transcript
- Slide 1
- Dr. Marwan Jabr Alwazzeh Assoc. Prof. of Medicine Consultant
Internist/Infectious Diseases University of Dammam 02/04/2012
- Slide 2
- Why Fever In ICU? Key Problem Requires Thoughtful Evaluation
and Treatment. Increasing health care costs. Exposes patients to
sometimes unnecessary invasive diagnostic procedures Inappropriate
use of antibiotics that promoting emergence of resistant
microbes.
- Slide 3
- When we say fever in the ICU patient? Definition of fever is
Arbitrary. Society of Critical Care Medicine and Infectious
diseases society of America >38.3 C (100.4F). Lower threshold
for surgery and immunocompromised patients >38.0 C
(100.4F).
- Slide 4
- Pathophysiology of Fever
- Slide 5
- Significance of Fever Enhancing the resistance to infection
Temperature elevation enhances immune function by: Increased
antibody production Promoting T-cell activation Increased cytokine
production Stimulates neutrophil and macrophage function
- Slide 6
- Significance of Fever Beneficial effects of hot baths and
malarial fevers in treating syphilis. In Gram negative bacteremia,
a positive correlation between maximum temperature on the day of
bacteremia and survival. Some pathogens such as Streptococcus
pneumoniae are inhibited by febrile temperatures.
- Slide 7
- Most patients should not routinely receive empiric antipyretic
medication. Acute hepatitis may occur in ICU patients with reduced
glutathione reserves (alcoholics, malnourished, etc.) who have
received regular therapeutic doses of acetaminophen. Aggressively
treating fever in critically ill patients may lead to a higher
mortality rate. Significance of Fever
- Slide 8
- Deleterious Effects Of Fever Cardiac Output Oxygen Consumption
(approx 10%/C) Carbon Dioxide Production Energy Expenditure
- Slide 9
- Accuracy of methods used for measuring temperature Most
accurate Pulmonary artery thermistor Urinary bladder catheter
thermistor Esophageal probe Rectal probe Other acceptable methods
in order of accuracy Oral probe Infrared ear thermometry Other
methods less desirable Temporal artery thermometer Axillary
thermometer Chemical dot AccuracyAccuracy
- Slide 10
- Recommendations for Measuring Temperature Axillary, temporal
artery, and chemical dot thermometers should not be used in the ICU
Rectal thermometers should be avoided in neutropenic patients
Whatever device chosen should be used in a manner that does not
facilitate spread of pathogens by the instrument or the
operator
- Slide 11
- Treating Fever per se Fever should be treated only in patients
with: Acute brain insults. Limited cardiorespiratory reserve (ie,
ischemic heart disease). Temperature increases above 40C
(104F)
- Slide 12
- Causes of fever in ICU Differential diagnosis influenced by
patient population Medical vs. Surgical Immunocompromised vs.
competent Community vs. Nosocomial Pediatric vs. Geriatric
- Slide 13
- Causes of fever in ICU
- Slide 14
- Main infectious Causes Intravascular Devices infection and
septicemia Pulmonary Infections and ICU-Acquired Pneumonia. Urinary
Tract Infections. Infectious Diarrhea. Sinus infections. Surgical
Site Infections. Central Nervous System Infection.
- Slide 15
- Fever In ICU
- Slide 16
- Infectious causes Definitions Septic shock Severe sepsis Sepsis
Systemic inflammatory response syndrome (SIRS)
- Slide 17
- Systemic Inflammatory Response Syndrome Tow or more of the
following: Temperature 38 C or 36 C Heart rate 90 beats/min
Respirations 20/min or arterial Carbone dioxide tension (PaCO2)
< 32 mm Hg White blood cell count 12,000/mm3 or 4000/mm3 or
>10% immature [band] forms
- Slide 18
- Systemic Inflammatory Response Syndrome Often noninfectious
etiology found: Pulmonary embolism Myocardial infarction
Gastrointestinal bleeding Acute pancreatitis Cardiopulmonary
bypass
- Slide 19
- Sepsis SIRS with a presumed or confirmed infectious
process
- Slide 20
- Severe sepsis Sepsis with one or more signs of organ failure:
Cardiovascular Renal Respiratory Hepatic Hematologic Central
nervous system Metabolic acidosis
- Slide 21
- Septic shock Sepsis-induced hypotension, despite adequate fluid
resuscitation, with presence of perfusion abnormalities
- Slide 22
- Infectious Causes Not all patients with infections are febrile.
10% of septic patients are Hypothermic. 35% are normothermic at
presentation. Septic patients who fail to develop a temperature
have a significantly higher mortality than febrile septic
patients.
- Slide 23
- Afebrile infected patients Elderly Open abdominal wounds. Large
burns Extracorporeal membrane oxygenation (ECMO) CHF CRF or
End-stage liver disease. Continuous renal replacement therapy
Taking anti-inflammatory or antipyretic drugs
- Slide 24
- How can I Diagnose Infection in absence of fever? Unexplained
hypotension Tachycardia Tachypnea Confusion Rigors Skin lesions
Respiratory manifestations Oliguria Lactic acidosis Leukocytosis
Leukopenia Immature neutrophils (i.e., bands) of >10%
Thrombocytopenia
- Slide 25
- When should I be worried? Immunocopromized patient Hemodynamic
instability Oliguria Increasing lactate Worsening conscious state
Falling platelet counts Worsening coagulopathy.
- Slide 26
- Intravascular Devices infection and septicemia
- Slide 27
- Intravascular Devices infection Localized infection Exit site
infection Tunnel infection Systemic infection
- Slide 28
- Catheter-Related Bloodstream Infection Definition A positive
catheter culture 15 CFU with concomitant positive blood culture of
the same organism. No other identifiable source of infection.
- Slide 29
- Growth of 15 or more CFU from a catheter specimen by
semiquantitative culture. Local signs of inflammation: erythema,
swelling, tenderness, purulent material. Negative peripheral blood
culture. Local Catheter-Related Infection Definition
- Slide 30
- Catheter-Related Bloodstream Infection Approximately 25% of
central venous catheters become colonized, and approximately 20-30%
of colonized catheters will result in catheter sepsis
- Slide 31
- Suppurative phlebitis Most often encountered in burn patients
or other ICU patients who develop catheter-related infection that
goes unrecognized, permitting microorganisms to proliferate to high
levels within an intravascular thrombus. bloodstream infection
characteristically persists after the catheter has been removed.
Clinical picture of overwhelming sepsis with high- grade bacteremia
or fungemia or with septic embolization.
- Slide 32
- Recommendations for Obtaining Blood Cultures For patients
without an indwelling vascular catheter, obtain at least 2 blood
cultures using strict aseptic technique from peripheral sites by
separate venipunctures after appropriate skin disinfection. For
patients with an indwelling vascular catheter Obtain 3-4 blood
cultures.
- Slide 33
- Recommendations for Obtaining Blood Cultures For cutaneous
disinfection: 2% chlorhexidine gluconate in 70% isopropyl alcohol
tincture of iodine is equally effective (30 sec. of drying time).
Povidine iodine is an acceptable alternative, but must wait greater
than 2 minutes to dry.
- Slide 34
- The injection port of the blood culture bottles should be wiped
with 70-90% alcohol before injecting the blood sample into the
bottle. Most blood culture bottles should not be swabbed with
iodine-containing antiseptics. Draw 20-30ml of blood per culture.
Label the blood culture with the exact time, date, and anatomic
site from which it was taken. Recommendations for Obtaining Blood
Cultures
- Slide 35
- Management of fever in ICU There is no evidence that the yield
of cultures drawn from an artery is different from the yield of
cultures drawn from a vein. Catheter Cultures: Short catheter: tip.
longer catheter: Tip and intracutaneous segment. Pulmonary artery
catheter: Tip and introducer. It is rarely necessary to culture
infusate specimens.
- Slide 36
- Candidemia Candida species are constituents of the normal flora
in about 30% of all healthy people. Antibiotic therapy increases
the incidence of colonization by up to 70%. Candida Infection
should be considered in febrile ICU patients who have been in the
ICU for 10 days and have received multiple courses of
antibiotics.
- Slide 37
- Although candiduria may be observed in up to 80% of patients
with systemic candidiasis, candidemia from a urinary tract source
is extremely rare. galactomannan and beta-D-glucan for
aspergillosis and Candida may be useful as supportive evidence of
infections but may be most useful to exclude invasive fungal
infection, given their high negative predictive value.
Candidemia
- Slide 38
- Catheter Related Blood Stream Infection Catheter Related Blood
Stream Infection CVC Insertion Bundle Hand hygiene. Maximal barrier
precautions. Chlorhexidine skin antisepsis. Optimal catheter site
selection, with avoidance of using the femoral vein for central
venous access in adult patients. The Canadian Collaborative, Safer
Healthcare Now
- Slide 39
- Daily review of line necessity and prompt removal of
unnecessary lines. Dedicated lumen for total parenteral nutrition
(TPN). Access the CVC lumens aseptically. Checking entry site for
inflammation with every change of dressing. The Canadian
Collaborative, Safer Healthcare Now Catheter Related Blood Stream
Infection Catheter Related Blood Stream Infection CVC Maintenance
Bundle
- Slide 40
- Pulmonary Infections and ICU-Acquired Pneumonia
- Slide 41
- Recommendations for Evaluation of Pulmonary Infections All
radiographs should be performed in an erect sitting position,
during deep inspiration if possible. The absence of infiltrates,
masses, or effusions does not exclude pneumonia, abscess, or
empyema. Obtain one sample of lower respiratory tract secretions
for direct examination and culture before initiation of or change
in antibiotics.
- Slide 42
- Recommendations for Evaluation of Pulmonary Infections
Isolation of enterococci, viridans streptococci, coagulase-negative
staphylococci, and Candida species should rarely if ever be
considered the cause of respiratory dysfunction. Quantitative
cultures can provide useful information in certain patient
populations when assessed in experienced laboratories.
- Slide 43
- Ventilator Bundle Elevate the Head of the bed to 30-45 degrees.
Peptic ulcer disease prophylaxis. Deep venous thrombosis
prophylaxis. Provide mouth care every 2-4 hours. Sedation vacation
every day. Repeated evaluation of the patients readiness to be
weaned from the ventilator.
- Slide 44
- Urinary Tract Infection
- Slide 45
- Pyuria may be absent in patients with catheter-associated
urinary tract infection and, even if present, is not reliably
predictive of infection or associated with symptoms referable to
the urinary tract. The rapid dipstick tests, which detect leukocyte
esterase and nitrite, are unreliable tests in the setting of
catheter-related urinary tract infection.
- Slide 46
- Urinary Tract Infection The concentration of urinary bacteria
or yeast needed to cause symptomatic urinary tract infection or
fever is unclear. Bacteriuria with 10 5 CFUs of bacteria per
milliliter of urine during bladder catheterization was associated
with a 2.8-fold increase in mortality.
- Slide 47
- Urinary Tract Infection Patients with urinary catheters in
place should have urine collected from the sampling port and not
from the drainage bag. Urine should be transported to the
laboratory and processed within one hour to avoid bacterial
multiplication. Gram stains of centrifuged urine will reliably show
the infecting organisms
- Slide 48
- UTI bundle Use sterile technique at insertion Perform a daily
review of the need for the urinary catheter. Provide perineal care
on a daily basis and after every bowel movment. Keep the drainage
bag lower than patient's bladder at all times. Secure all
catheters
- Slide 49
- Infectious Diarrhea
- Slide 50
- C.Difficile associated diarrhea May occur with any
antibacterial agent, but the most common causes are clindamycin,
cephalosporins, and fluoroquinolones. some patients with
C.difficile especially those who are postoperative, may present
with ileus or toxic megacolon or leukocytosis without
diarrhea.
- Slide 51
- C.difficileassociated diarrhea SensitivityMethods 40%Stool WBC
75%Lactoferrin latex agg. test 72% 1 st sample 84% 2 nd sample EIA
toxin 81% 1 st sample 91% 2 nd sample Tissue Culture assay 71%
severe disease 23% mild disease Sigmoidoscopy
- Slide 52
- C.difficileassociated diarrhea Cultures for C. difficile
require 2 to 3 days for growth, and are not specific in
distinguishing toxin-positive strains, toxinnegative strains, and
asymptomatic carriage. Infection with Klebsiella oxytoca should be
considered in patients who are negative for C. difficile. Acute
neutropenic enterocolitis or typhlitis should be sought in cancer
or stem cell transplant.
- Slide 53
- Sinusitis
- Slide 54
- Sinusitis Accounts for about 5% of nosocomial ICU infections.
Polymicrobial infection in up to 50% of cases, reflecting ICU
flora. Fever and Leucocytosis often present. Purulent nasal
discharge often lacking. Sinus opacification by plain radiography
is sensitive but nonspecific for the diagnosis. CT the modality of
choice if clinical evaluation suggests that sinusitis may be a
cause of fever.
- Slide 55
- Sinusitis Risk factors: Naso-tracheal tubes (incidence of up to
85% after a week of intubation). Naso-gastric tubes. nasal packing.
facial fractures. steroid therapy.
- Slide 56
- Surgical Site Infections & Postoperative fever
- Slide 57
- Surgical Site Infections Examine the surgical incision at least
once daily. If there is suspicion of infection, the incision should
be opened and cultured.
- Slide 58
- Surgical Site Infections Tissue biopsies or aspirates are
preferable to swabs. Superficial swab cultures are likely to be
contaminated with commensal skin flora and are not
recommended.
- Slide 59
- Surgical Site Infection Prevention Bundle Appropriate use of
Antibiotics. Appropriate hair removal. Preoperative glucose control
in all diabetic patients. Preoperative normothermia.
- Slide 60
- Postoperative fever 5 Ws Wind (atelectasis/pneumonia) Water
(UTI) Walk (DVT-PA) Wound (infection) Wonder (drug reaction)
- Slide 61
- Postoperative fever
- Slide 62
- Fever is a common occurrence during the first 48 hrs post OP,
usually noninfectious in origin. Fever after 96 hrs post OP usually
represents infection. Early wound infections (2-48hrs post OP):
Streptococcus or Clostridium.
- Slide 63
- Noninfectious fever
- Slide 64
- For unknown reasons, most noninfectious disorders usually do
not lead to a fever>102F (38.9C). Exceptions: Drug fever
Transfusion reaction Neoplasm Malignant hyperthermia Neuroleptic
malignant syndrome
- Slide 65
- Noninfectious causes Acalculous cholecystitis Acute myocardial
infarction Adrenal insufficiency Blood product transfusion
Cytokine-related fever Dressler syndrome Drug related fever Fat
emboli Fibroproliferative phase of acute respiratory distress
syndrome Gout Heterotopic ossification Immune reconstitution
inflammatory syndrome Intracranial bleed Jarisch-Herxheimer
reaction Pancreatitis Pulmonary infarction Pneumonitis without
infection Stroke Thyroid storm Transplant rejection Tumor lysis
syndrome Venous thrombosis
- Slide 66
- Acalculous cholecystitis
- Slide 67
- Occurs in approx 1.5% of critically ill ( incidence),
Potentially life threatening, frequently unrecognized. Complex
pathophysiology: G B ischemia, bile stasis, prolonged fasting,
positive-end expiratory pressure, parenteral nutrition and
sustained narcotic therapy). High rate of gangrene and perforation.
Should be considered in any post OP or acutely ill patient with
upper abdominal pain, fever or leukocytosis.
- Slide 68
- Acalculous cholecystitis US 90% Specific 100% Sensitive: wall
thickness (>3mm) intramural lucencies GB distension
pericholecystic fluid intramural sludge Treatment: Nonoperative
percutaneous drainage successful 80- 90%. Open cholecystectomy
remains treatment of choice. Mortality 15-30%.
- Slide 69
- Drug-Related Fever
- Slide 70
- Drug related fever Pathogenesis Hypersensitivity reaction.
Local inflammation at the site of administration : (Amphotericin B,
erythromycin, KCl, sulfonamides & cytotoxic chemotherapies)
Drugs or their delivery systems may contain pyrogens or microbial
contaminants. Stimulation of heat production: (e.g. thyroxine)
Limit heat dissipation: (e.g., atropine) Alter thermoregulation :
(e.g., phenothiazines, antihistamines, anti-parkinsonian
drugs).
- Slide 71
- Drug-Related Fever Rash occurs in a small fraction of cases.
Eosinophilia is also uncommon. Among drug categories:
Antimicrobials (especially B-lactam drugs). Antiepileptic drugs
(especially phenytoin). Antiarrhythmics (especially quinidine,
procainamide). Antihypertensives (methyldopa). Fever induced by
drugs may take several days to resolve 3-7.
- Slide 72
- Drug-Related Fever Withdrawal of certain drugs may be
associated with fever, often with associated tachycardia,
diaphoresis, and hyperreflexia. Alcohol, opiates (including
methadone), barbiturates, and benzodiazepines have all been
associated with this febrile syndrome. Withdrawal and related fever
may occur several hours or days after admission.
- Slide 73
- Drug-Related Fever Malignant Hyperthermia Due to genetic
predisposition and exposure to succinylcholine or inhaled
anesthetic agents. Autosomal-dominant abnormality of the skeletal
muscle membrane (1:50000). Pathophysiology: massive efflux of
calcium from skeletal muscle sarcoplastic reticulum. Patients may
undergo several operations safely before MH crisis occurs.
- Slide 74
- Drug-Related Fever Malignant Hyperthermia Onset can be delayed
for as long as 24 hrs, especially if the patient is on steroids.
Body temp increases rapidly,along with muscle rigidity, tachycardia
and increase CPK. Dantrolene 2 mg/kg q 5 minutes for a total dose
of 10mg. Monitor for myoglobinuria and renal failure. 10-30%
mortality.
- Slide 75
- Drug-Related Fever Neuroleptic malignant syndrome Drug-Related
Fever Neuroleptic malignant syndrome Rare but more often identified
in the ICU than malignant hyperthermia. It has been strongly
associated with phenothiazines, thioxanthenes, and butyrophenones.
In the ICU, haloperidol is perhaps the most frequently reported
drug. Use of droperidol and metoclopramide also has been reported.
The initiator of muscle contraction is central (increased levels of
dopamine because of blockade of dopaminergic receptors).
- Slide 76
- Drug-Related Fever Neuroleptic malignant syndrome Drug-Related
Fever Neuroleptic malignant syndrome Risk factors: Dehydration
Alcoholism Prior brain injury Use of rapid neuroleptic
- Slide 77
- High fever, extrapyramidal symptoms such as lead pipe rigidity,
hypercapnea, catatonia, stupor, rigidity, autonomic instability,
tremor and rhabdomyolysis. Treatment: Cessation of antipsychotic
medication Active cooling Hemodynamic support Dopamenergic agonists
(amantadine, bromocriptine) Dantrolene Drug-Related Fever
Neuroleptic malignant syndrome Drug-Related Fever Neuroleptic
malignant syndrome
- Slide 78
- Serotonin syndrome Caused by large number of medication either
alone in high dose or in combination. increasingly seen with
selective serotonin reuptake inhibitors in the treatment of various
psychiatric disorders.
- Slide 79
- Serotonin syndrome Characterized by altered mental status,
fever, agitation, myoclonus, ataxia. The serotonin syndrome may be
exacerbated with concomitant use of linezolid. Treatment supportive
and the serotonin blocker syproheptadine my be of benefit.
- Slide 80
- Management of fever In ICU Clinical assessment of new fever
should replace automatic, standing-order laboratory and radiologic
tests in the ICU. Serum procalcitonin levels and endotoxin activity
assay can be employed as an adjunctive diagnostic tool for
discriminating infection as the cause for fever or sepsis
presentations.
- Slide 81
- Management of fever In ICU
- Slide 82