab tests show ◦ leukocytosis ◦ eosinophils on peripheral smear (common) ◦ eosinophilia (low-grade) ◦ elevated ESR ◦ mildly elevated AST, ALT 5/5/2017 dr .yekefalah-phd of nursing 16 Common Causes of Drug Fever Antibiotics Antihypertensives Sleep Antidepressants medications Antiepileptics Stool Softeners Diuretics Antiarrhythmics NSAIDs 5/5/2017 dr .yekefalah-phd of nursing 17 Rare Causes of Drug Fever Digoxin Steroids Diphenhydramine Aspirin Vitamins Aminoglycosides Tetracyclines Erythromycins Chloramphenicol Vancomycin Imipenim 5/5/2017 dr .yekefalah-phd of nursing 18 Postoperative Fever Fever common post-operatively Most episodes noninfectious Probably due to intraoperative tissue trauma with subsequent release of endogenous pyrogens into the bloodstream 5/5/2017 dr .yekefalah-phd of nursing 19 Postoperative Fever 72% of fevers within the 48º after surgery are noninfectious Wound, urinary tract, and respiratory infections occur later than 48º 5/5/2017 dr .yekefalah-phd of nursing 20 Postoperative Fever Empiric antibiotics should be withheld in patients with fever within 48º of surgery if they lack a specific diagnosis after thorough evaluation Continuing perioperative prophylactic antibiotics does not prevent infection, only selects for resistant organisms 5/5/2017 dr .yekefalah-phd of nursing 21 Fever in Neurosurgical Patient Most important causes are: ◦Wound infection ◦Meningitis, an infrequent post-op complication, especially after open-head trauma 5/5/2017 dr .yekefalah-phd of nursing 22 Fever in Neurosurgical Patient ◦Can occur after any intracranial procedure ◦Symptoms due to blood in CSF 5/5/2017 dr .yekefalah-phd of nursing 23 Causes of High Fever (º) Central fevers ◦ intracranial hemorrhage, head trauma, infection, malignancy ◦ especially if the base of the brain or hypothalamus affected Infusion-related sepsis . Rarely, bacterial infection Drug fever (usually 102º to 106º) 5/5/2017 dr .yekefalah-phd of nursing 24 Causes of High Fever (º) Malignant hyperthermia ◦ Rare genetic disorder, probably autosomal dominant ◦ Incidence 1:15,000 in kids; less in adults ◦ Hypercatabolic reaction to anesthetic drugs ◦ Sustained muscle contraction . ◦ Tachycardia occurs in >90% of pts within 30 minutes ◦ Treated with dantrolene; mortality ~7% 5/5/2017 dr .yekefalah-phd of nursing 25 Causes of High Fever (º) Malignant neuroleptic syndromes ◦ Confusion, hyperthermia, muscle stiffness, autonomic instability ◦ Drugs implicated: phenothiazines, thioxanthines, butyrphenones-antipsychotics, tranquilizers, and antiemetics 5/5/2017 dr .yekefalah-phd of nursing 26 Intravenous-line Infections Prevalence: 5% in ICU patients with triplelumen and pulmonary artery catheters* Bloodstream infection is a serious catheter-related complication: ~1020% 5/5/2017 dr .yekefalah-phd of nursing 27 Intravenous-line Infections Look for local signs of infection: present in < 50% Remove line if no other source and T > 102º 5/5/2017 dr .yekefalah-phd of nursing 28 Scheduled Replacement? No support for changing lines every 3-5 days; change only if unexplained fever or catheter malfunction occurs 5/5/2017 dr .yekefalah-phd of nursing 29 Catheter-Associated Bacteriuria Foley catheters ◦ Result in acquisition of bacteriuria ◦ Nearly always represents colonization, not infection ◦ Pyuria often accompanies CAB, 5/5/2017 dr .yekefalah-phd of nursing 30 Catheter-Associated Bacteriuria Foley + high fever + bacteriuria ◦ does not necessarily mean urosepsis ◦ unless their is partial or total obstruction or pre-existing renal disease Asymptomatic CAB ◦ in normal hosts need not be treated ◦ in compromised hosts and chronically immunosuppressed must be treated promptly 5/5/2017 dr .yekefalah-phd of nursing 31 Nosocomial Sinusitis Bacteriology differs markedly from community-acquired disease Gram-negative bacilli cause most cases in intubated patients Polymicrobial infection in upto 50% of cases, reflecting ICU flora Paranasal sinusitis accounts for about 5% of nosocomial ICU infections 5/5/2017 dr .yekefalah-phd of nursing 32 Nosocomial Sinusitis Fever and leukocytosis often present Purulent nasal discharge often lacking Common in trauma and neurosurgical units 5/5/2017 dr .yekefalah-phd of nursing 33 Nosocomial Sinusitis Risk factors ◦ ◦ ◦ ◦ ◦ nasotracheal tubes nasogastric tubes nasal packing facial fractures steroid therapy Diagnosis made easier with sinus CT, which is more sensitive than plain films Avoid prolonged nasotracheal intubation 5/5/2017 dr .yekefalah-phd of nursing 34 Intra-abdominal Infections Suspect intra-abdominal abscess in patients with prolonged post-operative fever after abdominal surgery cholecystitis and subsequent biliary sepsis may complicate post-operative period 5/5/2017 dr .yekefalah-phd of nursing 35 Intra-abdominal Infections Suspect antibiotic-associated colitis due to Clostridium difficile in patients on broadspectrum antibiotics Fever and leukocytosis may be present prior to diarrhea or abdominal symptoms Splenic or hepatic abscesses may complicate other intra-abdominal infections (cholecystitis, appendicitis) causing prolonged fevers 5/5/2017 dr .yekefalah-phd of nursing 36 Nosocomial Pneumonia Almost all cases occur in mechanically ventilated patients Signs are: ◦ ◦ ◦ ◦ fever leukocytosis purulent tracheal secretions new or worsening infiltrates on CXR 5/5/2017 dr .yekefalah-phd of nursing 37 Nosocomial Pneumonia However, none of these are predictive of pneumonia; nosocomial pneumonia remains a clinical diagnosis Can be confused with fibroproliferative phase of ARDS, usually accompanied by lowgrade fever Semi-quantitative BAL and protected-brush specimen may be helpful, but not widely available 5/5/2017 dr .yekefalah-phd of nursing 38 Summary Fever in the ICU can have many infectious and noninfectious etiologies Crucial to identify the precise cause as some of the conditions in each groups are life-threatening, while others require no treatment “Routine fever work-up” not cost-effective If initial evaluation shows no infection, antibiotics should be withheld Empiric antibiotics may be started in the unstable patient, but stopped if infection is not evident later 5/5/2017 dr .yekefalah-phd of nursing 39 5/5/2017 dr .yekefalah-phd of nursing 40