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Fever in ICU Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statisticsPhD ( physiology), IDRA Why we should know ?? • Fever is a common problem in ICU • Around 80% (? 40 – 50 % in some books )of patients in ICU experience fever • It has good & bad effects • Can be infectious or non-infectious • Usually triggers lot of investigation • Increases cost and discomfort to patient • An effective and cost-conscious approach needed What is the normal temperature ?? • 370 C or 98. 60F • Exercise • Circadian rhythm • Menstrual cycle Definition • core temperature of 38.0°C (100.4°F), • fever as two consecutive elevations of 38.3°C (101.0°F). • In patients who are neutropenic, fever has been defined as a single oral temperature of 38.3°C (101.0°F) in the absence of an obvious environmental cause, • or a temperature elevation of 38.0°C (100.4°F) for 1 h Some environmental factors • • • • • • specialized mattresses, hot lights, air conditioning, cardiopulmonary bypass, peritoneal lavage, dialysis Where to measure ?? Places – pros and cons • • • • • • Don’t contaminate Site ? New onset ? Calibration Shot of steroids NSAIDS Beneficial fever ?? • Increases resistance to infection • Increases Ab production • Some pathogens are inhibited by fever directly • Thomas Sydenham (16241689), English physician: “Fever is Nature’s engine which she brings into the field to remove her enemy.” ill effects • • • • Tachycardia, tachypnea, Increase O2 consumption and CO2 production Increase energy expenditure Poorly tolerated in TBI & low CP reserve patients • Can cause fetal malformation & abortions Euthermic infection ?? • Hypotension • Unexplained tachycardia • Rigors • Leucocytosis • Leucopenia • Thrombocytopenia • • • • • CRF Liver disease Anti inflammatory drugs Open abdominal wounds Burns Fever - Causes • Infectious • Non infectious • Common • But one study in neuro ICU, 33 % non infectious Non infectious - not more than 102 • Acalculous cholecystitis – 1. 5 % of ill – complex pathophysiology • Gallbladder ischemia & Cholestasis with bile salt inpissation associated with parenteral nutrition and PEEP • Investigate • May need drainage • Blood products - fever high , 30 min- upto 24hours Non infectious fever • Drug fever –chills, eosinophilia , relative brady – Antibiotics, antidepressants , antiepileptics, halo etc.. • • • • DVT Pancreatitis Infarction – pulmonary, myocardial and CNS Thyroid storm --- etc… Blood transfusions • Complicate about 0.5% of blood transfusions, more common following platelet transfusion • Antibodies against membrane antigens of transfused leukocytes and/or platelets are responsible • Usually begin within 30 min to 2 h after a bloodproduct transfusion • The fever generally lasts between 2 to 24 h and may be preceded by chills • An acute leukocytosis lasting upto12h occurs commonly High Fever (º) • Malignant neuroleptic syndromes – Confusion, hyperthermia, muscle stiffness, autonomic instability – Drugs implicated: phenothiazines, thioxanthines, butyrphenones--antipsychotics, tranquilizers, and antiemetics – Dantrolene or bromocriptine, a dopamine agonist, effective in uncontrolled studies 17 Some common infectious causes • • • • • VAP -- 47% Catheter related sepsis – 12 % UTI – 17 % Sinusitis Clostridium diarrhea VAP • • • • • • • 25 % incidence 25 % mortality – attributable Fever Unexplained change in sputum color amount Increased need of FiO2 , ventilation Stiff lungs Empiric antibiotic • • • • • Physical examination X-ray chest – previous diseases – air bronchogram FOB – secretion Gram negative staining important – – within two hours • • • • CT or USG chest Still diagnosis ?? Blood for PCR Pleural fluid analyses – if needed • Some organisms are always pathogens (Legionella, M.tb, Pneumocystis) • Some organism are very rarely pathogens (enterococci, Strep.viridans, Candida) • Common organisms – Pseudomonas, MRSA, Acinetobacter, Stenotrophomonas, E.coli, Kleb. More than 6 score ! Clinical pulmonary infection score • Early onset - ceftriaxone • Late onset - Piperecillin or Carbopenems • 8 days enough • Wait for cultures Catheter related blood stream infections ( CRBSI) • Variable stats, 2-12% per 1000 cath days • Increases with time, number of ports & manipulation • Femoral and IJV – more – • no difference with tunneling • Sterile precaution in insertion & maintenance reduces infection • CRBSI - when both catheter & peripheral culture grow same bug • Common organism - S.aureus, Candida When to remove catheter ? • In CRBSI • Deteriorating patient with catheter >48hrs • Fever >102 in stable patient without obvious cause • If there is no need for a catheter Different sub classification of CRBSI reported Urinary tract infection • Catheter-associated bacteriuria or candiduria usually represents colonization, is rarely symptomatic • E coli, Enterococcus species, and yeasts • May be there – but ? Significance • Neutropenia • Obstruction • Uro surgery UTI – continued • • • • • • Urine collection from aspiration from tube Within one hour Gram stain and culture Community acquired infections – pyuria But catheter related = may not be Silver coated foley’s catheter Sinusitis • Not common • – – – – – nasotracheal tubes nasogastric tubes nasal packing facial fractures steroid therapy • Predispose • P. aeroginosa is common Taken from internet for closed academic purpose only • Cough purulent nasal discharge • Headache facial pain • CT • Empirical therapy • Aspiration and analyses (aerobes, anaerobes, and fungi) • Targeted therapy What is usual !! • Paranasal sinusitis is best treated by removal of all nasal tubes together with drainage of the maxillary sinuses. • Broad-spectrum antibiotics are generally recommended Diarrhea • • • • • • • • ICU patients Usually community acquired Drugs and enteral feedings Clostiridium difficile ( TCA and PCR ) Others are salmonella and viruses Stool culture then sigmoidoscopy Sick patient – vancomycin Other intra abdominal infections and CT in selected cases Blood cultures ?? • • • • • • Blood cultures in 24 hours atleast two Betadine or chlorhexidine paint and dry Bottle cap with 70 % alcohol and dry 20 – 30 ml ( recently 40 ml) Label , time date and site also Additional cultures for fungi Neuro surgical patient – fever • Most important causes are – Wound infection – Meningitis, an infrequent post-op complication, especially after open-head trauma Fever in Neurosurgical Patient • Commonest clinical entity is posterior fossa syndrome – stiff neck, low CSF glucose, elevated protein, mostly neutrophils – Can occur after any intracranial procedure – Symptoms due to blood in CSF – Culture negative, and symptoms subside as RBCs decrease over time in CSF 36 Clinical clues • Remittent or intermittent fever that, when due to infection, usually follow a diurnal variation. • Sustained fevers have been reported in patients with Gram-negative pneumonia or CNS damage. • Fevers that arise > 48 h after institution of mechanical ventilation may be secondary to a developing pneumonia. • Fevers that arise 5 to 7 days postoperatively may be related to abscess formation. • Fevers that arise 10 to 14 days post institution of antibiotics for intra-abdominal abscess may be due to fungal infections Do we need to treat fever • Ibuprofen , paracetomol • Decreases fever but overall mortality ? no difference • external cooling • Vasopressors usage – no change- but icu stay and mortality decreased 102 rule Temp < 102º • • • • • • Acute pancreatitis • Pulmonary embolism or infarct • Viral hepatitis • Uncomplicated wound infection Acute cholecystitis Acute MI Dressler’s Syndrome Thrombophlebitis GI bleed 41 Temp 102º • • • • Cholangitis • Non-viral liver disease: drug fever, Suppurative phlebitis leptospirosis… Pericarditis • Complicated wound Septic pulmonary infection embolism • Bowel infarction • Pancreatic abscess 42 Seven steps • 1. Record temperature • 2. History • 3. A thorough physical examination is an integral part of the diagnostic process and should include inspection of all devices, the sites of insertion, and all skin areas, especially the back and sacrum. • • • • 4. Investigations 5. Remove lines suspicious 6. Diagnosis 7. Treatment William osler • Humanity has but three great enemies • fever, famine and war; • of these by far the greatest, by far the most terrible, is fever’ Summary • • • • • • Fever common Definition Recording Causes Infectious and non infectious Diagnosis Message • Good microbiologist rather than a good looking microbiologist is necessary