New onset fever ICU.ppt

New onset fever in ICU:
Its not always infection
DR MANINDER S DHALIWAL
SENIOR CONSULTANT : PICU
AMRITA HOSPITAL, FARIDABAD

In PICU, we are all fighting a
common enemy 
a disease process….

New Onset fever
is always a stress
Fever
PICU

How to control and
approach fever in PICU?

Usual Scenario in PICU
Patient in PICU develops New Onset fever

We Blame Infection – We Blame nursing care – We Blame Lines, ET tube etc

We give anti-pyretics and send cultures and step up Antibiotics

Ceftriaxone Piperacillin - Tazo Ceftazidime Meropenem Colistin
Tigicycline
+Vancomycin Linezolide

Ceftriaxone Piperacillin - Tazo Ceftazidime Meropenem Colistin
Tigicycline
+Vancomycin Linezolide
Usual Choice, irrespective of unit or disease

Cases
A recovering dengue
Develops
New Onset Fever
Child undergoing hernia Sx
Develops
Post op
New Onset Fever
A recovering staph
osteomyilitis
Develops
New onset Fever
A Intubated patient with
central line etc
Develops
New Onset Fever

A recovering dengue
Develops
New Onset Fever
Develops
Post op
New Onset Fever
A recovering staph
osteomyilitis
Develops
New onset Fever
central line etc
Develops
New Onset Fever
Cases

Cases
A recovering dengue
Develops
New Onset Fever
Develops
Post op
New Onset Fever
A recovering staph
osteomyilitis
Develops
New onset Fever
central line etc
Develops
New Onset Fever
Can be HLH
Rx - Steroids
Benign Post Op fever
Rx - Observe
Think of DVT
Rx - LMWH
CRBSI
Rx – Antibiotics
As per unit policy
Local Antibiogram
Cases

Cases
A recovering dengue
Develops
New Onset Fever
Develops
Post op
New Onset Fever
A recovering staph
osteomyilitis
Develops
New onset Fever
central line etc
Develops
New Onset Fever
Can be HLH
Rx - Steroids
Benign Post Op fever
Rx - Observe
Think of DVT
Rx - LMWH
CRBSI
Rx – Antibiotics
As per unit policy
Local Antibiogram

Are deewano
Mujhe pehchaano
Kahan se aaya
Main hoon kaun
Cytokine Storm
HLH MAS CRS
MIS-C
The cytokine storm has captured the attention of both - the public and the scientific community

Exponential increase in the number of publications per year cited in
PubMed

Our common experience of Cytokine storm
Secondary HLH: Dengue, EBV, Rickettsial, Sepsis
MIS-C
MAS
TSS
Post Haploidentical BMT
HLH due to malignancy or chemotherapy
Congenital HLH

Recognizing the tip of the HLH/MAS iceberg
The iceberg may include many common things too-
Febrile hyperferritinemic states
MODS
SIRS
Negative and positive sepsis cultures.

Battling The Disease
ICU PATIENT
Cytokine Storm

Cytokine Storms (Hypercytokinemia) – Secondary to Infection
Cytokine Storms (Hypercytokinemia) are Central to Many Infections too-
Spanish Flu of 1918
Typhoid fever of 1978
Severe Acute Respiratory Syndrome
Seasonal influenza
Systemic sepsis
Dengue virus
Covid 19
Rickettsial Infection
EBV Viremia etc
On the one hand, proinflammatory cytokines
cause damage
On the other hand, the host needs them to
remove pathogenic microorganisms.

Severe Dengue – Can have HLH/ Cytokine storm at
Presentation or after 1 week with secondary worsening
At Presentation they come with
• Shock on pressors
• High fever
• Highly deranged liver functions (ALT>1000)
• High ferritin >1000ng/mL
• DIC with low fibrinogen
• Low sodium
• Dengue IgM / NS1 +
• No co-infection
Think of HLH
Treatment after confirmation:
Dexamethasone or IVIG
Recovering dengue on 2nd week has
• High fever
• Worsening liver functions (ALT>1000)
• High ferritin >500ng/mL
• Low fibrinogen
• Low sodium
• 2 cell lines affected
• Splenomegaly
• Culture negative
Think of HLH
Treatment after confirmation :
Dexamethasone or IVIG

HLH – Diagnostic Criteria 2004
Tick atleast least 5 of 8 diagnostic criteria based on HLH-2004:
1. Fever (> 38.5° C )
2. Splenomegaly
3. Cytopenia involving > 2 cell lines
4. Serum ferritin > 500 ng/mL
5. Hypertriglyceridemia (triglycerides > 300 mg/dL) or hypofibrinogenemia (fibrinogen < 150 mg/dL)
6. Hemophagocytosis (in biopsy samples of bone marrow, spleen, or lymph nodes)
7. Low or absent natural killer cell activity
8. Elevated soluble interleukin-2 (CD25) levels (>2400 U/mL)
Start doing
serum
ferritin

PICU Fever
 In general, a fever in the PICU is >38.3 °C, 2 readings in 24 hours
 Or >38.3 °C for > 1 hour
 Systematic review of observational studies in febrile critically ill children
reported many different definitions of pyrexia, with 38.3 °C being the
most frequently cited threshold

How to Obtain temperature in Intubated Patient in PICU
 Gold standard is thermistor in either PA catheter or bladder catheter
– Esophageal probes in distal 1/3 of esophagus are nearly equal in
accuracy
 Rectal temperatures can be used in leu of a
central measuring device
– Readings from the rectum are often a few tenths of a degree higher
than core temperature
 Oral temperatures are often easier to obtain but are not suggested
– Can be confounded by mouth breathers, heated gases, or fluid
ingestion
 Tympanic membrane temperature is believed to reflect the
temperature of the hypothalamus and, thus, the core body
temperature
– Poor consistency and lots of variables in obtaining accurate
measurements
 Infrared thermometry, axillary thermometry and chemical dot
thermometry should not be used in the ICU (level 2)

accuracy
ingestion
temperature
measurements
Rectal
Probe

accuracy
ingestion
temperature
measurements
Rectal
Probe
Non Intubated : Axillary (Disposable : Single Patient-Single Use)
Rectal Probe – Not for immunocomprimised patients as probe
can cause local injury and can lead to gut bacterial translocation

What to Do About New Fever in PICU?

Differential Diagnosis of New onset Fever
& Evaluate as per Individual Case
INFECTIOUS CAUSES - COMMON
Bacteremia
Catheter – related Infections
VAP
UTI
Surgical site infection
PneumoniaEmpyma
Endocarditis (Common in staph)
Sinusitis (Nasal - Intubated patient)
Thrombophelitis, Cellulitis
Meningitis Abscess
Hidden Pus (Cholangitis, Intra-abdominal collection)
NON – INFECTIOUS CAUSES – ALSO LIKELY

Differential Diagnosis of New onset Fever
& Evaluate as per Individual Case
INFECTIOUS CAUSES - COMMON
Bacteremia
Catheter – related Infections
VAP
UTI
Surgical site infection
PneumoniaEmpyma
Endocarditis (Common in staph)
Sinusitis (Nasal - Intubated patient)
Thrombophelitis, Cellulitis
Meningitis Abscess
Hidden Pus (Cholangitis, Intra-abdominal collection)
NON – INFECTIOUS CAUSES – ALSO LIKELY
Drug Fever
Pancreatitis
Benign Post op Fever
ICH
DVT
Transfusion reactions
Adrenal Insufficiency
Atropine & Aspirin overdose
Ischemic Colitis
Vasculitis
HLH , MAS etc

Let’s Make Treatment – Simple!!
How strong is the Indication for controlling fever?
Other cause of Hyperthermia Sepsis with organ dysfunction, but no
organ failure
Heat Stroke Sepsis with no organ dysfunction
Septic Shock with Organ Failure Sepsis
Sepsis Causing Tachycardia in stable child
Post CPR Discomfort to doctor
Brain Issues – High ICP Discomfort to child
Very Strong Not Very Strong
High Fever
>41
Low Fever
38 - 38.5
Mod Fever
>38.5-41
Fever – Not Good for Brain

How strong is the Indication for controlling fever?
Other cause of Hyperthermia Sepsis with organ dysfunction, but no
organ failure
Heat Stroke Sepsis with no organ dysfunction
Septic Shock with Organ Failure Sepsis
Sepsis Causing Tachycardia in stable child
Post CPR Discomfort to doctor
Brain Issues – High ICP Discomfort to child
Very Strong Not Very Strong
High Fever
>41
Low Fever
38 - 38.5
Mod Fever
>38.5-41
Fever – Not Good for Brain
Let’s Make Treatment – Simple!!

Don’t Just Sit There, Do SOMETHING!
So, we give PCM? Is this wrong?
antipyr
eti
less
than 3
Sullivan JE, Farrar HC. Fever and antipyretic use in
children. Pediatrics. 2011;127(3):580-7.
illness but
is, in
There is no evidence that reducing fever reduces morbidity or
mortality from a febrile seizure.

Don’t Just Sit There, Do SOMETHING!
So, we give PCM? Is this wrong?
antipyr
eti
less
than 3
Sullivan JE, Farrar HC. Fever and antipyretic use in
children. Pediatrics. 2011;127(3):580-7.
illness but
is, in
There is no evidence that reducing fever reduces morbidity or
mortality from a febrile seizure.
This is true for ER room or OPD practice – But Brain in PICU hates fever
So, if in PICU – Control fever for febrile seizure

Ok, it’s a fever. Now what should we do?

N Engl J Med 1997;336:912-8.
 He concluded that patients with sepsis, treatment with ibuprofen
It is safe in such patients
Reduces levels of prostacyclin and thromboxane
Decreases fever, tachycardia, oxygen consumption, and lactic acidosis
But
It does not prevent the development of shock or ARDS
It does not improve survival

Deleterious Effects Of Fever
 Increase in cardiac output
 Increase oxygen consumption (10% per 1°C)
Manthous CA et al, Am J Respir Crit Care Med 1995;151:10 -14.
 Increase carbon dioxide production
 Poor neurological outcomes in patients with stroke and traumatic brain injury who manifest
fever.
Ginsberg MD et al, Stroke 1998;29:529-34.
Marion DW et al, Current Pharm Dis 2001;7:1533-6.

Protective Effect Of Fever
It helps to rid of the host from invading pathogens: eg
Plasmodium species,
Spirochaetes,
Bacteria such as Streptococcus pneumoniae are inhibited by elevated
body temperatures.
Marik PE et al, Chest 2000;117:855-69.

Protective Effect Of Fever
Enhance parameters of immune function
Improves antibody production
Activates T-cell
Produces cytokines
Enhanced neutrophil and macrophage function
Marik PE et al, Chest 2000;117:855-69.
Jampel HD et al, J Exp Med 1983;157:1229-38. Sande MA et al, J Infect Dis 1987;156:849-50.
Bryant RE et al, Arch Intern Med 1971;127:120-8. Weinstein MR et al, Am J Med 1978;64:592 -8

When to Start Looking for
an Infectious Cause of
Fever
 Fever occurred in 82 patients (40.6%) during anytime of
their PICU
 If the fever occurs more than 48 hours after admission,
there is a greater likelihood that there is a new infectious
process occurring.
 If the new fever was found to be infectious, VAP, UTI, and
blood stream infection were most common if a source
was found; however, 60% of the cases had no microbial
growth despite elevated inflammatory markers and
clinical signs.

Ask 6 simple question?
1. Is there any underlying illness like malignancy, diabetes etc
2. What is the acute condition leading to ICU admission?
3. Any invasive procedures or lines or tubes in patient?
4. Fever chart – see trend and pattern?
5. Physical examination & do bedside USG
6. Make a differential diagnosis?

Do we need a blood culture?
 The bloodstream is a common site of infection in critical illness
– Infection from LRTI, abdominal and urinary sources can easily invade bloodstream
 Because a bacteremia can have a profound affect on prognosis and therapy, blood
cultures should be performed for patients with new fever, even when the
clinical findings do not strongly suggest a infectious cause, in sick PICU patient

SCCM and IDSA Recommendations for Work Up
 Blood Cultures:
– Obtain 1 set blood cultures within the first 24 hrs of the new onset of fever (level 2)
– For patients without an indwelling vascular catheter, obtain atleast two blood cultures
– If the patient has an intravascular catheter, one blood culture should be drawn by
venipuncture and at least one culture should be drawn through an intravascular catheter

Pediatric bacterial blood cultures:
Recommended blood volume
Patient Weight (kg) Recommended blood volume per
culture (mL)
<8.5 1
8.5 – 13.5 3
13.5 - 27 5
27 – 40 10
40 – 55 15
>55 20
1.Kaditis AG, O'Marcaigh AS, Rhodes KH, et al. Yield of positive blood cultures in pediatric oncology patients by a new
method of blood culture collection. Pediatr Infect Dis 1996; 15:615.
2.Specimen collection, transport, and processing: Bacteriology. In: Manual of Clinical Microbiology, 10th ed, Versalovic
J, Carroll KC, Funke G, et al (Eds), ASM Press, Washington, DC 2007.

SCCM and IDSA
Recommendations for Work Up
Pulmonary Infections and ICU-Acquired Pneumonia
• Physical examination, chest radiograph, and examination of pulmonary secretions
comprise the initial evaluation
• A chest imaging study should be obtained
• Obtain one sample of lower respiratory tract secretions for direct examination and
culture before initiation of or change in antibiotics

 CLINICAL DIAGNOSIS OF VAP
1. Imaging test evidence (new or progressive and persistent infiltrate, Consolidation)
2. Fever (>38.0°C or >100.4°F) or Leukopenia (≤4000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3
3. 2 or more of:
1
2
3
New onset of purulent sputum increased respiratory secretions
New onset or worsening cough, or dyspnea, or tachypnea Rales or bronchial
Worsening gas exchange (e.g., O2 desaturations (e.g., PaO2/FiO2 <240), increased oxygen requirement
 MICROBIOLOGIC METHODS TO DIAGNOSE VAP/HAP
1. Suggest noninvasive sampling with semiquantitative cultures to diagnose VAP

SCCM and IDSA Recommendations for Work Up –
UTI
Urinary Tract Infection:
• Catheter-associated bacteriuria or candiduria usually represents colonization, is
rarely symptomatic, and is rarely the cause of fever or secondary bloodstream
infection.
• Cultures from catheterized patients showing >103 cfu/mL represent true bacteriuria or
candiduria, but neither higher counts nor the presence of pyuria alone are of much
value in determining if the catheter-associated bacteriuria or candiduria is the
cause of a patient’s fever; in most cases, it is not the cause of fever

Indications to obtain a urinalysis and urine culture:
Bladder ultrasound to exclude Foley catheter dysfunction
◦ Obstruction of the Foley catheter causing inadequate drainage of urine may cause ascending urinary tract
infection.
◦ For an ICU patient with a Foley catheter, the best way to evaluate for urinary tract infection may be bladder
ultrasound to exclude Foley dysfunction (the presence of a significant volume of urine in the bladder indicates
inadequate drainage).
Indications to obtain a urinalysis and urine culture:
◦ (1) Patient who lacks a Foley catheter and has signs/symptoms of urinary tract infection.
◦ (2) Neutropenia.
◦ (3) Structural urologic abnormality (e.g., recent surgery or urological procedure, or status post renal
transplant)

UTI Diagnosis and
Treatment
 Diagnosis:
– Fever (especially >39°C [102.2°F] or >48 hours)
– Obtain a urine sample via catheterization or SPA along with a UA
If a “bag” urine is fresh (<1hr from void) and does not contain leukocyte esterase and nitrites, it is ok to watch and wait
– To diagnose a UTI, the UA should suggest infection (pyuria and/ or bacteriuria) and the presence of at
least 50,000 colony-forming units (cfu) per milliliter of a uropathogen cultured from a urine specimen
obtained through transurethral catheterization or SPA
 Treatment:
– Complicated UTI (ie, hospitalized, young or with fever) should be treated for 10 days

SCCM and IDSA
Postoperative Fever:
• Fever is a common phenomenon during the initial 48 hrs after surgery and is usually
noninfectious in origin
• A chest radiograph is not mandatory during the initial 72 hrs postoperatively if fever is
the only symptom
• A urinalysis and culture are not mandatory during the initial 72 hrs postoperatively if
fever is the only indication.
• Urinalysis and culture should be performed for those febrile patients having
indwelling bladder catheters for >72 hrs

“Fever in the first 48hrs in low risk postoperative patients is unlikely to represent
bacteremia. Blood cultures are unnecessary in low risk patients with fever.”

SCCM and IDSA
Sinusitis:
• The most common risk factor for sinusitis is anatomic obstruction of the ostia
draining the facial sinuses with upwards of 85% having evidence of sinusitis with
NG/ND tubes for >1 week
• Pseudomonas (60%) and staph aureus and CONS (33%) are the most common
bacterial causes
• If clinical evaluation suggests that : X ray PNS of the facial sinuses should be done

Considerations for Empiric Therapy During
Diagnostics
Recommendations for Empiric Therapy of Fever
• When clinical evaluation suggests that infection is the cause of fever,
consideration should be given to administering empirical antimicrobial therapy
as soon as possible after cultures are obtained, especially if the patient is
seriously ill or deteriorating.
• Initial empirical antibiotic therapy should be directed against likely pathogens,
as suggested by the suspected source of infection, the patient risk for infection
by multidrug-resistant pathogens, and local knowledge of antimicrobial
susceptibility patterns.

Indications for empiric antibiotics
•Fever itself isn't an indication for antibiotics.
• (They're antibiotics, not anti-pyretics.)
•Antibiotics may be indicated in the following situations:
(a) Neutropenic fever
(b) Septic shock (e.g., hypotension, tachycardia, oliguria, tachypnea).
(c) High index of suspicion for specific infection (e.g., ventilator associated pneumonia). In
many situations antibiotic initiation for a specific focus of infection is appropriate, while
awaiting additional diagnostic information (e.g., culture results).

Marik, Paul E.
CHEST , Volume 117 , Issue 3 ,
855 - 869

Don'ts in fever in ICU
•Failure to recognize neutropenic fever as a separate entity  requires immediate treatment.
•Routinely ordering urinalysis and sputum cultures (for most patients, this will only lead to false-positive
results & unnecessary antibiotic therapy).
•Excessive administration of antibiotics “just to be safe” in situations where they are not
indicated.
•Not performing an adequate physical & USG examination when evaluating a patient with fever

Conclusions
 Fever is very common in the PICU
 A fever should be measured by the most accurate means possible
(usually a rectal temp)
 The most widely accepted value for fever is >38.3°C
 Fever should trigger a clinician to examine the patient, NOT reflexively
order pan-cultures
 Think of Non-Infective causes of fever.

Conclusions
 Blood cultures are the most likely culture to yield a result but should be carefully considered
whether needed
– Daily cultures are unnecessary
– Central and peripheral cultures should be obtained = 1 set
 Respiratory cultures should be obtained if there is a worsening in the clinical status of the
patient
– A chest xray should be part of this workup
 Urinary sources are unlikely to be the cause of fever in critically ill patients without risk factors
 Postoperative fever is common and often does not need evaluation within the first 48-72 hours

New onset fever in ICU: Its not always infection
Thank You
DR MANINDER S DHALIWAL
SENIOR CONSULTANT : PICU
AMRITA HOSPITAL, FARIDABAD

New onset fever ICU.ppt

Recommended

Recommended

More Related Content

Similar to New onset fever ICU.ppt

Similar to New onset fever ICU.ppt (20)

Recently uploaded

Recently uploaded (20)

New onset fever ICU.ppt