Fever

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Fever

  1. 1. Crisbert I. Cualteros, M.D.
  2. 2. <ul><li>varies over the course of the day (0.5° C OR 0.9° F) </li></ul><ul><li>controlled in the thermoregulatory center in the anterior hypothalamus </li></ul><ul><li>balance between heat production and heat dissipation </li></ul><ul><li>low levels occur at 6AM : 37.2° C (98.9° F) </li></ul><ul><li>higher levels at 4 to 6PM: 37.7° C (99.9° F) </li></ul><ul><li>“ core body temperature” </li></ul><ul><li>rectal temperatures are generally 0.6° C (1° F) higher than oral readings </li></ul>
  3. 3. <ul><ul><li>elevation in core body temperature above the daily range for an individual </li></ul></ul><ul><ul><li>a feature of most infectious diseases but also found in a number of non-infectious processes </li></ul></ul><ul><ul><li>present if : rectal temperature > 38° C (100.4° F) </li></ul></ul><ul><ul><ul><ul><ul><li> oral temperature > 37.5° C ( 99.5° F) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>axillary temperature > 37.2° C (99° F) </li></ul></ul></ul></ul></ul><ul><ul><li>Mechanism: pyrogens cause elevation in PGE2 , causing an elevation in the hypothalamic temperature set-point. </li></ul></ul>
  4. 5. <ul><li>FEVER </li></ul><ul><li>HYPERTHERMIA </li></ul><ul><li>resetting of hypothalamic thermoregulatory center </li></ul><ul><li>+ </li></ul><ul><li>intact peripheral mechanisms for heat loss and production </li></ul><ul><li>unchanged hypothalamic set-point </li></ul><ul><li>Ѳ excessive heat production </li></ul><ul><li>Ѳ diminished heat dissipation </li></ul>
  5. 7. <ul><li>infection </li></ul><ul><li>inflammation </li></ul><ul><li>immunological diseases </li></ul><ul><li>tissue destruction </li></ul><ul><li>drug fever </li></ul><ul><li>transfusion reaction </li></ul><ul><li>malignancy </li></ul><ul><li>thrombo-embolic processes </li></ul><ul><li>heat stroke syndromes </li></ul><ul><li>metabolic diseases </li></ul><ul><li>pharmacologic agents </li></ul><ul><li>autonomic dysfunction </li></ul><ul><li>Malignant Hyperthermia </li></ul><ul><li>NMS </li></ul><ul><li>Serotonin Syndrome </li></ul>
  6. 9. <ul><li>Surgical site infection </li></ul><ul><li>Hospital-acquired pneumonia </li></ul><ul><li>Skin & soft tissue infections </li></ul><ul><li>Bloodstream infection </li></ul><ul><li>Gastrointestinal infection </li></ul><ul><li>CNS infection </li></ul><ul><li>Noninfectious etiologies </li></ul>
  7. 10. <ul><li>affects 5% of surgical patients </li></ul><ul><li>caused by endogenous flora </li></ul><ul><li>typically occurs 1 week after surgery </li></ul><ul><li>Emperic Tx: Piperacillin/Tazobactam + Vancomycin IV </li></ul><ul><li>could be early: Clostridium perfringens, Group A Strep </li></ul><ul><li>if suspected, wound should be opened </li></ul>
  8. 11. <ul><li>developing at least 48-72 hours after hospital admission </li></ul><ul><li>CXR </li></ul><ul><li>send sputum for Gram stain with culture & sensitivity </li></ul><ul><li>Common organisms: Staph aureus, Gm(-) bacilli </li></ul><ul><li>Emperic Tx: Piperacillin/Tazobactam + Tobramycin IV (+/- Vancomycin) </li></ul>
  9. 12. <ul><li>e.g. cellulitis, ulcer, abscess </li></ul><ul><li>skin flora (Staphylococci, Strep) </li></ul><ul><li>careful exam of the entire skin </li></ul><ul><li>may require surgical drainage or debridement </li></ul><ul><li>Emperic Tx: Cefazolin IV (Clindamycin) </li></ul><ul><li>Extensive cellulitis: Piperacillin/ Tazobactam </li></ul><ul><li>immediate surgical evaluation for necrotizing infections: necrotizing fasciitis </li></ul><ul><ul><li> Fournier gangrene </li></ul></ul><ul><ul><li> pyomyositis </li></ul></ul>
  10. 13. <ul><li>risk factors: immunosuppression, neutropenia, intravascular devices </li></ul><ul><li>2 sets of blood cultures (1 peripheral + 1 from a line) </li></ul><ul><li>remove catheters: bacteremia, septic, obvious exit site or tunnel infection </li></ul><ul><li>organisms: S. epidermidis, S. aureus </li></ul><ul><li> Enterococcus, Gm (-) bacilli </li></ul><ul><li> Candida </li></ul><ul><li>Emperic Tx: Vancomycin + Piperacillin/Tazobactam (+/- Gentamycin) </li></ul><ul><li>Hx of Multiple Antibiotic-resistance: Imepenem + Amikacin </li></ul>
  11. 14. <ul><li>C. difficile colitis </li></ul><ul><li>stool cultures for ova & parasites (rarely useful) </li></ul><ul><li>Acalculous cholecystitis </li></ul><ul><li>> fever, RUQ abdominal tenderness, jaundice </li></ul><ul><li>> risk factors: HIV, TPN, sepsis, diabetes </li></ul><ul><li>Tx: Ampicillin/Sulbactam + Gentamycin IV </li></ul>
  12. 15. <ul><li>altered mental status </li></ul><ul><li>new neurologic abnormalities </li></ul><ul><li>had neurosurgery, head trauma </li></ul><ul><li>Head CT scan: </li></ul><ul><li>> elderly patients </li></ul><ul><li>> new onset seizures </li></ul><ul><li>> focal deficits </li></ul><ul><li>> altered mental status </li></ul><ul><li>> increased ICP </li></ul><ul><li>lumbar puncture </li></ul><ul><li>Emperic Tx: Ceftriaxone + Vancomycin IV </li></ul><ul><li>PCN-allergy: Aztreonam + TMP-SMX IV </li></ul>
  13. 16. <ul><li>inflammation (IBD, skin lesions) </li></ul><ul><li>drug fever (direct effect, adverse reaction, drug discontinuation) </li></ul><ul><li>transfusion reaction (acute febrile reaction, acute hemolytic reaction) </li></ul><ul><li>neoplasms (renal cell CA, leukemia, lymphoma) </li></ul><ul><li>hematoma, thrombus (DVT, PE) </li></ul><ul><li>metabolic disorders (gout, porphyria) </li></ul><ul><li>autoimmune disease s </li></ul><ul><li>sarcoidosis </li></ul>
  14. 17. <ul><li>HYPERTHERMIA + MUSCLE RIGIDITY triggered by halogenated inhalation anesthetics (halothane) or depolarizing muscle relaxants (succinylcholine) </li></ul><ul><li>genetic predisposition </li></ul><ul><li>autosomal dominant (50%) </li></ul><ul><li>Excessive release of Ca++ from abnormal skeletal muscle Ryanodine receptor isoform 1 </li></ul><ul><li>Management: </li></ul><ul><ul><ul><li>prompt cessation of anesthetic </li></ul></ul></ul><ul><ul><ul><li>hemodynamic support </li></ul></ul></ul><ul><ul><ul><li>physical cooling (mist) </li></ul></ul></ul><ul><ul><ul><li>Dantrolene (reduces mortality from >70% to <5%) </li></ul></ul></ul>
  15. 18. <ul><li>a spectrum of inherited defects in genes that are responsible for a variety of Ca++ regulatory proteins within sympathetic neurons or in the hypothalamus </li></ul><ul><li>HYPERTHERMIA + MUSCLE RIGIDITY plus BRADYKINESIA + HYPOREFLEXIA*** </li></ul><ul><li>Altered level of consciousness </li></ul><ul><li>Elevated creatine kinase </li></ul><ul><li>inciting events: blockade of dopaminergic receptors (haloperidol) in corpus striatum OR withdrawal of exogenous dopaminergic agonists (anti-Parkinson drugs) </li></ul><ul><li>cause of death: autonomic dysfunction </li></ul><ul><li>Management: </li></ul><ul><ul><li>Discontinuation of affecting agent </li></ul></ul><ul><ul><li>Cooling </li></ul></ul><ul><ul><li>Pharmacologic treatment with Dantrolene, Bromocriptine </li></ul></ul>
  16. 19. <ul><li>triad: neuromuscular abnormality (tremors, clonus, hyperkinesia***), mental status change & autonomic hyperactivity (diarrhea) </li></ul><ul><li>pathogenesis: </li></ul><ul><ul><li>reduced serotonin uptake (SSRIs, TCAs) </li></ul></ul><ul><ul><li>increased serotonin release (amphetamine, cocaine, MDMA, LSD) </li></ul></ul><ul><ul><li>excess serotonin precursor (buspirone, L-dopa, lithium) </li></ul></ul><ul><ul><li>slowing of serotonin metabolism (MAO inhibitors) </li></ul></ul>
  17. 20. <ul><li>Management: </li></ul><ul><li>> Benzodiazepines </li></ul><ul><li>> 5-OH-tryptamine antagonists: </li></ul><ul><li>Cyproheptadine (may cause sedation) </li></ul><ul><li>Chlorpromazine (may cause orthostatic </li></ul><ul><li>hypotension) </li></ul>
  18. 21. <ul><li>FEVER </li></ul><ul><li>HYPERTHERMIA </li></ul><ul><li>antipyretics: </li></ul><ul><li>ASA </li></ul><ul><li> NSAIDs </li></ul><ul><li>Acetaminophen </li></ul><ul><li>combination of ASA + acetaminophen </li></ul><ul><li>cooling blankets </li></ul><ul><li>rapid reduction of temperature by physical means </li></ul><ul><li>cool or tepid (20° C) bathing </li></ul><ul><li>IVF for dehydration </li></ul><ul><li>antipyretics of NO use </li></ul><ul><li>submersion should be avoided </li></ul>
  19. 22. Thank you

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