Fever in the ICU Focused on 4C1102

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Fever in the ICU (Focused on 4C1-10-2)

• Ri ???

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Clinical History(1)

• 67-year-old male
• HTN(-), DM(-)
• CAD s/p CABG in 1999
• Smoking() for 40 years

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Clinical History(2)

• Bloody stool noted on 91-6-3
• Came to NTUH ER on 6/4
• Colonoscopy one ulcerative mass at cecum
• Pathology adenocarcinoma

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Clinical History(3)

• OP on 6/10 Right hemicolectomy
• Transferred to 4C1
• Extubation at 1600 on 6/10

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Clinical History(4)

• 6/11 Post-OP MI
• Unstable hemodynamics
• Fluid challenge
• NTG, Morphine, Heparin
• IABP and Swan-Ganz insertion

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Clinical History(5)

• 6/11 Acute pulmonary edema
• Breathing sound bilateral basal rales
• CXR bilateral diffuse infiltration
• Impression
• 1. r/o Cardiogenic edema
• 2. r/o ARDS
• Swan-Ganz
• C.O 67 L/min
• PCWP 813 (lt18 mm-Hg)
• - ARDS is more likely, cause unknown

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Clinical History(6)

• Fever developed since 6/11
• WBC 14780
• CRP 9.91
• Sepsis was suspected
• Abx Vancomycin Fortum Anegyn
• B/C, S/C, Swan-Ganz, CVP, U/A Negative
• Abdominal Echo no specific finding

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What is the cause of fever in this
patient?
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Characteristics of fever in this pt

• Fever pattern

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Characteristics of fever in this pt

• Fever pattern
• Leukocyte count

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Fever and leukocyte count

• Etiology of leukocytosis
• Infection
• Inflammation
• Stress
• Drugs
• Trauma
• Leukemia, Myeloproliferative disorders
• Leukocyte counts are non-discriminate of acute
  febrile conditions

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Characteristics of fever in this pt

• Fever pattern
• Leukocyte count
• Culture result

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Culture result

• Blood culture negative
• Swan-Ganz, CVP culture negative
• Sputum culture(6/22)
• Chryseobacterium indologenes3
• Nonfermentative GNB2
• Acinetobacter baumannii1
• - Tazocin sensitive
• Stool No Clostridium difficile

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Characteristics of fever in this pt

• Fever pattern
• Leukocyte count
• Culture result
• Antibiotics

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Characteristics of fever in this pt

• Fever pattern
• Leukocyte count
• Culture result
• Antibiotics
• CXR persistent bilateral diffuse infiltrates

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Fever in the ICU

• Def Body temperature gt 38?
• Pathophysiology

Leukocyte activation
Cytokine (IL-1, IL-6, TNF)
Stimulus
Hypothalamus reset thermoregulatory point
Heat production
Fever
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Cause of fever(1) Infectious

• Common
• Urinary tract
• Pneumonia
• Catheter related
• Sepsis
• Abdominal abscess

• Uncommon
• Sinusitis
• Cholecystitis
• Endocarditis
• Colitis
• Meningitis
• Cutaneous

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Cause of fever(2) Noninfectious

• Common
• Drug
• Transfusion
• Postoperative fever
• MI
• Tissue injury
• Hemorrhage
• DVT
• PE
• Atalectasis

• Uncommon
• Procedure related
• Aortic aneurysm
• Pericarditis
• Adrenal insufficiency
• Ethanol withdrawal
• Vasculitis
• Collagen vascular dz
• Pancreatitis
• Bowel infarction
• Tumor

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Drug fever

• Common offenders
• Amphotericin
• Cephalosporins
• Penicillins
• Phenytoin
• Procainamide
• Quinidine

• Occasional offenders
• Cimentidine
• Carbamazepine
• Hydralazine
• Rifampin
• Streptokinase
• Vancomycin

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Cause of fever in this patient

• Pneumonia?
• Sepsis?
• Abdominal abscess?
• Drug fever?
• ARDS?

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Acute Respiratory Distress Syndrome

• 1994 AECC Definition
• Acute onset of respiratory failure
• Bilateral chest infiltrates
• PAWP ? 18 mmHg
• PaO2/FiO2 lt 200 ? ARDS
• PaO2/FiO2 lt 300 ? Acute lung injury

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Conditions Associated with ARDS

• Direct lung injury
• Pneumonia
• Aspiration of gastric contents
• Pulmonary contusion
• Fat emboli
• Inhalation injury
• Near-drowning
• Reperfusion pulmonary edema

• Indirect lung injury
• Sepsis
• Multiple trauma
• Multiple blood transfusions
• Cardiopulmonary bypass
• Burns
• Acute pancreatitis
• Drug overdose

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Pathogenesis
Neutrophil activation
Insult
Cytokine
Inflammation
Epithelial and endothelial damage
Recover
Increased permeability
Exudation into alveolar space
Fibrosis
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Cause of fever in ARDS patient

• In 35 ARDS patient
• 26(75) were infectious in origin
• 9(25) were noninfectious in origin
• 5 were due to fibroproliferation of lung

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Fibroproliferative phase of ARDS

• Usually presented in late ARDS
• early ARDS lt48 hr after onset
• late ARDS gt48 hr after onset
• An inflammatory / ineffective repair process

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Fibroproliferative phase of ARDS

• Clinical presentation
• Persistent fever and leukocytosis
• Inability to improve lung function
• Low systemic vascular resistance
• No identifiable source of infection
• Difficult to discriminate from nosocomial
  infection clinically

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Fibroproliferative phase of ARDS

• Diagnosis BAL, open lung biopsy
• Treatment corticosteroid, high dose?
• Anti-inflammatory effect
• Immunosuppression
• Impair wound healing

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Cause of fever in this patient

• Pneumonia?
• Sepsis?
• Abdominal abscess?
• Drug fever?
• Fibroproliferative phase of ARDS?

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Thanks for your attention!