Transcript Fever: Nuts and Bolts

Fever:
Nuts and Bolts
Nightfloat Curriculum 2010-2011
Lucile Packard Children’s Hospital
Residency Program
Teaching Goals
• Assess patient with fever
• Initiate laboratory evaluation and empiric
therapy
• Determine which patients are at high risk
of developing sepsis
Definition of fever
• 38.0
– Neonates (birth-2 months)
– BMT patients
– Oncology patients (sustained ≥38 x 1 hour)
• 38.5
– Oncology patients (≥38.5 once)
• 39.0
– Previously healthy children, nontoxic appearing
• These are general guidelines, individual
patients/services may have different parameters
Assessment
• Vital signs
• Repeat physical exam
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Overall appearance (sick, toxic)
Central/peripheral lines
Incisions/wounds
VP shunt/tracheostomy/gastrostomy tube
Oral mucosa/perineal area for neutropenic patients
Perfusion
• Call for help if concerning vital signs/exam
– Hospitalist
– Rapid response team (RRT)/PICU
Laboratory evaluation
• CBC with differential
• Blood culture
• Urinalysis and urine culture for at-risk patients
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Circumcised males < 6 months
Uncircumcised males < 1 year
Females < 2 years
Oncology/BMT patients
History of UTI/pyelonephritis
Catheterized (except oncology/BMT) or clean-catch
Laboratory evaluation (2)
• Lumbar puncture
– Neonates ≤ 2 months
– Ill-appearing
– Altered mental status
– Studies:
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Gram stain and culture
Cell count and differential
Protein and glucose
Extra tube for additional studies (enteroviral PCR,
HSV PCR, CA encephalitis project)
Laboratory evaluation (3)
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Consider CRP, ESR
Consider chest x-ray
Consider nasopharyngeal DFA
For immunosuppressed patients consider:
– CMV PCR
– EBV PCR
– Additional imaging (CT scan)
Management
• Neonates ≤ 2 months
– If < 28 days old
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Ampicillin: meningitis 100 mg/kg/dose q6 hrs
non-meningitis 50 mg/kg/dose q6 hrs
AND Cefotaxime: meningitis 75 mg/kg/dose q6 hrs
non-meningitis 50 mg/kg/dose q6 hrs
OR Gentamicin: 2.5 mg/kg/dose q8 hrs
Acyclovir: 20 mg/kg/dose q8 hrs
– If 29-60 days old
• Ceftriaxone: meningitis 50 mg/kg/dose q12 hrs
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non-meningitis 50 mg/kg/dose q24 hrs
• AND Ampicillin (see above)
• OR Vancomycin 15 mg/kg/dose
Management (2)
• Oncology patients: febrile neutropenia
– Ceftazidime: GNR (including Pseudomonas)
– Meropenem: GNR (including Pseudomonas), anaerobes
(ill/septic patients)
– Amikacin: double-coverage for GNR resistant to gentamicin or
tobramycin (ill/septic patients)
– Vancomycin: skin, central line, esp AML, relapsed leukemia
(Staph/Strep viridans)
– Flagyl/clindamycin: mucositis, typhlitis (anaerobes)
• BMT patients
– Ceftazidime
– Vancomycin
• These are general guidelines, individual
patients/services may have different regimens
High-risk patients
• Neonates
• Transplant recipients
– Bone marrow
– Solid organ
• Oncology patients
– Undergoing therapy, mucositis, central line
– Most chemotherapy: nadir ~ 10 days after rx
• Asplenic patients, including sickle cell
Case # 1
• 4-month-old well-appearing girl admitted
for croup and respiratory distress.
Develops fever to 39.1.
Case # 2
• 12-year old boy with AML, in induction,
admitted for febrile neutropenia. Currently
on ceftazidime and vancomycin. Develops
another fever to 38.5, chills, and new
dizziness shortly after receiving antibiotics.