Causes, Diagnosis, and Treatment of Sinusitis, Diarrhea, and UTIs in ICU Patients, Slides of Pneumology

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Fever in ICU

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ever

Complex physiologic reaction to disease involving aComplex

physiologic reaction to disease involving a

cytokine mediated rise in core temperature, generationof acute-phase reactants, and activation of numerous

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physiologic endocrinologic and immunologic systems

Arch Intern Med 2000, 160:449-

FeverFever

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°C

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Normal body temperature is generally considered to be 37.0°C(98.6°F) with a circadian variation of between 0.5 to1.0°C

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The definition of fever is arbitrary depends on the purpose for whichit is defined

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The Society of Critical Care Medicine and IDSA suggested that at^

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38 3°C (101°F)

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temperature of above 38.3°C (101°F) should be considered a feverand should prompt a clinical assessment

Fever in ICUFever

in ICU

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Frequency of fever in ICU has been variably quoted between 26%*and 44%^and 44%^

Intensive Care Med 2004; 30:811–816Intensive Care Med 1999; 25:668–

^Crit Care Med 2008;36:1531-

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Presence of high grade fever at admission or during ICU stay is associatedwith poor outcome

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Crit Care Med 2008;36:1531-

Measurement of temperatureMeasurement

of temperature

Method

Merits

Demerits /Limitations

Axillary temp.

Underestimates core temp.

Sublingual temp.

Food, drinks, respiratory devices

Infrared ear thermometry

Inflammation or block of externalear interferes

Rectal temp

Few tenths of °C

Rectal trauma

Rectal temp.

Few tenths of

C

above core temp

Rectal traumaCl.difficle transmission

Mixed venous blood from

Optimal site for

Needs pulmonary artery

pulmonary artery

core temperature

catheter

Thermistor in urinarybladder

Represent coretemperature

CostlyRequires monitor

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Requires monitor

Thermistor placed indistal esophagus

Represent coretemperature

Position diff. to confirmUncomfortableRisk of perforation

Causes of fever in ICUCauses of fever in ICU

Drug related feverDrug

related fever

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Hypersensitivity reaction

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Hypersensitivity reaction

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Local inflammation at the site of administration : Amphotericin B,

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KCl

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erythromycin, KCl, sulfonamides, and cytotoxic chemotherapies

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Drugs or their delivery systems may contain pyrogens or microbialcontaminants

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Stimulation of heat production e.g., thyroxine

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Limit heat dissipation

e.g., atropine

Alter thermoregulation

e.g., phenothiazines, antihistamines

antiparkinson drugsantiparkinson drugs

Drug feverDrug

fever

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hill

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Unexplained high spiking temperatures and shaking chills

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Usually in 2

nd

week of drug administration

Usually in 2

week of drug administration

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May be associated with a with leukocytosis and eosinophilia

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Relative bradycardia, although commonly cited, is uncommon

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M d 1987 106 728

Ann Intern Med 1987; 106:728–

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Associated skin rash

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Rapid resolution of fever <72 hrs (if no rash), may take up to 7 days

Neurolept malignant syndromeNeurolept

malignant syndrome

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Idiosyncratic reaction to neuroleptic drugs (initiation or change of dose)

-^

Idiosyncratic reaction to neuroleptic drugs (initiation or change of dose)

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It manifests as altered mentation , hyperthermia, muscle rigidity,rhabdomyolysis, and autonomic dysfunctionrhabdomyolysis, and autonomic dysfunction

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Antipsychotic medications—phenothiazines, thioxanthenes, andbutyrophenones

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Antiemitics (prochlorperazine), prokinetics (metclopromide),sedatives (promethazine)Withdrawal of levodopa/carbidopa, amantidine

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In the ICU, haloperidol is the most common offending drug

-^

CNS dopamine deficiency or D2 receptor antagonism in hypothalamus,resets temperature set point

Neurolept malignant syndromeNeurolept

malignant syndrome

Major criteria:

Management:

Major criteria:•^

Fever

-^

Muscle rigidity

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Elevated CPK

Management:•^

Withdrawal of offending drugD

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Elevated CPK Minor criteria:•^

Tachycardia

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Dantrolene

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Dopamine agonists

Tachycardia

-^

Tachypnea

-^

Altered sensorium

-^

Abnormal BP

Bromocriptine (2.5- 5 mg TDS)Amantidine (100 mg TDS)Levodopa/carbidopa

-^

Diaphoresis

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Leukocytosis

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Electroconvulsive therapy

3 Major

Diagnostic

2 major + 4 minor

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Supportive care

Acalculous cholecystitisAcalculous

cholecystitis

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ICU

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0.2 to 1.5% of patients in ICU

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RUQ abdominal pain nausea vomiting

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RUQ abdominal pain, nausea, vomiting

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Laboratory investigations

Non specific

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Gallbladder ischemia & Cholestasis with bile salt inpissationassociated with parenteral nutrition and PEEPassociated with parenteral nutrition and PEEP

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Bacterial invasion is a secondary process

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May progress to gangrene and perforation

Acalculous cholecystitisAcalculous

cholecystitis

USG

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USG abdomen- gall bladder distension, intraluminal lucencies, wallthickening >3 mm, pericholecystic fluid

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CT abdomen – sensitive and specific

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Hepatobiliary scintigraphy- provides functional information

high negative predictive value

•^

Percutaneous cholecystostomy is procedure of choice

-^

Surgical drainage as salvage procedure

Infectious complicationsInfectious

complications

EPIC study:Single day prevalence of ICUacquired infection- 20%VAP (46.9%)UTI (17 6%)UTI (17.6%)Bacteremia (12%)

JAMA 1995; 274:639–

Ventilator Associated PneumoniaVentilator

Associated Pneumonia

Pneumonia in a patient who has been on ventilator for >48 hoursRisk of 3%/day during the first 5 days of ventilation, 2%/day duringDays 5 to 10 of ventilation and 1%/day after thatDays 5 to 10 of ventilation, and 1%/day after that“Attributable mortality” has been estimated to be between 33 and 50%

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ACCP definition of VAP:1.

New onset or progressively increasing infiltrates in CXR (sine quonon)

2

Fever

Fever

Leucocytosis

Purulence tracheobronchial secretions

2 out of 3