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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
What is causing this
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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Fever with thrombocytopenia
Malaria (notably falciparum)
Dengue
Leptospirosis
Rickettsial infections
Viral fevers
Fever with thrombocytopenia
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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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Fever with altered sensorium
Malaria cerebral malaria
Encephalitis
Meningitis
Typhoid fever
Septic encephalopathyBrain abscess
Fever with altered sensorium
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Patients
presentingwith febrileillness
Approach to fever
Patient developing feverin the ICU
Is there a focusof infection?
Acute undifferentiated
fever
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Infectious
causes
Where is thefocus?
Patient developing fever in the ICU
Non-infective causes
What is causing this
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
Is there a focusof infection?
Acute undifferentiated
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
What investigations should I send?
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Do not forget about non-infectivecauses
Acute Lung injury/ARDS, Aspiration
Deep venous thrombosis,thrombophlebitis
Drug feverDecubitus ulceration
What investigations should I send?
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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