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l.yekefalah-phd student of nursing
Fever in the ICU l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
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 l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
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 l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Fever is energetically costly increasing temperature 2-3ºC increases energy consumption 20% l.yekefalah-phd student of nursing 5/3/2018
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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 l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Nosocomial Fevers Hospital-acquired fevers occur in one-third of all medical inpatients Nosocomial fevers even more common in the ICU l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
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 non-infectious etiologies l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Diagnostic Approach Fever is a non-specific sign seen in inflammatory processes that may be infectious noninfectious, including neoplasm. l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Temp < 102º Acute cholecystitis Acute MI Thrombophlebitis GI bleed Acute pancreatitis Pulmonary embolism or infarct Viral hepatitis Uncomplicated wound infection Helps avoid needless antibiotic therapy l.yekefalah-phd student of nursing 5/3/2018
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Temp ³ 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 Helps avoid needless antibiotic therapy l.yekefalah-phd student of nursing 5/3/2018
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Causes of Fever in the ICU
Intravenous-line infections Nosocomial pneumonia Nosocomial sinusitis Intraabdominal infections Urinary catheter-associated bacteriuria Drug fever Post-operative fever Neurosurgical causes l.yekefalah-phd student of nursing 5/3/2018
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Systemic Inflammatory Response Syndrome
Definition of SIRS T > 38ºC or < 36ºC HR > 90 RR > or pCO2 < 32 WBC > 12 or < 4 Circulating inflammatory cytokines have been found that initiate a SIRS in CPB l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
SIRS Often noninfectious etiology found: Pulmonary embolism Myocardial infarction Gastrointestinal bleed Acute pancreatitis Cardiopulmonary bypass l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
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 l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Drug Fever On physical patient looks “inappropriately well” for degree of fever fever usually 102º to 104º relative bradycardia 5-10% have rash l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Drug Fever Lab tests show leukocytosis eosinophils on peripheral smear (common) eosinophilia (low-grade) elevated ESR mildly elevated AST, ALT l.yekefalah-phd student of nursing 5/3/2018
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Common Causes of Drug Fever
Antihypertensives Antidepressants Antiarrhythmics NSAIDs Antibiotics Sleep medications Antiepileptics Stool Softeners Diuretics l.yekefalah-phd student of nursing 5/3/2018
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Rare Causes of Drug Fever
Digoxin Steroids Diphenhydramine Aspirin Vitamins Aminoglycosides Tetracyclines Erythromycins Chloramphenicol Vancomycin Imipenim l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Postoperative Fever Fever common post-operatively Most episodes noninfectious Probably due to intraoperative tissue trauma with subsequent release of endogenous pyrogens into the bloodstream l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Postoperative Fever 72% of fevers within the 48º after surgery are non-infectious Wound, urinary tract, and respiratory infections occur later than 48º l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
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 l.yekefalah-phd student of nursing 5/3/2018
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Fever in Neurosurgical Patient
Most important causes are: Wound infection Meningitis, an infrequent post-op complication, especially after open-head trauma Wound infection and meningitis are the most important causes. Post-op bacterial meningitis is an infrequent complication, especially after open-head trauma The commonest clinical entity confused with post-neurosurgical meningitis is posterior fossa syndrome--stiff neck, low CSF glucose, protein elevated, and mostly PMNs. Can occur after any intracranial procedure; sx due to blood in CSF. Cx are (-) and decrease in meningeal sx as the RBCs decrease over time. Central fever may be caused by any intracranial space-occupying lesion or trauma, esp. if it affects the base of the brain or hypothalamus. Are usually very high. l.yekefalah-phd student of nursing 5/3/2018
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Fever in Neurosurgical Patient
Can occur after any intracranial procedure Symptoms due to blood in CSF l.yekefalah-phd student of nursing 5/3/2018
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Causes of High Fever (³ 106º)
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) l.yekefalah-phd student of nursing 5/3/2018
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Causes of High Fever (³ 106º)
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% l.yekefalah-phd student of nursing 5/3/2018
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Causes of High Fever (³ 106º)
Malignant neuroleptic syndromes Confusion, hyperthermia, muscle stiffness, autonomic instability Drugs implicated: phenothiazines, thioxanthines, butyrphenones--antipsychotics, tranquilizers, and antiemetics l.yekefalah-phd student of nursing 5/3/2018
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Intravenous-line Infections
Prevalence: 5% in ICU patients with triple-lumen and pulmonary artery catheters* Bloodstream infection is a serious catheter-related complication: ~10-20% l.yekefalah-phd student of nursing 5/3/2018
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Intravenous-line Infections
Look for local signs of infection: present in < 50% Remove line if no other source and T > 102º l.yekefalah-phd student of nursing 5/3/2018
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Scheduled Replacement?
No support for changing lines every 3-5 days; change only if unexplained fever or catheter malfunction occurs l.yekefalah-phd student of nursing 5/3/2018
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Catheter-Associated Bacteriuria
Foley catheters Result in acquisition of bacteriuria Nearly always represents colonization, not infection Pyuria often accompanies CAB, l.yekefalah-phd student of nursing 5/3/2018
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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 l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
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 l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Nosocomial Sinusitis Fever and leukocytosis often present Purulent nasal discharge often lacking Common in trauma and neurosurgical units l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
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 l.yekefalah-phd student of nursing 5/3/2018
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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 l.yekefalah-phd student of nursing 5/3/2018
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Intra-abdominal Infections
Suspect antibiotic-associated colitis due to Clostridium difficile in patients on broad-spectrum 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 l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
Nosocomial Pneumonia Almost all cases occur in mechanically ventilated patients Signs are: fever leukocytosis purulent tracheal secretions new or worsening infiltrates on CXR l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
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 low-grade fever Semi-quantitative BAL and protected-brush specimen may be helpful, but not widely available l.yekefalah-phd student of nursing 5/3/2018
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l.yekefalah-phd student of nursing
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 l.yekefalah-phd student of nursing 5/3/2018
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