ICU - Fever Critically Ill - Guidline 2008

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  • Special Article

    Guidelines for evaluation of new fever in critically ill adultpatients: 2008 update from the American College of Critical CareMedicine and the Infectious Diseases Society of America

    Naomi P. OGrady, MD; Philip S. Barie, MD, MBA, FCCM; John G. Bartlett, MD; Thomas Bleck, MD, FCCM;Karen Carroll, RN; Andre C. Kalil, MD; Peter Linden, MD; Dennis G. Maki, MD; David Nierman, MD, FCCM;William Pasculle, MD; Henry Masur, MD, FCCM

    I n some intensive care units(ICUs), the measurement of anewly elevated temperature trig-gers an automatic order set thatincludes many tests that are time con-suming, costly, and disruptive to the pa-

    tient and staff. Moreover, the patient mayexperience discomfort, be exposed to un-needed radiation, require transport out-side the controlled environment of theICU, or experience considerable bloodloss due to this testing, which is often

    repeated several times within 24 hrs anddaily thereafter. In an era when utiliza-tion of hospital and patient resources isunder intensive scrutiny, it is appropriateto assess how such fevers should be eval-uated in a prudent and cost-effectivemanner.

    The American College of Critical CareMedicine of the Society of Critical CareMedicine and the Infectious Diseases So-ciety of America reconvened a Task Forceto update practice parameters for theevaluation of a new fever in adult patients(i.e., 18 yrs of age) in an ICU (1). Thegoal of this update is to continue to pro-mote the rational consumption of re-sources and an efficient evaluation. Thisguideline presumes that any unexplainedtemperature elevation merits a clinicalassessment by a healthcare professionalthat includes a review of the patientshistory and a focused physical examina-

    Objective: To update the practice parameters for the evaluationof adult patients who develop a new fever in the intensive careunit, for the purpose of guiding clinical practice.

    Participants: A task force of 11 experts in the disciplinesrelated to critical care medicine and infectious diseases wasconvened from the membership of the Society of Critical CareMedicine and the Infectious Diseases Society of America. Spe-cialties represented included critical care medicine, surgery, in-ternal medicine, infectious diseases, neurology, and laboratorymedicine/microbiology.

    Evidence: The task force members provided personal experi-ence and determined the published literature (MEDLINE articles,textbooks, etc.) from which consensus was obtained. Publishedliterature was reviewed and classified into one of four categories,according to study design and scientific value.

    Consensus Process: The task force met twice in person, sev-eral times by teleconference, and held multiple e-mail discussionsduring a 2-yr period to identify the pertinent literature and arriveat consensus recommendations. Consideration was given to the

    relationship between the weight of scientific evidence and thestrength of the recommendation. Draft documents were com-posed and debated by the task force until consensus was reachedby nominal group process.

    Conclusions: The panel concluded that, because fever canhave many infectious and noninfectious etiologies, a new fever ina patient in the intensive care unit should trigger a careful clinicalassessment rather than automatic orders for laboratory and ra-diologic tests. A cost-conscious approach to obtaining culturesand imaging studies should be undertaken if indicated after aclinical evaluation. The goal of such an approach is to determine,in a directed manner, whether infection is present so that addi-tional testing can be avoided and therapeutic decisions can bemade. (Crit Care Med 2008; 36:13301349)

    KEY WORDS: fever; intensive care unit; critical illness; bloodcultures; catheter infection; pneumonia; colitis; sinusitis; surgicalsite infection; nosocomial infection; temperature measurement;urinary tract infection

    From the National Institutes of Health, Bethesda,MD (NPO, HM); Weill Cornell Medical College, NewYork, NY (PSB); Johns Hopkins University Schoolof Medicine, Baltimore, MD (JGB, KC); North-western University, Chicago, IL (TB); University ofNebraska, Omaha, NE (ACK); University of PittsburghMedical Center, Pittsburgh, PA (PL, WP); Universityof Wisconsin Medical School, Madison, WI (DGM);and The Mount Sinai Hospital, New York, NY (DN).

    The American College of Critical Care Medicine(ACCM), which honors individuals for their achieve-ments and contributions to multidisciplinary criticalcare medicine, is the consultative body of the So-ciety of Critical Care Medicine (SCCM), which pos-sesses recognized expertise in the practice of crit-ical care. The College has developed administrativeguidelines and clinical practice parameters for

    the critical care practitioner. New guidelines andpractice parameters are continually developed, andcurrent ones are systematically reviewed and re-vised.

    This guideline was developed in collaboration withthe Infectious Diseases Society of America.

    For information regarding this article, E-mail:nogrady@mail.cc.nih.gov

    Dr. Bartlett holds consultancies with HIV-Bristol-Myers, Abbott, Merck, Johnson & Johnson, and Ti-botec; and a patent with Gilead.

    The remaining authors have not disclosed anypotential conflicts of interest.

    Copyright 2008 by the Society of Critical CareMedicine

    DOI: 10.1097/CCM.0b013e318169eda9

    1330 Crit Care Med 2008 Vol. 36, No. 4

  • tion before any laboratory tests or imag-ing procedures are ordered.

    This update specifically addresses howto evaluate a new fever in an adult patientalready in the ICU who has previouslybeen afebrile and in whom the source offever is not initially obvious. This updatewill assist intensivists and consultants asa starting point for developing an effec-tive and cost-conscious approach appro-priate for their patient populations. Thespecific recommendations are rated bythe strength of evidence, using the pub-lished criteria of the Society of CriticalCare Medicine (Table 1).

    Initiating a Fever Evaluation:Measuring Body Temperatureand Defining Fever as Thresholdsfor Diagnostic Effort

    Definition of Fever. The definition offever is arbitrary and depends on the pur-pose for which it is defined. Some litera-ture defines fever as a core temperatureof 38.0C (100.4F) (24), whereasother sources define fever as two consec-utive elevations of 38.3C (101.0F). Inpatients who are neutropenic, fever hasbeen defined as a single oral temperatureof38.3C (101.0F) in the absence of anobvious environmental cause, or a tem-perature elevation of 38.0C (100.4F)for 1 hr (4). A variety of definitions offever are acceptable, depending on howsensitive an indicator of thermal abnor-mality an ICU practitioner wants to uti-lize. Normal body temperature is gener-

    ally considered to be 37.0C (98.6F) (4,5). In healthy individuals, this tempera-ture varies by 0.5 to 1.0C, according tocircadian rhythm and menstrual cycle(6). With heavy exercise, temperature canrise by 2 to 3C (7). Whereas many bio-logical processes can alter body temper-ature, a variety of environmental forcesin an ICU can also alter temperature,such as specialized mattresses, hot lights,air conditioning, cardiopulmonary by-pass, peritoneal lavage, dialysis, and con-tinuous hemofiltration (810). Thermo-regulatory mechanisms can also bedisrupted by drugs or by damage to thecentral or the autonomic nervous sys-tems. Thus, it is often difficult to deter-mine whether an abnormal temperatureis a reflection of a physiologic process, adrug, or an environmental influence.

    A substantial proportion of infectedpatients are not febrile: such patientsmay be euthermic or hypothermic. Thesepatients include the elderly, patients withopen abdominal wounds, patients withlarge burns, patients receiving extracor-poreal membrane oxygenation or contin-uous renal replacement therapy (11),patients with congestive heart failure,end-stage liver disease, or chronic renalfailure, and patients taking anti-inflam-matory or antipyretic drugs. A patientwho is hypothermic or euthermic mayhave a life-threatening infection. Othersymptoms and signs in the absence offever, such as otherwise unexplained hy-potension, tachycardia, tachypnea, confu-sion, rigors, skin lesions, respiratorymanifestations, oliguria, lactic acidosis,leukocytosis, leukopenia, immature neu-trophils (i.e., bands) of 10%, or throm-bocytopenia, might appropriately man-date a comprehensive search for infectionand aggressive, immediate empiricaltherapy.

    As a broad generalization, it is reason-able in many ICUs to consider everyonewith a temperature of 38.3C (101F)to be febrile and to warrant special atten-tion to determine whether infection ispresent. However, a lower threshold maybe used for immunocompromised pa-tients because they are not able to man-ifest a similar fever response as the oneseen in immunocompetent patients. Ef-fective management of patients in an ICUmandates that infection be considered inpatients regardless of temperature butthat laboratory tests to search for infec-tion should be initiated in febrile patientsonly after a clinical assessment indicates

    a reasonable possibility that infectionmight be present.

    Site and Technology of TemperatureMeasurement. The ideal system for mea-suring temperature should provide reli-able, reproducible values safely and con-veniently. Any device must be calibratedproperly and checked periodically accord-ing to the manufacturers specifications.

    Most authorities consider the ther-mistor of a pulmonary artery catheter tobe the standard for measuring core tem-perature against which other devicesmust be compared (6, 1216). Not allpatients have such a thermistor in place.Even when available, these thermistorsare not all equal in technical perfor-mance. Thermistors in indwelling blad-der catheters provide essentially id