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

Information on various infections that commonly affect icu patients, including sinusitis, diarrhea, and urinary tract infections. It discusses the risk factors, symptoms, diagnosis methods, and treatment options for each condition. The document also mentions the microbiology of these infections and the importance of proper diagnosis and timely intervention.

Typology: Slides

2011/2012

Uploaded on 12/22/2012

anna.joe
anna.joe šŸ‡®šŸ‡³

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Fever in ICU
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Fever in ICU

FF

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

p

physiologic endocrinologic and immunologic systems

Arch Intern Med 2000, 160:449-

FeverFever

N

l b d

i^

ll^

id

d^

b^

°C
•^

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

-^

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

-^

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

t^

f^

b^

38 3°C (101°F)

h^

ld b

id

d^

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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

•^

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-

-^

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

p^

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

•^

Hypersensitivity reaction

-^

Hypersensitivity reaction

-^

Local inflammation at the site of administration : Amphotericin B,

th

i^

KCl

lf^

id

d^

t t

i^

h^

th

i

erythromycin, KCl, sulfonamides, and cytotoxic chemotherapies

-^

Drugs or their delivery systems may contain pyrogens or microbialcontaminants

-^

Stimulation of heat production e.g., thyroxine

p^

g ,

y

Limit heat dissipation

e.g., atropine

Alter thermoregulation

e.g., phenothiazines, antihistamines

antiparkinson drugsantiparkinson drugs

Drug feverDrug

fever

U

l i

d hi h

iki

d^

h ki

hill

•^

Unexplained high spiking temperatures and shaking chills

-^

Usually in 2

nd

week of drug administration

Usually in 2

week of drug administration

•^

May be associated with a with leukocytosis and eosinophilia

-^

Relative bradycardia, although commonly cited, is uncommon

A^

I t

M d 1987 106 728

Ann Intern Med 1987; 106:728–

•^

Associated skin rash

-^

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

Neurolept malignant syndromeNeurolept

malignant syndrome

-^

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

-^

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

-^

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

-^

Antipsychotic medications—phenothiazines, thioxanthenes, andbutyrophenones

y^

p

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

-^

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

-^

Elevated CPK

Management:•^

Withdrawal of offending drugD

t^

l

-^

Elevated CPK Minor criteria:•^

Tachycardia

•^

Dantrolene

-^

Dopamine agonists

Tachycardia

-^

Tachypnea

-^

Altered sensorium

-^

Abnormal BP

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

-^

Diaphoresis

-^

Leukocytosis

p^

p

•^

Electroconvulsive therapy

3 Major

Diagnostic

2 major + 4 minor

•^

Supportive care

Acalculous cholecystitisAcalculous

cholecystitis

f^

i^

i^

ICU
•^

0.2 to 1.5% of patients in ICU

-^

RUQ abdominal pain nausea vomiting

N^

ifi

RUQ abdominal pain, nausea, vomiting

-^

Laboratory investigations

Non specific

•^

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

-^

Bacterial invasion is a secondary process

y p

•^

May progress to gangrene and perforation

Acalculous cholecystitisAcalculous

cholecystitis

USG

bd

ll bl dd

di

i^

i^

l^

i^

l l

i^

ll

•^

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

-^

CT abdomen – sensitive and specific

-^

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 thatā€œAttributable mortalityā€ has been estimated to be between 33 and 50%

y

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