Transcript 1 MB - fever_in_icu_mgmc1

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
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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
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specialized mattresses,
hot lights,
air conditioning,
cardiopulmonary bypass,
peritoneal lavage,
dialysis
Where to measure ??
Places – pros and cons
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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
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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
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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..
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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
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Some common infectious causes
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VAP -- 47%
Catheter related sepsis – 12 %
UTI – 17 %
Sinusitis
Clostridium diarrhea
VAP
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25 % incidence
25 % mortality – attributable
Fever
Unexplained change in sputum color amount
Increased need of FiO2 , ventilation
Stiff lungs
Empiric antibiotic
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Physical examination
X-ray chest – previous diseases –
air bronchogram
FOB – secretion
Gram negative staining important –
– within two hours
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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
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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
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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
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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 ??
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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
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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
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• Acute pancreatitis
• Pulmonary
embolism or infarct
• Viral hepatitis
• Uncomplicated
wound infection
Acute cholecystitis
Acute MI
Dressler’s Syndrome
Thrombophlebitis
GI bleed
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Temp 102º
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Cholangitis
• Non-viral liver
disease: drug fever,
Suppurative phlebitis
leptospirosis…
Pericarditis
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Complicated
wound
Septic pulmonary
infection
embolism
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Bowel
infarction
• Pancreatic abscess
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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.
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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
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Fever common
Definition
Recording
Causes
Infectious and non infectious
Diagnosis
Message
• Good microbiologist rather
than a good looking
microbiologist is necessary