Transcript Fever in ICU

Dr. Marwan Jabr Alwazzeh
Assoc. Prof. of Medicine
Consultant Internist/Infectious Diseases
University of Dammam
02/04/2012
Why Fever In ICU?
 Key Problem Requires Thoughtful Evaluation
and Treatment.
 Increasing health care costs.
 Exposes patients to sometimes unnecessary
invasive diagnostic procedures
 Inappropriate use of antibiotics that
promoting emergence of resistant microbes.
When we say “fever” in the ICU
patient?
 Definition of fever is Arbitrary.
 Society of Critical Care Medicine and
Infectious diseases society of America
>38.3 °C (100.4°F).
 Lower threshold for surgery and
immunocompromised patients
>38.0 °C (100.4°F).
Pathophysiology of Fever
Significance of Fever
 Enhancing the resistance to infection
 Temperature elevation enhances immune
function by:
 Increased antibody production
 Promoting T-cell activation
 Increased cytokine production
 Stimulates neutrophil and macrophage
function
Significance of Fever
 Beneficial effects of hot baths and malarial fevers
in treating syphilis.
 In Gram negative bacteremia, a positive
correlation between maximum temperature on
the day of bacteremia and survival.
 Some pathogens such as Streptococcus
pneumoniae are inhibited by febrile
temperatures.
Significance of Fever
 Most patients should not routinely receive
empiric antipyretic medication.
 Acute hepatitis may occur in ICU patients with
reduced glutathione reserves (alcoholics,
malnourished, etc.) who have received regular
therapeutic doses of acetaminophen.
 Aggressively treating fever in critically ill
patients may lead to a higher mortality rate.
Deleterious Effects Of Fever
 ↑↑ Cardiac Output
 ↑↑ Oxygen Consumption (approx 10%/°C)
 ↑↑ Carbon Dioxide Production
 ↑↑ Energy Expenditure
 Most accurate
 Pulmonary artery thermistor
 Urinary bladder catheter thermistor
 Esophageal probe
 Rectal probe
 Other acceptable methods in order of accuracy
 Oral probe
 Infrared ear thermometry
 Other methods less desirable
 Temporal artery thermometer
 Axillary thermometer
 Chemical dot
Accuracy
Accuracy of methods used for
measuring temperature
Recommendations for Measuring
Temperature
 Axillary, temporal artery, and chemical dot
thermometers should not be used in the ICU
 Rectal thermometers should be avoided in
neutropenic patients
 Whatever device chosen should be used in a
manner that does not facilitate spread of
pathogens by the instrument or the operator
Treating Fever per se
 Fever should be treated only in
patients with:
 Acute brain insults.
 Limited cardiorespiratory reserve (ie,
ischemic heart disease).
 Temperature increases above 40°C
(104°F)
Causes of fever in ICU
 Differential diagnosis influenced by
patient population
 Medical vs. Surgical
 Immunocompromised vs. competent
 Community vs. Nosocomial
 Pediatric vs. Geriatric
Causes of fever in ICU
Main infectious Causes
 Intravascular Devices infection and septicemia
 Pulmonary Infections and ICU-Acquired
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Pneumonia.
Urinary Tract Infections.
Infectious Diarrhea.
Sinus infections.
Surgical Site Infections.
Central Nervous System Infection.
Fever In ICU
Infectious causes
Definitions
Systemic inflammatory response syndrome (SIRS)
Sepsis
Severe sepsis
Septic shock
Systemic Inflammatory
Response Syndrome
 Tow or more of the following:
 Temperature ≥38 °C or ≤36 °C
 Heart rate ≥90 beats/min
 Respirations ≥20/min or arterial Carbone
dioxide tension (PaCO2) < 32 mm Hg
 White blood cell count ≥12,000/mm3 or
≤4000/mm3 or >10% immature [band] forms
Systemic Inflammatory Response
Syndrome
 Often noninfectious etiology found:
 Pulmonary embolism
 Myocardial infarction
 Gastrointestinal bleeding
 Acute pancreatitis
 Cardiopulmonary bypass
Sepsis
SIRS with a presumed or
confirmed infectious
process
Severe sepsis
 Sepsis with one or more signs of organ
failure:
 Cardiovascular
 Renal
 Respiratory
 Hepatic
 Hematologic
 Central nervous system
 Metabolic acidosis
Septic shock
Sepsis-induced hypotension, despite
adequate fluid resuscitation, with
presence of perfusion
abnormalities
Infectious Causes
 Not all patients with infections are
febrile.
 10% of septic patients are Hypothermic.
 35% are normothermic at presentation.
 Septic patients who fail to develop a
temperature have a significantly higher
mortality than febrile septic patients.
Afebrile infected patients
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Elderly
Open abdominal wounds.
Large burns
Extracorporeal membrane oxygenation (ECMO)
CHF
CRF or End-stage liver disease.
Continuous renal replacement therapy
Taking anti-inflammatory or antipyretic drugs
How can I Diagnose Infection in
absence of fever?
 Unexplained
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hypotension
Tachycardia
Tachypnea
Confusion
Rigors
Skin lesions
Respiratory
manifestations
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Oliguria
Lactic acidosis
Leukocytosis
Leukopenia
Immature neutrophils
(i.e., bands) of >10%
 Thrombocytopenia
When should I be worried?
 Immunocopromized patient
 Hemodynamic instability
 Oliguria
 Increasing lactate
 Worsening conscious state
 Falling platelet counts
 Worsening coagulopathy.
Intravascular Devices
infection and
septicemia
Intravascular Devices infection
and septicemia
Intravascular
Devices
infection
Localized
infection
Systemic
infection
Exit site
infection
Tunnel
infection
Catheter-Related Bloodstream Infection
Definition
 A positive catheter culture 15 CFU with
concomitant positive blood culture of the
same organism.
 No other identifiable source of infection.
Local Catheter-Related Infection
Definition
 Growth of 15 or more CFU from a
catheter specimen by semiquantitative
culture.
 Local signs of inflammation: erythema,
swelling, tenderness, purulent material.
 Negative peripheral blood culture.
Catheter-Related Bloodstream
Infection
Approximately 25% of central venous
catheters become colonized, and
approximately 20-30% of colonized
catheters will result in catheter sepsis
Suppurative phlebitis
 Most often encountered in burn patients or other
ICU patients who develop catheter-related
infection that goes unrecognized, permitting
microorganisms to proliferate to high levels
within an intravascular thrombus.
 bloodstream infection characteristically persists
after the catheter has been removed.
 Clinical picture of overwhelming sepsis with highgrade bacteremia or fungemia or with septic
embolization.
Recommendations for Obtaining
Blood Cultures
 For patients without an indwelling vascular
catheter, obtain at least 2 blood cultures using
strict aseptic technique from peripheral sites by
separate venipunctures after appropriate skin
disinfection.
 For patients with an indwelling vascular catheter
Obtain 3-4 blood cultures.
Recommendations for Obtaining
Blood Cultures
 For cutaneous disinfection:
 2% chlorhexidine gluconate in 70%
isopropyl alcohol
 tincture of iodine is equally effective (30 sec.
of drying time).
 Povidine iodine is an acceptable alternative,
but must wait greater than 2 minutes to dry.
Recommendations for Obtaining
Blood Cultures
 The injection port of the blood culture bottles
should be wiped with 70-90% alcohol before
injecting the blood sample into the bottle.
 Most blood culture bottles should not be swabbed
with iodine-containing antiseptics.
 Draw 20-30ml of blood per culture.
 Label the blood culture with the exact time, date,
and anatomic site from which it was taken.
Management of fever in ICU
 There is no evidence that the yield of cultures drawn
from an artery is different from the yield of cultures
drawn from a vein.
 Catheter Cultures:
 Short catheter: tip.
 longer catheter: Tip and intracutaneous segment.
 Pulmonary artery catheter: Tip and introducer.
 It is rarely necessary to culture infusate specimens.
 It is rarely necessary to culture infusate specimens.
Candidemia
 Candida species are constituents of the
normal flora in about 30% of all healthy
people.
 Antibiotic therapy increases the incidence of
colonization by up to 70%.
 Candida Infection should be considered in
febrile ICU patients who have been in the ICU
for ≥10 days and have received multiple
courses of antibiotics.
Candidemia
 Although candiduria may be observed in up to
80% of patients with systemic candidiasis,
candidemia from a urinary tract source is
extremely rare.
 galactomannan and beta-D-glucan for
aspergillosis and Candida may be useful as
supportive evidence of infections but may be
most useful to exclude invasive fungal
infection, given their high negative predictive
value.
Catheter Related Blood Stream Infection
CVC Insertion Bundle
 Hand hygiene.
 Maximal barrier precautions.
 Chlorhexidine skin antisepsis.
 Optimal catheter site selection, with avoidance of
using the femoral vein for central venous access in
adult patients.
The Canadian Collaborative, Safer Healthcare Now
Catheter Related Blood Stream Infection
CVC Maintenance Bundle
 Daily review of line necessity and prompt removal
of unnecessary lines.
 Dedicated lumen for total parenteral nutrition
(TPN).
 Access the CVC lumens aseptically.
 Checking entry site for inflammation with every
change of dressing.
The Canadian Collaborative, Safer Healthcare Now
Pulmonary Infections
and ICU-Acquired
Pneumonia
Recommendations for Evaluation of
Pulmonary Infections
 All radiographs should be performed in an
erect sitting position, during deep inspiration
if possible.
 The absence of infiltrates, masses, or effusions
does not exclude pneumonia, abscess, or
empyema.
 Obtain one sample of lower respiratory tract
secretions for direct examination and culture
before initiation of or change in antibiotics.
Recommendations for Evaluation of
Pulmonary Infections
 Isolation of enterococci, viridans streptococci,
coagulase-negative staphylococci, and
Candida species should rarely if ever be
considered the cause of respiratory
dysfunction.
 Quantitative cultures can provide useful
information in certain patient populations
when assessed in experienced laboratories.
Ventilator Bundle
 Elevate the Head of the bed to 30-45 degrees.
 Peptic ulcer disease prophylaxis.
 Deep venous thrombosis prophylaxis.
 Provide mouth care every 2-4 hours.
 Sedation vacation every day.
 Repeated evaluation of the patient’s readiness to
be weaned from the ventilator.
Urinary Tract
Infection
Urinary Tract Infection
 Pyuria may be absent in patients with
catheter-associated urinary tract infection
and, even if present, is not reliably predictive
of infection or associated with symptoms
referable to the urinary tract.
 The rapid dipstick tests, which detect
leukocyte esterase and nitrite, are unreliable
tests in the setting of catheter-related urinary
tract infection.
Urinary Tract Infection
 The concentration of urinary bacteria or yeast
needed to cause symptomatic urinary tract
infection or fever is unclear.
 Bacteriuria with ≥ 105 CFUs of bacteria per
milliliter of urine during bladder
catheterization was associated with a 2.8-fold
increase in mortality.
Urinary Tract Infection
 Patients with urinary catheters in place
should have urine collected from the sampling
port and not from the drainage bag.
 Urine should be transported to the laboratory
and processed within one hour to avoid
bacterial multiplication.
 Gram stains of centrifuged urine will reliably
show the infecting organisms
UTI bundle
 Use sterile technique at insertion
 Perform a daily review of the need for the urinary
catheter.
 Provide perineal care on a daily basis and after
every bowel movment.
 Keep the drainage bag lower than patient's
bladder at all times.
 Secure all catheters
Infectious Diarrhea
C.Difficile associated
diarrhea
 May occur with any antibacterial agent, but
the most common causes are clindamycin,
cephalosporins, and fluoroquinolones.
 some patients with C.difficile especially those
who are postoperative, may present with ileus
or toxic megacolon or leukocytosis without
diarrhea.
C.difficile–associated diarrhea
Methods
Stool WBC
Lactoferrin latex agg. test
Sensitivity
40%
75%
EIA toxin
72% 1st sample
84% 2nd sample
81% 1st sample
91% 2nd sample
71% severe disease
23% mild disease
Tissue Culture assay
Sigmoidoscopy
C.difficile–associated diarrhea
 Cultures for C. difficile require 2 to 3 days for
growth, and are not specific in distinguishing
toxin-positive strains, toxinnegative strains,
and asymptomatic carriage.
 Infection with Klebsiella oxytoca should be
considered in patients who are negative for C.
difficile.
 Acute neutropenic enterocolitis or typhlitis
should be sought in cancer or stem cell
transplant.
Sinusitis
Sinusitis
 Accounts for about 5% of nosocomial ICU
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infections.
Polymicrobial infection in up to 50% of cases,
reflecting ICU flora.
Fever and Leucocytosis often present.
Purulent nasal discharge often lacking.
Sinus opacification by plain radiography is
sensitive but nonspecific for the diagnosis.
CT the modality of choice if clinical evaluation
suggests that sinusitis may be a cause of fever.
Sinusitis
 Risk factors:
 Naso-tracheal tubes
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(incidence of up to
85% after a week of
intubation).
Naso-gastric tubes.
nasal packing.
facial fractures.
steroid therapy.
Surgical Site Infections
&
Postoperative fever
Surgical Site Infections
 Examine the surgical incision at least
once daily.
 If there is suspicion of infection, the
incision should be opened and cultured.
Surgical Site Infections
 Tissue biopsies or aspirates are
preferable to swabs.
 Superficial swab cultures are likely to be
contaminated with commensal skin
flora and are not recommended.
Surgical Site Infection Prevention
Bundle
 Appropriate use of Antibiotics.
 Appropriate hair removal.
 Preoperative glucose control in all
diabetic patients.
 Preoperative normothermia.
Postoperative fever
5 Ws
 Wind (atelectasis/pneumonia)
 Water (UTI)
 Walk (DVT-PA)
 Wound (infection)
 Wonder (drug reaction)
Postoperative fever
Time post OP
Main causes
<24 hours
Transfusion reactions
Thyroid storm
Addisonian crisis
Intestinal leaks
1-2 days
Central line infections
3-5 days
Acalculous cholecystitis
Candidiasis (total parenteral nutrition)
Hematomas
leakage
6 days or more
Abscesses
Clostridium difficile colitis
Infected Hematomas
Parotitis (Staph. aureus)
Sinusitis
Postoperative fever
 Fever is a common occurrence during the first 48
hrs post OP, usually noninfectious in origin.
 Fever after 96 hrs post OP usually represents
infection.
 Early wound infections (2-48hrs post OP):
Streptococcus or Clostridium.
Noninfectious fever
Noninfectious fever
 For unknown reasons, most noninfectious
disorders usually do not lead to a fever>102°F
(38.9°C).
 Exceptions:
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Drug fever
Transfusion reaction
Neoplasm
Malignant hyperthermia
Neuroleptic malignant syndrome
Noninfectious causes
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Acalculous cholecystitis
Acute myocardial infarction
Adrenal insufficiency
Blood product transfusion
Cytokine-related fever
Dressler syndrome
Drug related fever
Fat emboli
Fibroproliferative phase of
acute respiratory distress
syndrome
 Gout
 Heterotopic ossification
 Immune reconstitution
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inflammatory syndrome
Intracranial bleed
Jarisch-Herxheimer reaction
Pancreatitis
Pulmonary infarction
Pneumonitis without
infection
Stroke
Thyroid storm
Transplant rejection
Tumor lysis syndrome
Venous thrombosis
Acalculous cholecystitis
Acalculous cholecystitis
 Occurs in approx 1.5% of critically ill (↑incidence),
Potentially life threatening, frequently
unrecognized.
 Complex pathophysiology: G B ischemia, bile
stasis, prolonged fasting, positive-end expiratory
pressure, parenteral nutrition and sustained
narcotic therapy).
 High rate of gangrene and perforation.
 Should be considered in any post OP or acutely ill
patient with upper abdominal pain, fever or
leukocytosis.
Acalculous cholecystitis
 US 90% Specific 100% Sensitive:
 ↑ wall thickness (>3mm)
 intramural lucencies
 GB distension
 pericholecystic fluid
 intramural sludge
 Treatment:
 Nonoperative percutaneous drainage successful 8090%.
 Open cholecystectomy remains treatment of choice.
 Mortality 15-30%.
Drug-Related Fever
Drug related fever
Pathogenesis
 Hypersensitivity reaction.
 Local inflammation at the site of administration :
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(Amphotericin B, erythromycin, KCl, sulfonamides &
cytotoxic chemotherapies)
Drugs or their delivery systems may contain pyrogens
or microbial contaminants.
Stimulation of heat production: (e.g. thyroxine)
Limit heat dissipation: (e.g., atropine)
Alter thermoregulation : (e.g., phenothiazines,
antihistamines , anti-parkinsonian drugs).
Drug-Related Fever
 Rash occurs in a small fraction of cases.
 Eosinophilia is also uncommon.
 Among drug categories:
 Antimicrobials (especially B-lactam drugs).
 Antiepileptic drugs (especially phenytoin).
 Antiarrhythmics (especially quinidine, procainamide).
 Antihypertensives (methyldopa).
 Fever induced by drugs may take several days to
resolve 3-7.
Drug-Related Fever
 Withdrawal of certain drugs may be associated
with fever, often with associated tachycardia,
diaphoresis, and hyperreflexia.
 Alcohol, opiates (including methadone),
barbiturates, and benzodiazepines have all been
associated with this febrile syndrome.
 Withdrawal and related fever may occur several
hours or days after admission.
Drug-Related Fever
Malignant Hyperthermia
 Due to genetic predisposition and exposure to
succinylcholine or inhaled anesthetic agents.
 Autosomal-dominant abnormality of the skeletal
muscle membrane (1:50000).
 Pathophysiology: massive efflux of calcium from
skeletal muscle sarcoplastic reticulum.
 Patients may undergo several operations safely
before MH crisis occurs.
Drug-Related Fever
Malignant Hyperthermia
 Onset can be delayed for as long as 24 hrs,
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especially if the patient is on steroids.
Body temp increases rapidly ,along with muscle
rigidity, tachycardia and increase CPK.
Dantrolene 2 mg/kg q 5 minutes for a total dose of
10mg.
Monitor for myoglobinuria and renal failure.
10-30% mortality.
Drug-Related Fever
Neuroleptic malignant syndrome
 Rare but more often identified in the ICU than
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malignant hyperthermia.
It has been strongly associated with phenothiazines,
thioxanthenes, and butyrophenones.
In the ICU, haloperidol is perhaps the most frequently
reported drug.
Use of droperidol and metoclopramide also has been
reported.
The initiator of muscle contraction is central
(increased levels of dopamine because of blockade of
dopaminergic receptors).
Drug-Related Fever
Neuroleptic malignant syndrome
 Risk factors:
 Dehydration
 Alcoholism
 Prior brain injury
 Use of rapid neuroleptic
Drug-Related Fever
Neuroleptic malignant syndrome
 High fever, extrapyramidal symptoms such as lead
pipe rigidity, hypercapnea, catatonia, stupor,
rigidity, autonomic instability, tremor and
rhabdomyolysis.
 Treatment:
 Cessation of antipsychotic medication
 Active cooling
 Hemodynamic support
 Dopamenergic agonists (amantadine,
bromocriptine)
 Dantrolene
Serotonin syndrome
 Caused by large number of medication
either alone in high dose or in
combination.
 increasingly seen with selective
serotonin reuptake inhibitors in the
treatment of various psychiatric
disorders.
Serotonin syndrome
 Characterized by altered mental status,
fever, agitation, myoclonus, ataxia.
 The serotonin syndrome may be
exacerbated with concomitant use of
linezolid.
 Treatment supportive and the serotonin
blocker syproheptadine my be of
benefit.
Management of fever In ICU
 Clinical assessment of new fever should
replace automatic, standing-order laboratory
and radiologic tests in the ICU.
 Serum procalcitonin levels and endotoxin
activity assay can be employed as an
adjunctive diagnostic tool for discriminating
infection as the cause for fever or sepsis
presentations.
Management of fever In ICU