APPROACH TO FEVER IN TRAUMA PATIENTS IN ICU

1. APPROACH TO FEVER IN
TRAUMA PATIENT
DR. VITRAG H SHAH
MD Medicine, FNB Critical Care, EDIC-UK (European Diploma in Critical Care)
PHYSICIAN & CHIEF INTENSIVIST
VELOCITY HOSPITAL
www.drvitragshah.com

3. Outline
• Defining Fever in ICU
• Site of Temperature Measurement
• Approach to fever in critically ill trauma patient
• Infectious vs Non-Infectious causes of Fever
• Epidemiology , Fever – Good or Bad?
• Interactive Case with following discussion
◦ Non-Infectious vs Infectioius Fever
◦ Role of Prophylactic Antibiotic
◦ Central Fever
◦ PostOperative Fever
◦ PSS
◦ Infective Fever
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4. Defining Fever in ICU
• The IDSA defined fever in the ICU as a temperature above
38.3/101.This is generally a useful rule of thumb. However, a lower
threshold for fever (>38/100.4 for >1 hour) may be appropriate in
some patients:
◦ Immunocompromised patients (e.g. neutropenic, CKD, CLD etc)
◦ Elderly patients
◦ Patients on scheduled acetaminophen or NSAIDs, steroids etc
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A rectal temperature is 0.3°C (0.5°F) to 0.6°C (1°F) higher than an oral
temperature. An armpit (axillary) temperature is usually 0.3°C (0.5°F) to
0.6°C (1°F) lower than an oral temperature

5. Approach to fever in Trauma
• As polytrauma patients have multiple source of fever & infection, it is
difficult to find out source of fever / infection many times.
◦ Early (Within 48 hours) vs Late (After 96 hours) onset of fever
◦ Site of trauma( TBI or no TBI)
◦ Type of trauma (Compound fracture, Gunshot/Stab (penetrating vs blunt
trauma)
◦ Any Surgery in 48 hours
◦ Obvious source of infection or not

6. Infectious vs Non-Infectious
Infectious source Non-infectious source
ET /TT Tube (VAP) /
Aspiration
Bed-ridden (DVT/PE)
Ryle’s tube (Sinusitis) Drugs
Foley’s Catheter (UTI) Acalculus cholecystitis
Central/Arterial line/HD Cath
(CRBSI)
Vasculitis
Drains / Wound – SSI - SSTI Burns, Pancreatitis, Post-op
(SIRS), Thrombophlebitis
Bedsore Central fever

7. www.drvitragshah.com
Early fever is common in trauma, with or without brain injury. Early
fever may be a consequence of tissue trauma with resultant aseptic
inflammation rather than hypothalamic damage.

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9. Clinical Vignette
• 28 yr male, came with RTA-polytrauma , primary survey done.
• O/E : GCS E2VTM4, No penetrating injury anywhere. Minor CLW over
scalp and B/L leg.
• Intubated in ER in view of low GCS (E2V2M4) for airway protection and
taken on mechanical ventilator.
• Routine labs sent and CT Brain with cervical spine screen, Chest & B/L
leg X-Ray done in ER
• Patient had rt. leg tibia-fibula #, lung contusions, right sided
pneumothorax and Rt frontal & Parietal contusion & perileisonal
oedema.
• Having persistent fever (99-102) on first and second day, associated
with increasing TLC s but hemodynamically stable and static Fio2 and
ventilator support.

10. Questions?
• 1. Cause of Fever?
◦ Non-Infective >> Infective (Early onset, no obvious source of infection)
◦ Can be central fever as severe TBI
◦ Can be ??aspiration pneumonia , SSTI – less likely
• 2. Role of Prophylactic Antibiotic?
◦ Can give for 24-48 hours and stop if no obvious infective source of infection
• 3. Workup
◦ CBC, RFT, LFT, 3H, PT, aPTT, Urine R/M
◦ Blood cultures, ET Culture if secretions
◦ HRCT Thorax, USG Abdomen
• 4. What is Central/Neurogenic Fever?
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11. PENETRATING BRAIN INJURY
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PENETRATING CHEST INJURY

12. PENETRATING ABDOMINAL TRAUMA
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13. OPEN FRACTURE
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16. Central Fever / Neurogenic fever
• It is diagnosis of exclusion. Extreme hyperpyrexia, defined as fever ≥
41.1℃ (106°F), is usually noninfectious.
• Onset usually within 72 hours of brain injury. CF is disproportionately
high and persistent. The temperature peak is higher & generally less
fever-free period and the cumulative fever load is high. Usually there is
relative bradycardia with a notable absence of perspiration except with
PSS.
• Probable mechanism : Inflammatory markers causing fever may be
triggered by extreme physiologic stress in acute neurologic injury. Brain
injury may also lead to the disruption of the mesencephalic-
diencephalic mechanisms responsible for the inhibition of
thermogenesis
• CF is common after spontaneous ICH & SAH and the risk of
developing CF is increased in patients with larger ICH and in those with
IVH extension.
• DAI and frontal injury are high risk factor/predictor of central fever in
patient with TBI.
• It is considered as a poor prognostic factor in patients with ICH, it
is associated with increased mortality rates, shorter lifespan and with
reduced chances for favorable outcome.
• Morphine, Baclofen,Bromocriptine, Chlorpromazine have been
found useful. www.drvitragshah.com

17. CAUSES OF CENTRAL FEVER
• Subarachnoid haemorrhage
• Intraventricular haemorrhage
• Intracerbral haemorrhage
• Tumours: sella, diencephalon, and intraventricular region
• Traumatic brain injury
• Ischemic stroke
• Pontine haemorrhage
• Tuberculous meningitis
• Following hemispherectomies
• Following hemidecortication
• Traumatic spine injury
• Basilar artery occlusion
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19. Algorithm for the evaluation of fever in
the traumatically brain injured patient
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Thompson HJ, Pinto-Martin J, Bullock MR. Neurogenic fever after traumatic brain injury: an
epidemiological studyJournal of Neurology, Neurosurgery & Psychiatry 2003;74:614-619.

20. Treatment on admission
• Inj Piperacillin + Tazobactam
• Inj Clindamycin
• Inj Eptoin
• Inj Mannitol (tapering doses)
• Mechanical DVT prophylaxis
• NG tube feed as per wt- tolerating well

21. Today’s Progress Chart – Day 4
• Continuous fever 39°C
• No change in character of tracheal secretions
• No change in SOFA score
• CVC insertion sites appear free of infection

22. Pan Cultures sent 3 days back
• Blood Central : Negative
• Blood Peripheral : GPCs
• Tracheal Gm Stain: Few GPCs+GNBs+ budding yeast cells with few
epithelial cells n few PMN cells
• Tracheal culture : No Growth
• Urine culture: no significant growth but 20 pus cells

23. Proposed change in treatment
• Inj Meropenam 1gm iv tid
• Inj Teicoplanin 400 mg stat and bd
• Inj Fluconazole 400 mg bd
• Pt’s relatives counseled and reassured that cause of fever is sorted ????
• Repeat NCCT Brain s/o same changes, no increase in midline shift/edema.
• Patient remains hemodynamicaly stable, tracheostomy done, weaned from
ventilator, no fever for 48 hours.
• As patient stabilized, surgery for right tibia fracture done on day 10.

24. Day 12 – Again Fever
• Patient had intermittent episode of high grade fever, tachycardia,
tachypnea, perspiration & posturing.
• Fresh blood & TT & Urine cultures sent
• BP normal, no vasopressor requirement, No other organ dysfunction
• No increase in oxygen requirement, on sos intermittent PSV-CPAP
support
• No increase in TT secretion
• TLC high , PCT <0.5
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25. Questions?
• 1. Reason of Fever?
◦ ?CRBSI, ?HAP/VAP, CAUTI
◦ ?Post-Operative Fever
◦ ?PSS
◦ Drug Fever
◦ Thrombophlebitis
◦ ?DVT/PE
• 2. What is post operative fever?
• 3. What is PSS?
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26. POSTOPERATIVE FEVER
• Immediate: Within hours of surgery
• Early: Postoperative days 0 through 3
• Late: Postoperative days 4 through 30
• Delayed: More than 30 days after the procedure
Fever can be a normal response to surgery or be due to another cause.
Infection is only one of the other possible causes.
Most early postoperative fevers are due to surgical trauma.
Most patients with fever after the third postoperative day have an
infection.
Noninfectious causes of fever that are potentially life-threatening can
occur in the immediate and early postoperative periods. (Malignant
Hyperthermia)
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27. Diencephalic storms / paroxysmal
sympathetic storms
• It is associated with episodic hyperhidrosis, hypertension, tachypnea,
tachycardia, and abnormal posturing. Onset usually after 5-7 days of
brain injury.
• The DAI may contribute to disassociation of the sympathetic and
parasympathetic systems.
• Multiple drugs including morphine sulfate, oxycodone, midazolam,
baclofen, propranolol, clonidine, chlorpromazine, bromocriptine,
dantrolene , atenolol, and labetalol have shown effectiveness in treating
storming.
• Bromocriptine, a dopamine receptor agonist, has been effective in
reducing hyperthermia and diaphoresis in individuals during storming.
(Dose : 0.025 mg/kg twice a day and increasing to 0.05 mg/kg three
times a day)
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https://www.medscape.com/viewarticle/469858_6

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Goyal, K., Garg, N., & Bithal, P. (2020). Central fever: a challenging clinical entity in
neurocritical care. Journal of Neurocritical Care, 13(1), 19-31.

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31. Day 15 : Problem- still NO ACCHE DIN
• High grade spike of fever since 3 days
• All lines changed y’day n repeat pan cultures sent. Previous blood, ET
culture were negative & urine culture candida.
• Day 16 - Now Mucopurulent tracheal secretions & culture growing GNBs ,
blood culture sterile, urine has candida..
• Microbiologist calls to tell that it’s MDR pseudomonas sensitive to collistin
only……

32. Huddle and Saddle up
• Patient becoming haemodynamically unstable and increasing FiO2
• Worsening metabolic acidosis with raising creatinine
• Resuscitation with fluid challenges+ vasopressors but needed RRT
• Collistin 2mu i.v. tid added along with echinochindin , family given a grave
prognosis

33. Now My Patient is Dead
▪ Did we do
enough?
▪ Did we do it
right?
▪ Can we reflect
what
went wrong and
WHEN?

34. Was my patient
infected ?
NOT EVERY FEVER MEANS INFECTION….

35. Try using
diagnostics
MORE THAN ANTIBIOTICS……

36. Antibiotic - Fallacies
• Broader is better
• Failure to respond is failure to cover
• Response implies diagnosis
• When in doubt, change drugs (or add another)
• Antibiotics are harmless
Kim JH. Am J Med. 1989; 87: 201-206

37. General principles in evaluating
infections
• Antibiotic is not magic bullet.
• Response to fever is an evaluation, not changing antibiotics.
• Keep in mind non-infectious causes of fever
• Evaluate potential sources of infection
• Source control with least invasive method earliest possible
• Get cultures from relevant sites before starting/changing antibiotics
• Start empiric broad spectrum combination therapy only if
hemodynamically unstable
• Start empirical therapy as per your local antibiogram

38. Antibiotic prescription should ideally comprise
of the following phases
• Perception of need: Is an antibiotic necessary?
• Choice of antibiotic: Which is the most appropriate antibiotic?
• Choice of regimen : What dose, route, frequency and duration are
needed?
• Monitoring efficacy : Is the antibiotic effective?

39. Dosing consideration
• Loading dose
• Target site penetration
• Clearance
• Volume of distribution
• Time Vs Concentration dependent
• Dosing in obese patients
• Dosing with RRT & ECMO

40. Dose in polytrauma after resuscitation / sepsis
• Depends on :
◦ High CrCl (Low if AKI/CKD)
◦ Vd (High)
◦ Albumin level (Low)

41. Dose in sepsis/septic shock
Higher doses required in septic shock due to:
• Elevated Cr Cl in young healthy persons
• Increased volume of distribution due to vasodilatation & leaky
capillaries
Recommended doses:
• Cefoperazone-sulbactam 3g q8-12h
• Cefepime 2g q8h
• Pip-Taz 4.5g q6h
• Imipenem 1g q8h, Meropenam 2gm 8 hourly
• Vancomycin 1g q8h
• Colistin 9 MU stat f/b 4.5 MU BD by continuous infusion

43. Antibiotic stewardship
• The set of activities and policies to improve the rational use of antibiotics is
known as antibiotic stewardship

44. De-escalation
• Once culture report available and patient is stabilized, usually at 72-96
hours
• Narrow the spectrum (Targeted from empiric therapy) & optimize
duration
• Failure to do so will
Raise cost
Predispose to resistant nosocomial infection
Impact the entire hospital’s sensitivity profile

47. FEVER WORKUP ALGORITHM
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Meier, K., & Lee, K. (2017). Neurogenic fever: review of pathophysiology, evaluation,
and management. Journal of intensive care medicine, 32(2), 124-129.

48. Take home message
• There are many confounding factors & potential source of infection in
polytrauma patient - multiple lines in situ & on ventilator –
CRBSI/HAP/CAUTI and CLWs - SSTI, Postoperative fever, Central fever,
PSS, DVT, Thrombophlebitis, drug fever, acalculous cholesystitis etc
• Timing of onset of fever from onset of trauma/surgery, site and type of
trauma, intensity & frequency of fever along with cultures and clinical
examination helps to differentiates from different etiologies of fever in
trauma patient.
• Don’t send pancultures, send culture of relavant sites from which infection
is suspected.
• Keep sending blood cultures every 4-5 days until patient is
afebrile/stabilized, as previously non-infectious fever fever may convert
into infectious fever due to multiple risk factors and timely clinical
recognition is difficult without positive blood cultures.
• SOS HRCT>X-Ray to ruleout VAP over VAT/colonization.

49. Take home message
• Non-infectious fever is common in first 3-4 days and infectious fever
after 3-4 days in polytrauma patient
• No role of prophylactic antibiotic in minor wounds/ clw.
• Don’t use prophylactic antibiotic for >24-48 hours if no obvious source of
infection and no penetrating injury.
• Always keep PSS in mind if tachycardia, tachypnea, perspiration,
hypertension along with fever in severe TBI patient after 5-7 days of
injury.
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50. Take home message
• “Penicillin should only be used if there
is a properly
diagnosed reason
&
if it needs to be used,
use the highest possible
dose for the shortest time
necessary
Otherwise antibiotic
resistance will develop”

51. O’Grady, Naomi P. MD et al. Guidelines for evaluation of new fever in
critically ill adult patients: 2008 update from the ACCCM & the IDSA. Critical
Care Medicine: April2008 - Volume 36 - Issue 4 - p 1330-1349 doi:
10.1097/CCM.0b013e318169eda9
Honig, Asaf et al. “Central fever in patients with spontaneous intracerebral
hemorrhage: predicting factors and impact on outcome.” BMC neurology vol.
15 6. 4 Feb. 2015, doi:10.1186/s12883-015-0258-8
Several other review articles
Sanford Guide to Antimicrobial Therapy
Johns Hopkins ABX (Antibiotic) Guide
Apps : Lexicomp, MedScape, Epocrates
LIFTL : https://lifeinthefastlane.com/
UpToDate : www.uptodate.com

52. Question?
Contact :
dr.vitrag@gmail.com
9712909924
Facebook / Instagram : #drvitragshah

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Dr. Vitrag Shah
Email: dr.vitrag@gmail.com
Mo. 9712909924
THANK
YOU