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Feverinicucopy 130407142041 Phpapp02
Feverinicucopy 130407142041 Phpapp02
DR MUHAMMAD AKRAM
M.C.H.JEDDAH
PHYSIOLOGY
• Body temperature is controlled by the
hypothalamus
• Neurons in pre-optic ant hypothal & post
hypothal
• Receive two kinds of signals
• Peripheral N transmit info from warmth/cold receptors
of skin
• Other from temp of blood bathing the region
• Both signals are integrated by Temp
Regulation Centre (TRC) of hypothalamus
• Maintain normal temp
• In neutral temp environment
• Humans produces more heat than is needed
• To maintain core body temp at 37°C
2
TEMPERATURE
MEASUREMENT
Mean oral temp = 36.8° ± 0.4°C (98.2°
± 0.7°F)
Lowest at 6 A.M. and highest between 4 to
6 PM
Maximum normal oral temp
37.2°C (98.9°F) at 6 AM
37.7°C (99.9°F) at 4 PM (99 %)
Fever Definition ( Harrison)
A.M temperature of >37.2°C (>98.9°F) or
P.M. temperature of >37.7°C (>99.9°F)
3
TEMPERATURE
MEASUREMENT
Normal daily temp variation is 0.5°C (0.9-
1°F)
During febrile illness diurnal variation is
higher
Daily temp variation is fixed in early
childhood
Elderly individuals have reduced ability to
develop fever even in severe infections
Rectal temp 0.4°C (0.7°F) > oral readings
Lower-esophageal temp reflects core temp
TEMPERATURE
MEASUREMENT
Tympanic membrane (TM)
thermometer
Measure radiant heat from TM & ear canal
TM values are 0.8°C (1.6°F) < rectal
temp
In women who menstruate AM temp
lower in the 2 weeks before ovulation
It rises by ~0.6°C (1°F) with ovulation
Remains at that level until menses occur
DEFFINITION OF FEVER IN
ICU
The Society of Critical Care
Medicine practice parameters
define fever in the ICU as
a temperature > 38.3°C (
101°F).Unless the patient has other
features of an infectious process,
only a temperature > 38.3°C (
101°F) warrants further
investigation.
EPIDEMIOLOGY
Fever complicates up to 70 percent of all ICU
admissions and is often due to an infection
In one observational study of 24,204 adult ICU
admissions, fever ≥39.5ºC (103 ºF) was associated
with an increase in mortality (20 versus 12 percent)
FEVER PATTERNS
Most patients have 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.
The appearance of fever at different time points
in the course of a patient’s illness may however
provide some diagnostic clues.
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.
CAUSES OF FEVER IN THE ICU
Any disease process that results in the release of the
proinflammatory cytokines IL-1, IL-6, and TNF- will
result in the development of fever
Infections are the commonest cause of fever in ICU
patients, many noninfectious inflammatory
conditions cause the release of the proinflammatory
cytokines with a febrile response.
Similarly, it is important to appreciate that not all
patients with infections are febrile.
Approximately 10% of septic patients are hypothermic
and 35% are normothermic at presentation.
Septic patients who fail to develop a temperature have a
significantly higher mortality than febrile septic patients
The reason that patients with established infections fail
to develop a febrile response is unclear; however,
preliminary evidence suggests that this aberrant
response is not due to diminished cytokine production.
DIFFERENTIAL DIAGNOSIS
Sources of fever in the ICU may be
Infectious
Non infectious
NONINFECTIOUS CAUSES
For reasons that are not entirely clear, most noninfectious
disorders usually do not lead to a fever > 38.9°C (102°F);
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
> 102°F.
Similarly, fever secondary to blood transfusion may be >
102°F.
On the basis of the number of medications administered to
patients in the ICU, one would expect drug fever to be a
relatively common event.
Drug fever should be considered in patients with an
otherwise unexplained fever, particularly if they are
receiving ß-lactam antibiotics.
Drug fever is usually characterized by high spiking
temperatures and shaking chills. It may be associated with
a with leukocytosis and eosinophilia. Relative bradycardia,
although commonly cited, is uncommon.
NONINFECTIOUS CAUSES
ATELECTASIS is commonly implicated as a
cause of fever. Standard ICU texts list
atelectasis as a cause of fever, although
they provide no primary source.
FEBRILE REACTIONS
complicate about 0.5% of blood transfusions
More common following platelet transfusion.
Antibodies against membrane antigens of
transfused leukocytes and/or platelets are
responsible for most febrile reactions to cellular
blood components.
Febrile reactions usually begin within 30 min to 2
h after a blood-product transfusion is begun.
The fever generally lasts between 2 h and 24 h
and may be preceded by chills.
An acute leucocytosis lasting up to 12 h
commonly occurs following a blood transfusion.
NONINFECTIOUS CAUSES
ARDS may progress to a "chronic" stage characterized
by pulmonary fibroproliferation and fevers
ACALCULOUS CHOLECYSTIS occurs in approximately
1.5% of critically ill patients. An important
"noninfectious" cause of fever in critically ill patients, as
it is frequently unrecognized and therefore potentially
life threatening
The pathophysiology of acalculous cholecystitis is related
to the complex interplay of a number of pathogenetic
mechanisms, including gallbladder ischemia, bile stasis with
inpissation in the absence of stimuli for emptying of the
gallbladder, positive-end expiratory pressure, and
parenteral nutrition.
Bacterial invasion of the gallbladder appears to be a
secondary phenomenon.
The diagnosis of acalculous cholecystitis is often
exceedingly difficult and requires a high index of suspicion.
Pain in the right upper quadrant is the finding that most
often leads the clinician to the correct diagnosis, but it may
frequently be absent.
NONINFECTIOUS CAUSES
The most difficult patients are those recovering from
abdominal sepsis who deteriorate again, misleadingly
suggesting a flare-up of the original infection.
Rapid diagnosis is essential because ischemia may
progress rapidly to gangrene and perforation, with
attendant increase in the already high morbidity and
mortality
The diagnosis should therefore be considered in every
critically ill patient who has clinical findings of sepsis
with no obvious source
Ultrasound is the most common radiologic investigation
used in the diagnosis of acalculous cholecystitis
Features include increased wall thickness, intramural
lucencies, gallbladder distension, pericholecystic fluid,
and intramural sludge. Wall thickness 3 mm is reported
to be the most important diagnostic feature on
ultrasound examination, with a specificity of 90% and a
sensitivity of 100%.
Percutaneous cholecystostomy may be the procedure of
choice
Posterative fever upto 48 Hrs.
VENTILATOR-ASSOCIATED
PNEUMONIA
occurs in approximately 25% of
patients undergoing mechanical
ventilation
Fagon and colleagues reported an
attributable mortality of 27%.
Diagnosis of VAP remains one of the
most difficult clinical dilemmas in
critically ill patients receiving
mechanical ventilation
initial empiric antibiotic regimen must
be broad and cover both Gram-
positive and negative organisms,
DIAGNOSTIC APPROACH
A thorough review of the medical history and a full physical
examination should be performed whenever a patient develops
an unexplained fever in the ICU.
Blood cultures are the only mandatory diagnostic tests in patients
with a new fever
SPUTUM..
indicated for febrile patients with any of the following findings
new sputum production; a change in the color, amount, or
thickness of their sputum.
a new or progressive pulmonary infiltrate.
an increased respiratory rate.
an increased minute volume; a decreased tidal volume;
decreased oxygenation.
needing more ventilatory support; or requiring more inspired
oxygen.
DIAGNOSTIC APPROACH
URINE .
Urinalysis and urine culture are
indicated for febrile patients with
○ a urethral catheter.
○ urinary obstruction.
○ renal calculi.
○ recent genitourinary surgery or trauma,
or neutropenia.
DIAGNOSTIC APPROACH
CHEST IMAGING
A chest radiograph is worthwhile in
many patients with
respiratory symptoms or signs.
It may detect a new or progressive
pulmonary infiltrate.
distinguish pneumonia from
tracheobronchitis, or identify a respiratory
source of fever other than pneumonia or
tracheobronchitis
Computed tomography (CT) should be
reserved for the clarification of abnormal
chest radiographic findings.
DIAGNOSTIC APPROACH
S.CHEMISTRY
Done for LFT, Urine fucntions,
electrolyte imbalance
TFT(THYROID FUCTION TEST)
Done if thyroid storm is suspected
Blood Cultures
B/C should be obtained in patients with a new fever
when clinical evaluation does not strongly suggest a
noninfectious cause
Skin Preparation
The site of venipuncture should be cleaned with either
2% chlorhexidine gluconate in 70% isopropyl alcohol
(2% alcoholic chlorhexidine), or 1–2% tincture of iodine
(iodine in alcohol). Povidone iodine (10%), although
acceptable, is a less efficient agent.
When blood is to be inoculated into a culture or
transport tube, the needle used for venipuncture should
not be replaced by a sterile needle. The risk of a needle
stick injury during the switch in needles is currently
thought to outweigh the risk of contamination
Blood Cultures
Labeling