Fever, Friend or Foe? - Paul Young's Talk at SMACC

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LITFL's Paul Young looks at the evidence for and against a beneficial role for fever in the critically ill in this whimsical and erudite walk through medical history and science. For audio go here: https://gmep.org/media/14605

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  • Disclosures...
  • Confessions...
  • Nothing to do with social media...and very little to do with critical care
  • Recently, I have been writing my PhD thesis. As it would happen it is on fever and antipyresis in critical illness which is lucky because I sure that some of you are already under the impression that I will not actually get round to saying anything in this talk. 15 years ago I wrote a thesis for a science degree and it was a fecking nightmare you go to the library and ask them to get you something and then you wait a month and then it comes and it turns out to be irrelevant. Now you click a button and get what you need. One click got me this...
  • This is very quotable and many review articles on fever include this quote. Of course, in 1896 antibiotics hadn’t been invented yet and Osler was not actually ready talking about fever. He was talking about the scourge of infectious diseases in the pre-antibiotic era and he was right. Infectious diseases are bad – they are a major public health problem
  • Background Although the burden of infectious diseases seems to be decreasing in developed countries, few national studies have measured the total incidence of these diseases. We aimed to develop and apply a robust systematic method for monitoring the epidemiology of serious infectious diseases. Methods We did a national epidemiological study with all hospital admissions for infectious and non-infectious diseases in New Zealand from 1989 to 2008, to investigate trends in incidence and distribution by ethnic group and socioeconomic status. We extended a recoding system based on the ninth revision of international classification of diseases (ICD-9) to the tenth revision (ICD-10), and applied this to data for hospital admissions from the New Zealand Ministry of Health, National Minimum Dataset. We filtered results to account for changes in health-care practices over time. Acute overnight admissions were the events of interest. Findings Infectious diseases made the largest contribution to hospital admissions of any cause. Their contribution increased from 20·5% of acute admissions in 1989–93, to 26·6% in 2004–08. We noted clear ethnic and social inequalities in infectious disease risk. In 2004–08, the age-standardised rate ratio was 2·15 (95% CI 2·14–2·16) for Māori (indigenous New Zealanders) and 2·35 (2·34–2·37) for Pacific peoples compared with the European and other group. The ratio was 2·81 (2·80–2·83) for the most socioeconomically deprived quintile compared with the least deprived quintile. These inequalities have increased substantially in the past 20 years, particularly for Māori and Pacific peoples in the most deprived quintile. Interpretation These findings support the need for stronger prevention efforts for infectious diseases, and reinforce the need to reduce ethnic and social inequalities and to address disparities in broad social determinants such as income levels, housing conditions, and access to health services. Our method could be adapted for infectious disease surveillance in other countries. 2004 to 2008.
  • Fever is one of the cardinal signs of infection. Fever is potentially treatable (and is often treated) but should it be?
  • Biopesticide based on fungal pathogen Metarhizium flavoviride
  • Percentage survival of desert iguanas infected with Aeromonas hydrophila and maintained at temperatures of 34° to 42°C. The number of lizards in each group is given in parenthesis. (From Kluger et al. 1975 30 )
  • This study was a prospective observational investigation conducted in 25 hospitals: 10 in Korea and 15 in Japan. At each participating site, all adult patients who required intensive care for more than 48 hours from 1 September 2009 to 30 November 2009 were candidates for enrollment in the study; we excluded patients with post-cardiac arrest, post craniotomy, traumatic brain injury, central nervous system infection, subarachnoid hemorrhage, intracerebral hemorrhage or stroke at their ICU admission. We separated our cohorts into patients with and without sepsis for the first 24 hours of ICU admission. Sepsis was defined as the presence of microbiologically proven, clinically affirmed or suspected infection along with the presence of systemic inflammatory response syndrome.
  • Point prevalence data. 311 had sepsis or other inflammatory pathologies in the absence of neurological injury or recent elective surgery
  • N=399
  • Severe sepsis 10mg/kg of ibuprofen six hourly for eight doses.
  • Sepsiscool
  • Randomised all patients on day 3 of admission (except TBI) to permissive vs aggressive temperature management. Aggressive 650mg Q6hrly for temp>38.5 and cooling blanket added for >39.5. Permissive paracetamol and cooling blanket at 40C
  • Fever, Friend or Foe? - Paul Young's Talk at SMACC

    1. 1. Fever: friend or foe? Paul Young ICU Specialist, Wellington Hospital, NZ
    2. 2. Fever: friend or foe?
    3. 3. Fever is one of the cardinal signs of
    4. 4. Why doesn’t Campylobacter make chickens sick?
    5. 5. Kluger MJ, Ringler DH, Anver MR. Fever and survival. Science 1975;188:166-8.
    6. 6. Neurosyphilis resolves after febrile illness Malaria causes a fever Does Malaria cure syphilis?
    7. 7. n=269,078
    8. 8. antipyretics physical cooling
    9. 9. n= 689
    10. 10. permissive vs. aggressive temperature management
    11. 11. febrile ICUfebrile ICU patients withpatients with infectionsinfections ? friend or foe
    12. 12. DesignDesign • Multi-centreMulti-centre - 22 sitesin Australiaand New Zealand- 22 sitesin Australiaand New Zealand • RandomisedRandomised • Double-blindDouble-blind • Placebo-controlledPlacebo-controlled • Phase2 trialPhase2 trial N= 700 patientsN= 700 patients
    13. 13. •PatientsPatients – ICU patients with fever + infectionICU patients with fever + infection •InterventionIntervention – Intravenous paracetamol vs. placeboIntravenous paracetamol vs. placebo •OutcomeOutcome – ICU free days at day 28ICU free days at day 28
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