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Fever in icu
1.
2. Fever is a co-ordinated neuro endocrine,
autonomic and behavioral response that is
adaptive, and an essential part of the acute-
phase response to immune stimulus or tissue
injury
Co-ordinated by the hypothalamus
Neural input from peripheral thermoreceptors
Humoral cues from inflammation or infection
3. 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.
4. Enhances parameters of immune function
Improves antibody production
Activates T-cells
Produces cytokines
Enhances neutrophil and macrophage function
5. 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
7. 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
8. 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
9.
10. Normal temperature
98.2O F (36.8OC)
Diurnal variations of temperature with evening rise
up to 100O F (37.8O C)
11. 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)
12. 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?
13. Patient with an
obvious focus of
infection
Where is the
focus?
Acute un-differentiated
fever
What is causing this
fever?
14. Community acquired pneumonia
Acute CNS infection
Urinary tract infection
Abdominal focus of infection
Wound infection / Pus collections
Trauma with infection
15. And why do they come to the ICU
Ventilatory support – respiratory failure –
pneumonia
Hemodynamic support – shock
Renal replacement therapy – renal failure, severe
acidosis
Monitoring, Neurological dysfunction,
Hematologic
16. Patients
presenting with
a febrile illness
Patient developing fever
in the ICU
Is there a focus
of infection?
Acute undifferentiated
fever√
17. Where no specific focus identified
Look for specific clues to guide in the
diagnosis
25. 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 maybe >102°F.
29. Patients
presenting with
a febrile illness
Patient developing fever
in the ICU
Is there a focus
of infection?
Acute undifferentiated
fever
Infective
Causes
Non-infective
Causes
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57. Should I be worried?
YES
In an immunocompromised
patient
If hemodynamic instability
Decreasing UOP
Increasing lactate
Worsening conscious state
Falling platelet counts
Worsening coagulopathy
NO
Small spike
No hemodynamic instability
Carefully examine clinically
for an obvious focus of
infection
58.
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60.
61. 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
