Pyrexia - PACT - ESICM

Acute acalculous cholecystitis
Task 2. Determining the cause of fever in the critically ill patient
After multiple trauma, burns, severe sepsis and major surgery, the gallbladder
may become inflamed in the absence of gall stones. This inflammation, called
acalculous cholecystitis, has an estimated incidence of 1.5% especially in septic
patients or in patients recovering from abdominal sepsis. The low incidence is
probably because of the non-specific clinical signs (pain in the right upper
quadrant and nausea) and laboratory work-up. The detected wall thickness >3
mm, intramural lucencies, gallbladder distension, pericholecystic fluid, and
intramural sludge are helpful radiological findings while hepatobiliary
scintigraphy is characterised by a high false-positive rate (>50%). Frequently,
the diagnosis is delayed and the disease progresses to ischaemia, gangrene and
perforation, indicating the necessary high index of suspicion while the
treatment of choice is cholecystectomy. However, in very unstable patients,
radiologic percutaneous drainage (cholecystostomy) may be preferred as a
temporary measure and has replaced surgical cholecystectomy as a first choice
treatment in many centres. In many patients, antibiotics will be prescribed,
aimed at the causative organism, identified after percutaneous puncture and
culture of the bile. For further details see:
Boland G, Lee MJ, Mueller PR. Acute cholecystitis in the intensive care unit. New
Horiz 1993; 1(2): 246–260. PMID 7922407
Barie PS, Fischer E. Acute acalculous cholecystitis. J Am Coll Surg 1995; 180(2):
232–244. PMID 7850064
Other causes
Be aware of central nervous system infections in patients with (internal or
external) neurosurgical monitoring or draining devices. Coagulase-negative
staphylococci are often involved. Suspected infection should prompt obtaining
cerebrospinal fluid (CSF) for Gram stain and culture.
Pseudomembranous colitis caused by Clostridium difficile has become a
prevalent problem in many ICUs. In milder forms of the infection, diarrhoea
may be the only feature. C. difficile -related diarrhoea is a relatively frequent
occurrence in the critically ill, particularly if there has been treatment with
multiple courses of broad-spectrum antibiotics. More severe forms of the
disease are frequently characterised by a marked leukocytosis and elevated
creatinine. Occasionally, an acute abdomen may result from C. difficile infection
and surgical colectomy may be required. More virulent strains causing severe
disease have recently emerged.
The bacteria can be transmitted from patient to staff and vice
versa, so that inadequate handwashing (alcohol gel is
inadequate and soap and water is required for spore removal)
may result in small outbreaks in the ICU. The diagnosis is
established by a positive faecal toxin A and B (or tissue culture
cytotoxicity) assays and increased faecal leukocytes. A negative
[26]
Rigorous attention to
simple hygienic measures
in the ICU is imperative.
Alcohol hand cleansing is
regarded as inadequate
to clear C diff spores; a
(traditional) physical
handwash is required