* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Fever in the ICU
Sarcocystis wikipedia , lookup
West Nile fever wikipedia , lookup
Orthohantavirus wikipedia , lookup
Clostridium difficile infection wikipedia , lookup
Anaerobic infection wikipedia , lookup
Traveler's diarrhea wikipedia , lookup
Hepatitis C wikipedia , lookup
Carbapenem-resistant enterobacteriaceae wikipedia , lookup
Gastroenteritis wikipedia , lookup
Trichinosis wikipedia , lookup
Hepatitis B wikipedia , lookup
Dirofilaria immitis wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Oesophagostomum wikipedia , lookup
Yellow fever wikipedia , lookup
Typhoid fever wikipedia , lookup
Schistosomiasis wikipedia , lookup
Marburg virus disease wikipedia , lookup
Neonatal infection wikipedia , lookup
1793 Philadelphia yellow fever epidemic wikipedia , lookup
Leptospirosis wikipedia , lookup
Yellow fever in Buenos Aires wikipedia , lookup
Rocky Mountain spotted fever wikipedia , lookup
FEVER IN THE ICU Dr. Ankit Jain DEFINITIONS Normal Body Temperature 37°C (98.6°F) Diurnal Variation 1.3°C Core Body Temperature vs Peripheral Measurements Elderly Subjects have lower body temperatures. DEFINITIONS Fever in the ICU Body Temperature ≥ 38.3°C (101°F) Body Temperature ≥ 38.0°C (100.4°F) in Immunocompromised patients, neutropenia. THERMOMETRY – WHERE TO MEASURE? Thermistor Equipped Catheters (Core Body Temperature) Pulmonary Artery Oesophagus Urinary Bladder More Accurate Continuous Monitoring THERMOMETRY – WHERE TO MEASURE? Peripheral Temperature Rectal CBT < 0.2 to 0.3 than Rectal temp Avoid in Neutropenic Patients Oral CBT > 0.5 Measure with Electronic Probes not Mercury Cold Liquids Tympanic Membrane Head Injury/Stroke? Cerebral Temp vs Core Temp Axillary Temporal Artery THE FEBRILE RESPONSE Inflammatory Cytokines – Endogenous Pyrogens. Reset of the Hypothalamic Thermostat Neuroecndocrine Control Mechanisms. THE FEBRILE RESPONSE Fever is a sign of Inflammation not Infection. Infection is most significant cause of Inflammation. Severity of Fever ≠ Severity of Infection FEVER VS. HYPERTHERMIA Hyperthermia Abnormal Temperature Regulation. Eg: Heat Exhaustion, Heat Stroke, MH, NMS, Serotonin Syndrome. Fever Thermoregulatory Centre is Intact i.e Normal Temperature Regulation. But Operating at a Higher Set Point. Adaptive Response. Eg: Infectious and Non Infectious causes of Fever. INITIAL APPROACH New Onset Fever in the ICU INFECTIOUS OR NON INFECTIOUS? 50:50 Medical and Surgical Noninfectious causes once Infectious Causes are Ruled Out! Infectious Causes?? Likely if the Risk Factors are Present. Fever>38.9C(102.2)more likely Infectious Fever>41.1 (105.9)more likely non infectious/neurological. ASSESSMENT OF RISK FACTORS Risk Factors for Nosocomial Microbial Infections in the ICU PATIENT FACTORS SOURCES OF INFECTION Advanced Age Intravascular Catheters Severe Underlying Disease Intubation and Mechanical Ventilation Neutropenia Bladder Catheters Immunosuppression Nasogastric Tubes Neurological Disease with Impaired Consciousness Surgical Drains Stress Ulcer Prophylaxis Prosthesis Prolonged ICU Stay Bed Sores RISK FACTORS 4 Infections account for 3/4th of ICU Acquired Infections 3 of these involve indwelling plastic devices Pneumonias – 83% in Intubated Patients UTI – 97% in Catheterized patients Bloodstream Infections – 87% from IV Catheters. Surgical Site Infections. (Richards MJ, Edwards JR, Culver DH, Gaynes RP. The National Nosocomial Infections Surveillance System. Nosocomial infections in combined medicalsurgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000; 21:510–515) VENTILATOR ASSOCIATED PNEUMONIA VENTILATOR ASSOCIATED PNEUMONIA Suspect: Fever Pt. on Ventilator Increased Volume of Respiratory Secretions Change in Character of Secretions Lab Clues Leukocytosis/Leukopenia CXR: New or Progressive Infiltrate VAP Limited Diagnostic Accuracy of Clinical Criteria Non Specific Nature of Pulmonary Infiltrates Conditions other than pneumonia are the most frequent causes of pulmonary infiltrates in ICU patients Non Infectious Causes of Pulmonary Infiltrates Pulmonary Oedema ARDS Atelectasis Sensitivity OF CXR?? Vs CT Diagnosis of Pneumonia cannot be ruled out with a portable CXR. VAP New Clinical Criteria National Healthcare Safety Network No involvement of CXR Findings. Deterioration in Arterial Oxygenation Change In Body Temperature/ WBC VAP MICROBIOLOGICAL EVALUATION Sample Tracheal Aspirate BAL Before Antibiotics Role of Blood Cultures VAP - PREVENTION Aspiration – of Oropharyngeal flora. Oral Decontamination – Oral Chlorhexidine Gargles Routine Airway Care – Reduce Endotracheal Suctioning. Clearance of Subglottic secretions. CATHETER ASSOCIATED URINARY TRACT INFECTIONS URINARY TRACT INFECTIONS Suspect Fever Urinary Catheter (Most patients in ICU) Majority are Colonizers NOT NECESSARILY • • • • A UTI Common symptoms of UTI such as dysuria and frequency are not relevant in catheterized patients, and the usual signs of infection (fever, leukocytosis) can lack specificity in catheterized patients. Fever or Leucocytosis (Another Infection?) Cloudy Urine White Blood Cells in Urine(But absence of Pyuria against CA-UTI ) CA-UTI DAIGNOSIS Catheter <30 days - urine through the catheter port or catheter tubing. Catheter > 30 days- catheter should be replaced before collecting the urine specimen. Significant bacteriuria in catheterized patients ≥105 cfu/mL. How-ever, over 90% of patients with significant bacteriuria have no other evidence of infection (asymptomatic bacteriuria) (8). CA-UTI DAIGNOSIS Catheter-associated urinary tract infection (CAUTI) is defined as a urine culture that grows >103 cfu/mL in a patient with clinical signs of a symptomatic UTI. These can include: Bacteremia with the same organism isolated in blood and urine. New costovertebral tenderness. Rigors. New onset of delirium or depressed consciousness. Increased spasticity in patients with spinal cord injuries. CA-UTI PREVENTION Remove catheter when no longer needed. DO NOT use prophylactic antibiotics. ? Antibiotic Impregnated Urinary Catheters CA-UTI TREATMENT Change catheter Empirical Abx Abx as per C/S UTI - CANDIDURIA Colonization Disseminated Candidiasis Candiduria the result not Cause. Candiduriathe only evidence of Disseminated Candidiasis. Blood Cultures inrevealing in >50% Assess clinical condition of Patient. UTI - CANDIDURIA Asymptmatic Candiduria Remove Catheter when possible. Repeat Cultures No treatment (Unless neutropenic.) Persistant Candiduria – Blood, Kidney. Symptomatic Candiduria Blood Cultures Kidney Imaging Antifungals CATHETER RELATED BLOOD STREAM INFECTIONS VASCULAR CATHETER RELATED INFECTIONS Suspect: Fever Leucocytosis Catheter >3days Local Signs of Infection WHAT IS NOT A CRBSI Local Signs of Infection No Predictive value of presence of Septicemia. Purulent drainage uncommon – Exit site infection without blood stream infection WHAT IS?? Diagnosis with Cultures. (Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49:1–45.) WHICH METHOD TO USE? Leave the Catheter Alone Most evaluations of CRBSI do not confirm the daignosis. Guidewire Replacements have adverse effects. Replace Catheter over Guidewire Risk of dislodging clot. Difficult Access. Remove and insert new catheter at new site Prosthetic Valves, Indwelling pacemaker wires, purulent discharge, neutropenia. PERSISTENT SEPSIS Persistent fever/sepsis after 72 hrs of Abx Suppurative Thrombophlebitis/Intravascular Abscess Endocarditis SURGICAL SITE INFECTIONS SURGICAL SITE INFECTION Versus Normal Response to trauma Starts almost immediately. Less than 2 days. Fever < 38.5Lasts Suspect Fever > 38.5 Lasts longer than 2 days. Starts on 3rd post op day. (Exception – Necrotizing Wound Infections) Local Signs (Remove Dressing and see) Treatment Surgical Opinion. Surgical Debridement Antibiotics. CLOSTRIDIUM DIFFICILE INFECTION Suspect New Onset Diarrhoea Acid Suppression with PPI Diagnosis Stool Cultures Unreliable ELISA to detect Cytotoxins Two stool samples better than One. (85 vs 95% Sensitivity) Treat Antibiotics Stop Antiperistaltic agents Discontinue PPIs OTHER CAUSES OF INFECTIOUS FEVER SINUSITIS Suspect: Nasogastric Tubes Nasal Intubation Orotracheal Tubes Sinus Tenderness Investigate Bedside Plain Radiograms CT PNS Needle Aspiration with Microscopy C/S. Treat Antibiotics FESS ACUTE ACALCULOUS CHOLECYSTITIS Often Missed Complications: Gangrenous Cholecystitis, Perforation. Pain and RUQ tenderness absent in 1/3rd patients Fever, Elevated Bilirubin. Ix: USG, CT. Tx: Cholecystectomy, Percutanious Drainage, Antibiotics. NON INFECTIOUS CAUSES OF FEVER IN ICU. EARLY POST OPERATIVE FEVER Due to Tissue Injury and Inflammation. Suspect Fever on First Postop day. No Apparent Infection. Resolves in 24-48 hours. VENOUS THROMBOEMBOLISM Suspect Risk Factors for VTE Acute Pulmonary Embolism can cause fever that lasts upto 1 week. BLOOD TRANSFUSIONS Mechanism Even in Absence of Infection or Hemolysis. Antileukocyte Ab in recepient that react with donor leucocytes. Suspect More Common with Platelet Transfusions Fever during or upto 6 hrs after transfusion. Treat Stop BT Send Donor and Recipient Sample for Ix. DRUG FEVER Suspect No other cause Onset of fecver: Few hours to 3weeks after starting drug ?Hypersensitivity reaction(Rash, Eosinophilia,) absent in >75%. Common Drugs DRUG FEVER Treatment Stop Offending Drug if possible Fever should stop within 2-3 days Can Persist for upto7 days ADRENAL FAILURE Mechanism Spontaneous Adrenal Hemorrhaging in Anticoagulation therapy, DIC. IATROGENIC FEVER Faulty Regulators Check Temperature settings on Air Mattresses Forced air Warmers ANTIPYRETIC THERAPY SHOULD FEVER BE TREATED?? BENEFITS OF FEVER Fever as a Host Defense Mechanism Fever is a normal Adaptive response that enhances the ability to eradicate infection. FEVER AS HOST DEFENCE Arons MM, Wheeler AP, Bernard GR, et al. Effects of ibuprofen on the physiology and survival of hypothermic sepsis. Critical Care Med 1999; 27:699–707. Clemmer TP, Fisher CJ, Bone RC, et al. Hypothermia in the sepsis syndrome and clinical outcome. Crit Care Med 1990; 18:801–806. WHEN IS FEVER HARMFUL? Tachycardia – Patients with Heart Disease. Post Cardiac Arrest and Ischemic Stroke: Aggravates Ischemic Brain Injury. Hyperpyrexia : Temp > 42 C for greater than 1 hr – Non Ischemic Brain Damage. COOLING BLANKETS AND FEVER Understand the Febrile Response Cutaneous Vasoconstriction Increased Skeletal Muscle Activity (Shivering and Rigors) Body behaves like it is already wrapped in a cooling blanket Ineffective!! Appropriate in Hyperthermia HYPERTHERMIA DRUG INDUCED HYPERTHERMIA Source of thermal stress Heat Stroke : environment. Unlikely in the ICU. Versus Drug induced metabolic Heat production. Examples Malignant Hyperthermia Neuroleptic Malignant Syndrome Serotonin Syndrome MALIGNANT HYPERTHERMIA Suspect: In OT Exposure to Halogenated Inhalation Agents, NM Blocking Agents Sudden Rise in EtCO2 Generalized Muscle Rigidity (Rhabdomyolisis, Myoglobinuria ) Hyperthermia >104 F Altered Mental Status Autonomic Instabiity Treatment Discontinue offending agent Supportive Care Dantrolene NEUROLEPTIC MALIGNANT SYNDROME Suspect Drugs (Inhibit Dopaminergic Transmission) Antipsychotics HALOPERIDOL (Serenase) Antiemetics eg Metaclopramide, prochlorpreazine CNS Stimulants: Amphetamines TCAs Discontinuation of Dopaminergic Drugs eg: Levodopa, Bromocriptine No Relation between Intensity or Duration of Tx. NMS Suspect: Muscle Rigidity (Myoglubinuria) Altered Sensorium Symptoms 24-72 hrs after onset of tx. Hyperthermia following Muscle Rigidity >41 C Autonomic Instability Labs CPK > 1000 U/L Can Mimic Sepsis with TLC >40K SEROTONIN SYNDROME Suspect Recent ingestion of Seritonergic Drugs.(Linezolid) Usually within last few Hours Maybe upto 5 weeks Hyperkinesis, Hyperreflexia and Clonus.