Pyrexia - PACT - ESICM

Task 3. Fever in specific categories of critically ill patient
3/ FEVER IN SPECIFIC CATEGORIES OF CRITICALLY
ILL PATIENT
Some categories of critical care patients deserve special mention. In some
centres, surgical ICU is a separate entity but even where surgical patients are
part of a general critical care population, some distinctive considerations
pertain particularly in the early postoperative period. Fever in the immune
suppressed and in neurological patients is also included here.
The surgical critical care patient – determining the
cause of fever
The normal response to trauma and surgery includes release of proinflammatory
mediators and an elevation of body temperature that usually does
not exceed 38.5 °C and does not last longer than two days, unless the surgery
was done for infection itself, e.g. peritonitis. Hence, any elevation of
temperature above 38.5 °C, lasting longer than two days or developing on the
third day, may indicate concomitant microbial infection and sepsis. About 10%
of trauma patients develop a nosocomial infection.
Trauma has some immunodepressant effect thereby increasing the risk
for infection.
Other risk factors relate to advanced age, underlying morbidity and extent of
trauma and surgery. Risk factors also include prolonged hypotension,
haematoma, foreign bodies and blood transfusion. Repeated and careful
searches for a source and micro-organisms are mandatory in these patients.
Gram-negative pneumonia and wound infection are among the most common
sources. Careful search should be made for an infective focus, including removal
of dressings and wound inspection. Bear in mind, however, that at least 35% of
episodes of fever after trauma or surgery are of non-infective origin, and
thromboembolism may lead the list of causes.
Causes of fever of recent onset and infection in descending order of
likelihood are:
Nosocomial pneumonia (and rarely empyema)
Urinary tract infection
Wound infection
Catheter-related infection
Sinusitis
Gram-negative bacteraemia
Miscellaneous.
Empirical antibiotics should only be given after appropriate clinical assessment
and provisional diagnosis, imaging and obtaining specimens for culture.
Antibiotic therapy if started should be reviewed, in the clinical context, once
staining and culture results become available.
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