Fever is a co-ordinated neuro endocrine,

autonomic and behavioral response that is

adaptive, and an essential part of the acutephase response to immune stimulus or tissue
injury
Co-ordinated by the hypothalamus

Neural input from peripheral thermoreceptors

Humoral cues from inflammation or infection

Cytokines released by monocytic cells play a central role in

the genesis of fever. IL- 1, IL-6, and(TNF)-a.
the cytokine receptor interaction activates phospholipase
A2, resulting in the liberation of plasma membrane
arachidonic acid as substrate for the cyclo-oxygenase
pathway.
Some cytokines appear to increase cyclo-oxygenase
expression directly, leading to liberation of prostaglandin
E2. This small lipid mediator diffuses across the blood
brain barrier, where it acts to decrease the rate of firing of
preoptic warm-sensitive neurons, leading to activation of
responses designed to decrease heat loss and increase
heat production.
In a small proportion of hospitalized patients,
hyperthermia may result from increased sympathetic
activity with increased heat production.

 Enhances

parameters of immune function

Improves

antibody production

Activates

T-cells

Produces

cytokines

Enhances

neutrophil and macrophage function

Hot baths for malaria fever for treatment of syphilis

Positive correlation between maximum temperature
on the day of bacteremia and survival
Temperature > 38 C improved survival in patients
with SBP
In children with chicken pox, treatment with
acetaminophen increased time to crusting of skin
lesions

Increased cardiac output

Increased oxygen consumption

Increased carbon-di-oxide production

Increased basal metabolic rate

Poorer neurological outcomes in patients with

stroke and traumatic brain injury who manifest
temperature
Fever poorly tolerated in patients with reduced
cardio-respiratory reserve
Maternal fever cause of fetal malformations as
well as spontaneous abortions

Peripheral temperature measurements

Measured in the outer 1.6 mm of skin or mucus

membranes
Considered unreliable as influenced by environmental
temperatures, mouth breathing etc.
Examples oral temperature, axillary, skin
temperature

Core temperature measurements

Not influenced by external factors

More accurately reflects temperature in the internal
organs
Examples pulmonary, rectal, esophageal, urinary,
tympanic

 Normal
98.2O

temperature
F (36.8OC)

Diurnal

variations of temperature with evening rise

up to 100O F (37.8O C)

 Society

of Critical Care Medicine (SCCM)

and Infectious diseases society of America
recommend investigations in the ICU if
temperature is above
101O

F (38.3OC)

Patient who
comes in with a
febrile illness
Cause of fever need
to be ascertained

Patient in the ICU

develops fever
What is causing this
fever?

Patient with an
obvious focus of
infection
Where is the
focus?

Acute un-differentiated
fever
What is causing this
fever?

Community acquired pneumonia

Acute CNS infection
Urinary tract infection
Abdominal focus of infection
Wound infection / Pus collections
Trauma with infection

 And
Ventilatory

pneumonia

why do they come to the ICU

support respiratory failure

Hemodynamic

support shock

Renal

replacement therapy renal failure, severe

acidosis

Monitoring,

Neurological dysfunction,
Hematologic

Patients
presenting with
a febrile illness

Is there a focus
of infection?

Patient developing fever

in the ICU

Acute undifferentiated
fever

Where no specific focus identified

Look for specific clues to guide in the

diagnosis

Fever with thrombocytopenia

Fever with hepato-renal dysfunction
Fever with pulmonary renal syndrome
Fever with altered sensorium

Fever with thrombocytopenia

Malaria (notably falciparum)
Dengue
Leptospirosis
Rickettsial infections
Viral fevers

Fever with hepato-renal dysfunction

Malaria (falciparum)
Leptospirosis
Scrub typhus
Fulminant hepatic failure with hepatorenal

Fever with pulmonary-renal dysfunction

Malaria (falciparum)
Leptospirosis
Scrub typhus
Hantavirus infection
Severe legionella / pneumococcal pneumonia

Fever with altered sensorium

Malaria cerebral malaria
Encephalitis
Meningitis
Typhoid fever
Septic encephalopathy
Brain abscess

Patients
presenting with
a febrile illness

Is there a focus
of infection?

Patient developing fever

in the ICU

Acute undifferentiated
fever

Infectious causes

Where is the focus?

Non-infective causes

What is causing this

fever?

most noninfectious disorders usually do not

lead to a fever> 38.9C (102F); therefore, if
the temperature increases above this
threshold, the patient should be considered
to have an infectious etiology as the cause of
the fever However, patients with
drug fever may have a temperature >102F
Similarly, fever secondary to blood
transfusion maybe >102F.

Ventilator associated pneumonia

Catheter related blood stream infections
Urosepsis
Intra-abdominal infections
Sinus infections
Diarrhoea

Fungal infections including candidemia

Surgical wound infections
Acalculous cholecystitis
Endocarditis
Meningitis

Patients
presenting with
a febrile illness

Is there a focus
of infection?

Patient developing fever

in the ICU

Acute undifferentiated
fever

Infective
Causes

Non-infective
Causes

Should I be worried?
YES

NO

In an immunocompromised
patient
If hemodynamic instability
Decreasing UOP
Increasing lactate
Worsening conscious state
Falling platelet counts
Worsening coagulopathy
Small spike
No hemodynamic instability
Carefully examine clinically
for an obvious focus of
infection

Bloods counts, procalcitonin

Imaging CXR, Scans as indicated
(abdomen, sinus, CT brain)

Cultures as appropriate ETA, BAL,

Urine, Blood cultures (peripheral and
through lines), cultures from pus,
wound etc, Stool for clostridium