Fever in ICU Dr. S. Parthasarathy - PowerPoint Presentation

Slide1

Fever in ICU

Dr. S.

Parthasarathy

MD., DA., DNB, MD (

Acu

), Dip.

Diab

. DCA, Dip. Software statistics-

PhD ( physiology), IDRA Slide2

Why we should know ?? Slide3

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 neededSlide4

What is the normal temperature ??

37

0

C or 98. 6

0

F

Exercise

Circadian rhythm

Menstrual cycleSlide5

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 hSlide6

Some environmental factors

specialized mattresses,

hot lights,

air conditioning,

cardiopulmonary bypass,

peritoneal lavage,

dialysisSlide7

Where to measure ?? Slide8

Places – pros and cons Slide9

Don’t contaminate

Site ?

New onset ?

Calibration

Shot of steroids

NSAIDS Slide10

Beneficial fever ??

Increases resistance to infection

Increases

Ab

production

Some pathogens are inhibited by fever

directly

Thomas Sydenham (1624-1689), English physician: “Fever is Nature’s engine which she brings into the field to remove her enemy.” Slide11

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 & abortionsSlide12

Euthermic infection ??

Hypotension

Unexplained tachycardia

Rigors

Leucocytosis

Leucopenia

Thrombocytopenia

CRF

Liver disease

Anti inflammatory drugs

Open abdominal wounds

Burns Slide13

Fever - Causes

Infectious

Common

Non infectious

But one study in

neuro

ICU, 33 % non infectious Slide14

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 Slide15

Non infectious fever

Drug fever –chills, eosinophilia , relative

brady

Antibiotics, antidepressants ,

antiepileptics

, halo etc..

DVT

Pancreatitis

Infarction – pulmonary, myocardial and CNS

Thyroid storm --- etc… Slide16

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 blood-product transfusion

The

fever generally lasts between 2 to 24 h and may be preceded

by

chills

An acute leukocytosis lasting upto12h occurs commonlySlide17

17

High Fever (

³ 106

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 studiesSlide18

Some common infectious causes

VAP -- 47%

Catheter related sepsis – 12 %

UTI – 17 %

Sinusitis

Clostridium diarrhea Slide19

VAP

25 % incidence

25 % mortality – attributable

Fever

Unexplained change in sputum color amount

Increased need of FiO2 , ventilation

Stiff lungs

Empiric antibiotic Slide20

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 Slide21

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

.Slide22

More than 6 score !

Clinical pulmonary infection score Slide23

Early onset - ceftriaxone

Late onset -

Piperecillin

or

Carbopenems

8 days enough

Wait for cultures Slide24

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 Slide25

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 catheterSlide26

Different sub classification of CRBSI reported Slide27

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 Slide28

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 Slide29

Sinusitis

Not common

nasotracheal

tubes

nasogastric tubes

nasal packing

facial fractures

steroid therapy

Predispose

P.

aeroginosa

is common Slide30

Taken from internet for closed academic purpose only Slide31

Cough purulent nasal discharge

Headache facial pain

CT

Empirical therapy

Aspiration and analyses (aerobes, anaerobes, and fungi)

Targeted therapy Slide32

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 recommendedSlide33

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 Slide34

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 fungiSlide35

Neuro surgical patient – fever

Most

important causes are

Wound infection

Meningitis, an infrequent post-op complication, especially after open-head traumaSlide36

36

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 CSFSlide37
Slide38

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 infectionsSlide39

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 Slide40

102 rule Slide41

41

Temp < 102º

Acute cholecystitis

Acute MI

Dressler’s Syndrome

Thrombophlebitis

GI bleed

Acute pancreatitis

Pulmonary embolism or infarct

Viral hepatitis

Uncomplicated wound infectionSlide42

42

Temp

³

102

º

Cholangitis

Suppurative phlebitis

Pericarditis

Septic pulmonary embolism

Pancreatic abscess

Non-viral liver disease: drug fever, leptospirosis…

Complicated wound infection

Bowel infarctionSlide43

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.

Slide44

4. Investigations

5. Remove lines suspicious

6. Diagnosis

7. Treatment Slide45

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’Slide46

Summary

Fever common

Definition

Recording

Causes

Infectious and non infectious

Diagnosis Slide47

Message

Good microbiologist rather than a good looking microbiologist is necessary