Association of body temperature and antipyretic treatments with mortality of critically ill patients with and without sepsis: multi-centered prospective observational study

The Association of Fever with Total Mechanical Ventilation Time in Critically Ill Patients

This research aims to investigate the impact of fever on total mechanical ventilation time (TVT) in critically ill patients. Subgroup analysis was conducted using a previous prospective, multicenter observational study. We included mechanically ventilated patients for more than 24 hours from 10 Korean and 15 Japanese intensive care units (ICU), and recorded maximal body temperature under the support of mechanical ventilation (MAX(MV)). To assess the independent association of MAX(MV) with TVT, we used propensity-matched analysis in a total of 769 survived patients with medical or surgical admission, separately. Together with multiple linear regression analysis to evaluate the association between the severity of fever and TVT, the effect of MAX(MV) on ventilator-free days was also observed by quantile regression analysis in all subjects including non-survivors. After propensity score matching, a MAX(MV) ≥ 37.5°C was significantly associated with longer mean TVT by 5.4 days in medical admission, and by 1.2 days in surgical admission, compared to those with MAX(MV) of 36.5°C to 37.4°C. In multivariate linear regression analysis, patients with three categories of fever (MAX(MV) of 37.5°C to 38.4°C, 38.5°C to 39.4°C, and ≥ 39.5°C) sustained a significantly longer duration of TVT than those with normal range of MAX(MV) in both categories of ICU admission. A significant association between MAX(MV) and mechanical ventilator-free days was also observed in all enrolled subjects. Fever may be a detrimental factor to prolong TVT in mechanically ventilated patients. These findings suggest that fever in mechanically ventilated patients might be associated with worse mechanical ventilation outcome.

Paracetamol in fever in critically ill patients-an update

Fever, which is arbitrary defined as an increase in body temperature above 38.3°C, can affect up to 90% of patients admitted in intensive care unit. Induction of fever is mediated by the release of pyrogenic cytokines (tumor necrosis factor α, interleukin 1, interleukin 6, and interferons). Fever is associated with increased length of stay in intensive care unit and with a worse outcome in some subgroups of patients (mainly neurocritically ill patients). Although fever can increase oxygen consumption in unstable patients, on the contrary, it can activate physiologic systems that are involved in pathogens clearance. Treatments to reduce fever include the use of antipyretics. Thus, the reduction of fever might reduce the ability to develop an efficient host response. This balance, between harms and benefits, has to be taken into account every time we decide to treat or not to treat fever in a given patient. Among the antipyretics, paracetamol is one of the most common used. Paracetamol is a synthetic, nonopioid, centrally acting analgesic, and antipyretic drug. Its antipyretic effect occurs because it inhibits cyclooxygenase-3 and the prostaglandin synthesis, within the central nervous system, resetting the hypothalamic heat-regulation center. In this clinical review, we will summarize the use of paracetamol as antipyretic in critically ill patients (sepsis, trauma, neurological, and medical).

Should we treat pyrexia? And how do we do it?

The concept of pyrexia as a protective physiological response to aid in host defence has been challenged with the awareness of the severe metabolic stress induced by pyrexia. The host response to pyrexia varies, however, according to the disease profile and severity and, as such, the management of pyrexia should differ; for example, temperature control is safe and effective in septic shock but remains controversial in sepsis. From the reported findings discussed in this review, treating pyrexia appears to be beneficial in septic shock, out of hospital cardiac arrest and acute brain injury.Multiple therapeutic options are available for managing pyrexia, with precise targeted temperature management now possible. Notably, the use of pharmacotherapy versus surface cooling has not been shown to be advantageous. The importance of avoiding hypothermia in any treatment strategy is not to be understated.Whilst a great deal of progress has been made regarding optimal temperature management in recent years, further studies will be needed to determine which patients would benefit the most from control of pyrexia and by which means this should be implemented. This narrative review is part of a series on the pathophysiology and management of pyrexia.

The neurological and cognitive consequences of hyperthermia

An elevated temperature has many aetiologies, both infective and non-infective, and while the fever of sepsis probably confers benefit, there is increasing evidence that the central nervous system is particularly vulnerable to damage from hyperthermia. A single episode of hyperthermia may cause short-term neurological and cognitive dysfunction, which may be prolonged or become permanent. The cerebellum is particularly intolerant to the effects of heat. Hyperthermia in the presence of acute brain injury worsens outcome. The thermotoxicity involved occurs via cellular, local, and systemic mechanisms. This article reviews both the cognitive and neurological consequences and examines the mechanisms of cerebral damage caused by high temperature.

The pathophysiological basis and consequences of fever

There are numerous causes of a raised core temperature. A fever occurring in sepsis may be associated with a survival benefit. However, this is not the case for non-infective triggers. Where heat generation exceeds heat loss and the core temperature rises above that set by the hypothalamus, a combination of cellular, local, organ-specific, and systemic effects occurs and puts the individual at risk of both short-term and long-term dysfunction which, if severe or sustained, may lead to death. This narrative review is part of a series that will outline the pathophysiology of pyrogenic and non-pyrogenic fever, concentrating primarily on the pathophysiology of non-septic causes.

Neurogenic Fever

Fever is a relatively common occurrence among patients in the intensive care setting. Although the most obvious and concerning etiology is sepsis, drug reactions, venous thromboembolism, and postsurgical fevers are all on the differential diagnosis. There is abundant evidence that fever is detrimental in acute neurologic injury. Worse outcomes are reported in acute stroke, subarachnoid hemorrhage, and traumatic brain injury. In addition to the various etiologies of fever in the intensive care setting, neurologic illness is a risk factor for neurogenic fevers. This primarily occurs in subarachnoid hemorrhage and traumatic brain injury, with hypothalamic injury being the proposed mechanism. Paroxysmal sympathetic hyperactivity is another source of hyperthermia commonly seen in the population with traumatic brain injury. This review focuses on the detrimental effects of fever on the neurologically injured as well as the risk factors and diagnosis of neurogenic fever.

Controversies in the temperature management of critically ill patients

Although body temperature is a classic primary vital sign, its value has received little attention compared with the others (blood pressure, heart rate, and respiratory rate). This may result from the fact that unlike the other primary vital signs, aging and diseases rarely affect the thermoregulatory system. Despite this, when humans are exposed to various anesthetics and analgesics and acute etiologies of non-infectious and infectious diseases in perioperative and intensive care settings, abnormalities may occur that shift body temperature up and down. A recent upsurge in clinical evidence in the perioperative and critical care field resulted in many clinical trials in temperature management. The results of these clinical trials suggest that aggressive body temperature modifications in comatose survivors after resuscitation from shockable rhythm, and permissive fever in critically ill patients, are carried out in critical care settings to improve patient outcomes; however, its efficacy remains to be elucidated. A recent, large multicenter randomized controlled trial demonstrated contradictory results, which may disrupt the trends in clinical practice. Thus, updated information concerning thermoregulatory interventions is essential for anesthesiologists and intensivists. Here, recent controversies in therapeutic hypothermia and fever management are summarized, and their relevance to the physiology of human thermoregulation is discussed.

Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference

Since the inception of the Pediatric Cardiac Intensive Care Society (PCICS) in 2003, remarkable advances in the care of children with critical cardiac disease have been developed. Specialized surgical approaches, anesthesiology practices, and intensive care management have all contributed to improved outcomes. However, significant morbidity often results from immunologic or infectious disease in the perioperative period or during a medical intensive care unit admission. The immunologic or infectious illness may lead to fever, which requires the attention and resources of the cardiac intensivist. Frequently, cardiopulmonary bypass leads to an inflammatory state that may present hemodynamic challenges or complicate postoperative care. However, inflammation unchecked by a compensatory anti-inflammatory response may also contribute to the development of capillary leak and lead to a complicated intensive care unit course. Any patient admitted to the intensive care unit is at risk for a hospital acquired infection, and no patients are at greater risk than the child treated with mechanical circulatory support. In summary, the prevention, diagnosis, and management of immunologic and infectious diseases in the pediatric cardiac intensive care unit is of paramount importance for the clinician. This review from the tenth PCICS International Conference will summarize the current knowledge in this important aspect of our field.

Body Temperature at the Emergency Department as a Predictor of Mortality in Patients With Bacterial Infection

Hypothermia is a risk factor for death in intensive care unit (ICU) patients with severe sepsis and septic shock. In the present study, we investigated the association between body temperature (BT) on arrival at the emergency department (ED) and mortality in patients with bacterial infection.We conducted a retrospective cohort study in consecutive ED patients over 15 years of age with bacterial infection who were admitted to an urban teaching hospital in Japan between 2010 and 2012. The main outcome measure was 30-day in-hospital mortality. Each patient was assigned to 1 of 6 categories based on BT at ED admission. We conducted multivariable logistic regression analysis to adjust for predictors of death.A total of 913 patients were enrolled in the study. The BT categories were <36, 36 to 36.9, 37 to 37.9, 38 to 38.9, 39 to 39.9, and ≥40 °C, with respective mortalities of 32.5%, 14.1%, 8.7%, 8.2%, 5.7%, and 5.3%. Multivariable analysis showed that the risk of death was significantly low in patients with BT 37 to 37.9 °C (adjusted odds ratio [AOR]: 0.2; 95% confidence interval [CI] 0.1-0.6, P = 0.003), 38-38.9 °C (AOR: 0.2; 95% CI 0.1-0.6, P = 0.002), 39-39.9 °C (AOR: 0.2; 95% CI 0.1-0.5, P = 0.001), and ≥40 °C (AOR: 0.1; 95% CI 0.02-0.4, P = 0.001), compared with hypothermic patients (BT <36 °C).The higher BT on arrival at ED, the better the outcomes observed in patients with bacterial infection were.

Prostaglandin E₂ constrains systemic inflammation through an innate lymphoid cell-IL-22 axis

Systemic inflammation, which results from the massive release of proinflammatory molecules into the circulatory system, is a major risk factor for severe illness, but the precise mechanisms underlying its control are not fully understood. We observed that prostaglandin E2 (PGE2), through its receptor EP4, is down-regulated in human systemic inflammatory disease. Mice with reduced PGE2 synthesis develop systemic inflammation, associated with translocation of gut bacteria, which can be prevented by treatment with EP4 agonists. Mechanistically, we demonstrate that PGE2-EP4 signaling acts directly on type 3 innate lymphoid cells (ILCs), promoting their homeostasis and driving them to produce interleukin-22 (IL-22). Disruption of the ILC-IL-22 axis impairs PGE2-mediated inhibition of systemic inflammation. Hence, the ILC-IL-22 axis is essential in protecting against gut barrier dysfunction, enabling PGE2-EP4 signaling to impede systemic inflammation.

[Is control fever mandatory in severe infections?]

Temperature control during severe sepsis is currently used in intensive care and involves 66% and 70% of severe sepsis and septic shock, respectively. Nevertheless, the conclusive evidence of the benefit of such a strategy is still lacking.We might wonder, with regards to experimental works and recent noninterventional studies, about the risk of a control strategy on an ongoing infectious process, the patient's outcome, and the safety of the means implemented to obtain temperature control. On the other hand, it is also demonstrated that fever increases oxygen consumption, which may lead in some clinical situations to tissular ischemia and that fever may be associated with a deleterious focal inflammatory process. Methods to control the temperature include external and/or internal cooling and/or antipyretic medications such as paracetamol and nonsteroidal antiinflammatory drugs. In septic patients, external cooling and paracetamol are the mains means used to control temperature. Despite the uncertainties about the benefit to control or not the temperature, it could be stated that extreme temperature (hypo- or hyperthermia) should be avoided and that the benefit/risk of temperature control must be individually weighted.

Breakthrough in cardiac arrest: reports from the 4th Paris International Conference

Jean-Luc Diehl The French Intensive Care Society organized on 5th and 6th June 2014 its 4th "Paris International Conference in Intensive Care", whose principle is to bring together the best international experts on a hot topic in critical care medicine. The 2014 theme was "Breakthrough in cardiac arrest", with many high-quality updates on epidemiology, public health data, pre-hospital and in-ICU cares. The present review includes short summaries of the major presentations, classified into six main chapters: Epidemiology of CA Pre-hospital management Post-resuscitation management: targeted temperature management Post-resuscitation management: optimizing organ perfusion and metabolic parameters Neurological assessment of brain damages Public healthcare.

Glutamine may repress the weak LPS and enhance the strong heat shock induction of monocyte and lymphocyte HSP72 proteins but may not modulate the HSP72 mRNA in patients with sepsis or trauma

Objective. We assessed the lipopolysaccharide (LPS) or heat shock (HS) induction of heat shock protein-72 (HSP72) in peripheral blood mononuclear cells (PBMCs) of patients with severe sepsis (SS) or trauma-related systemic inflammatory response syndrome (SIRS), compared to healthy individuals (H); we also investigated any pre- or posttreatment modulating glutamine (Gln) effect. Methods. SS (11), SIRS (10), and H (19) PBMCs were incubated with 1 μg/mL LPS or 43°HS. Gln 10 mM was either added 1 h before or 1 h after induction or was not added at all. We measured monocyte (m), lymphocyte (l), mRNA HSP72, HSP72 polymorphisms, interleukins (ILs), monocyte chemoattractant protein-1 (MCP-1), and cortisol levels. Results. Baseline lHSP72 was higher in SS (p < 0.03), and mHSP72 in SIRS (p < 0.02), compared to H. Only HS induced l/mHSP72/mRNA HSP72; LPS induced IL-6, IL-8, IL-10, and MCP-1. Induced mRNA was related to l/mHSP72, and was related negatively to cytokines. Intracellular l/mHSP72/HSP72 mRNA was related to serum ILs, not being influenced by cortisol, illness severity, and HSP72 polymorphisms. Gln did not induce mRNA in any group but modified l/mHSP72 after LPS/HS induction unpredictably. Conclusions. HSP72 mRNA and l/mHSP72 are higher among critically ill patients, further induced by HS, not by LPS. HSP72 proteins and HSP72 mRNA are related to serum ILs and are negatively related to supernatant cytokines, not being influenced by HSP72 polymorphisms, cortisol, or illness severity. Gln may depress l/mHSP72 after LPS exposure and enhance them after HS induction, but it may not affect early induced HSP72 mRNA.

Targeted temperature management in intensive care - Do we let nature take its course?

Should we aim to intervene and control fever in the critically ill patient? The answer is not straightforward and there is certainly no universal agreement on the subject. This article aims to discuss whether we should over-ride nature and disallow it to take it's course, particularly where it appears that this evolutionary response to invading pathogens is actually becoming harmful to the patient. Also discussed here are the physiology of temperature control and the scope of our current understanding of the impact of fever in patients manifesting systemic inflammatory response syndrome (SIRS) and sepsis in ICU, the possible interventions to combat fever (both physical and pharmacological) and the evidence for anti-pyretic drug therapy. The final section examines the potential role of targeted temperature management in the management of sepsis / SIRS in the critically ill.

Role of acute physiology and chronic health evaluation II scoring system in determining the severity and prognosis of critically ill patients in pediatric intensive care unit

Objective:

This study was conducted to validate the use of Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system in pediatric population in predicting the risk of mortality and to compare the predicted death rate (using APACHE II) with the actual death rate of the patients.

Design:

Hospital-based prospective study.

Setting:

Tertiary care Pediatric Intensive Care Unit (PICU) in Western Rajasthan, India.

Methods:

A total of 100 critically ill children between 1 and 18 years of age admitted to PICU and fulfilling the inclusion criteria were enrolled. APACHE II score was calculated in each patient on the day of admission. The predicted mortality was calculated on the basis of this score.

Results:

The mean APACHE II score was 21.35 ± 5.76. Mean APACHE II score among the survivors was 16.60 ± 6.12, and mean APACHE II score among the nonsurvivors was 26.11 ± 5.41, and the difference was statistically significant (P = 0.00). The area under the receiver operating characteristic curve for APACHE II score was found to be 0.889 (P = 0.008) indicating good discrimination.

Conclusion:

APACHE II scoring system has a good discrimination and calibration when applied to a pediatric population.

Respective impact of lowering body temperature and heart rate on mortality in septic shock: mediation analysis of a randomized trial

PURPOSE

We previously showed that external cooling decreases day 14 mortality in febrile septic shock. Because cooling may participate in heart rate control, we studied the respective impact of heart rate and temperature lowering on mortality.

METHODS

Post hoc analysis of the Sepsiscool randomized controlled trial database (NCT00527007). Cooling was applied to maintain normothermia (36.5-37 °C) during 48 h. We assessed the time spent below different thresholds of temperature and heart rate on day 14 mortality. The best threshold was selected by AUC-ROC and tested as a potential mediator of mortality reduction. Mediation analysis was adjusted for severity and treatments influencing temperature and heart rate evolution. Sensitivity analysis was done using only patients with appropriate antimicrobial therapy.

RESULTS

A total of 197/200 patients with adequate heart rate and temperature monitoring were analyzed. The best threshold differentiating survivors and nonsurvivors was 38.4 °C for temperature and 95 b/min for heart rate. During the 48 h of intervention, cooling significantly increased the time spent with a temperature below 38.4 °C, p = 0.001, and with a heart rate below 95 b/min, p < 0.01. The longer was the time spent with a temperature below 38.4 °C, the lower was the mortality [adjOR 0.17 (0.06-0.49), p = 0.001]. The time spent with a heart rate below 95 b/min was similar in survivors and nonsurvivors [adjOR 0.68 (0.27-1.72), p = 0.42]. Mediation analysis showed that the time spent with a temperature below 38.4 °C was a significant mediator of mortality.

CONCLUSION

The time spent with a temperature below 38.4 °C was independently associated with patient's outcome and explained 73% of the effect of the randomization on the day 14 mortality. Heart rate lowering was not a mediator of mortality.

Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection

BACKGROUND

Fever suppression may be beneficial for patients with traumatic brain injury (TBI) and stroke, but for patients with meningitis or encephalitis [central nervous system (CNS) infection], the febrile response may be advantageous.

OBJECTIVE

To evaluate the relationship between peak temperature in the first 24 h of intensive care unit (ICU) admission and all-cause hospital mortality for acute neurological diseases.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort design from 2005 to 2013, including 934,159 admissions to 148 ICUs in Australia and New Zealand (ANZ) and 908,775 admissions to 236 ICUs in the UK.

RESULTS

There were 53,942 (5.8 %) patients in ANZ and 56,696 (6.2 %) patients in the UK with a diagnosis of TBI, stroke or CNS infection. For both the ANZ (P = 0.02) and UK (P < 0.0001) cohorts there was a significant interaction between early peak temperature and CNS infection, indicating that the nature of the relationship between in-hospital mortality and peak temperature differed between TBI/stroke and CNS infection. For patients with CNS infection, elevated peak temperature was not associated with an increased risk of death, relative to the risk at 37-37.4 °C (normothermia). For patients with stroke and TBI, peak temperature below 37 °C and above 39 °C was associated with an increased risk of death, compared to normothermia.

CONCLUSIONS

The relationship between peak temperature in the first 24 h after ICU admission and in-hospital mortality differs for TBI/stroke compared to CNS infection. For CNS infection, increased temperature is not associated with increased risk of death.

Drug-induced hyperthermia in critical care

Fever is common in critically ill patients and the cause is frequently not infection. Drug fevers occur in the intensive care and there are many pharmacological agents, by a variety of mechanisms, which increase body temperature beyond normal range. This article is a review of the common classes of drugs that can induce hyperthermia, highlighting the deleterious effects of a sustained high temperature and outlining available treatments.

Paracetamol therapy and outcome of critically ill patients: a multicenter retrospective observational study

Introduction

In this study, we aimed to examine the association between paracetamol administration in the intensive care unit (ICU) and mortality in critically ill patients.

Methods

We conducted a multicenter retrospective observational study in four ICUs. We obtained information on paracetamol use, body temperature, demographic, clinical and outcome data from each hospital’s clinical information system and admissions and discharges database. We performed statistical analysis to assess the association between paracetamol administration and hospital mortality.

Results

We studied 15,818 patients with 691,348 temperature measurements at 4 ICUs. Of these patients, 10,046 (64%) received at least 1 g of paracetamol. Patients who received paracetamol had lower in-hospital mortality (10% vs. 20%, P <0.001), and survivors were more likely to have received paracetamol (66% vs. 46%; P <0.001). However, patients treated with paracetamol were also more likely to be admitted to the ICU after surgery (70% vs. 51%; P <0.001) and/or after elective surgery (55% vs. 37%; P <0.001). In multivariate logistic regression analysis including a propensity score for paracetamol treatment, we found a significant and independent association between the use of paracetamol and reduced in-hospital mortality (adjusted odds ratio =0.60 (95% confidence interval (CI), 0.53 to 0.68), P <0.001). Cox proportional hazards analysis showed that patients who received paracetamol also had a significantly longer time to death (adjusted hazard ratio =0.51 (95% CI, 0.46 to 0.56), P <0.001). The association between paracetamol and decreased mortality and/or time to death was broadly consistent across surgical and medical patients. It remained present after adjusting for paracetamol administration as a time-dependent variable. However, when such time-dependent analysis was performed, the association of paracetamol with outcome lost statistical significance in the presence of fever and suspected infection and in patients in the lower tertiles of Acute Physiology and Chronic Health Evaluation II scores.

Conclusions

Paracetamol administration is common in the ICU and appears to be independently associated with reduced in-hospital mortality and time to death after adjustment for multiple potential confounders and propensity score. This association, however, was modified by the presence of fever, suspected infection and lesser illness severity and may represent the effect of indication bias.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0865-1) contains supplementary material, which is available to authorized users.

Body temperature and mortality in patients with acute respiratory distress syndrome

BACKGROUND

Little is known about the relationship between body temperature and outcomes in patients with acute respiratory distress syndrome (ARDS). A better understanding of this relationship may provide evidence for fever suppression or warming interventions, which are commonly applied in practice.

OBJECTIVE

To examine the relationship between body temperature and mortality in patients with ARDS.

METHODS

Secondary analysis of body temperature and mortality using data from the ARDS Network Fluid and Catheter Treatment Trial (n = 969). Body temperature at baseline and on study day 2, primary cause of ARDS, severity of illness, and 90-day mortality were analyzed by using multiple logistic regression.

RESULTS

Mean baseline temperature was 37.5°C (SD, 1.1°C; range, 27.2°C-40.7°C). At baseline, fever (≥ 38.3°C) was present in 23% and hypothermia (< 36°C) in 5% of the patients. Body temperature was a significant predictor of 90-day mortality after primary cause of ARDS and score on the Acute Physiology and Chronic Health Evaluation III were adjusted for. Higher temperature was associated with decreased mortality: for every 1°C increase in baseline temperature, the odds of death decreased by 15% (odds ratio, 0.85; 95% CI, 0.73-0.98, P = .03). When patients were divided into 5 temperature groups, mortality was lower with higher temperature (P for trend = .02).

CONCLUSIONS

Early in ARDS, fever is associated with improved survival rates. Fever in the acute phase response to lung injury and its relationship to recovery may be an important factor in determining patients' outcome and warrants further study.

Should we treat fever in critically ill patients? A summary of the current evidence from three randomized controlled trials

Fever is a nonspecific response to various types of infectious or non-infectious insult and its significance in disease remains an enigma. Our aim was to summarize the current evidence for the use of antipyretic therapy in critically ill patients. We performed systematic review and meta-analysis of publications from 1966 to 2013. The MEDLINE and CENTRAL databases were searched for studies on antipyresis in critically ill patients. The meta-analysis was limited to: randomized controlled trials; adult human critically ill patients; treatment with antipyretics in one arm versus placebo or non-treatment in another arm; and report of mortality data. The outcomes assessed were overall intensive care unit mortality, changes in temperature, intensive care unit length of stay, and hospital length of stay. Three randomized controlled trials, covering 320 participants, were included. Patients treated with antipyretic agents showed similar intensive care unit mortality (risk ratio 0.91, with 95% confidence interval 0.65-1.28) when compared with controls. The only difference observed was a greater decrease in temperature after 24 hours in patients treated with antipyretics (-1.70±0.40 versus - 0.56±0.25ºC; p=0.014). There is no difference in treating or not the fever in critically ill patients.

Mild induced hypothermia: effects on sepsis-related coagulopathy--results from a randomized controlled trial

INTRODUCTION

Coagulopathy associates with poor outcome in sepsis. Mild induced hypothermia has been proposed as treatment in sepsis but it is not known whether this intervention worsens functional coagulopathy.

MATERIALS AND METHODS

Interim analysis data from an ongoing randomized controlled trial; The Cooling And Surviving Septic shock (CASS) study. Patients suffering severe sepsis/septic shock are allocated to either mild induced hypothermia (cooling to 32-34°C for 24hours) or control (uncontrolled temperature).

TRIAL REGISTRATION

NCT01455116. Thrombelastography (TEG) is performed three times during the first day after study enrollment in all patients. Reaction time (R), maximum amplitude (MA) and patients' characteristics are here reported.

RESULTS

One hundred patients (control n=50 and intervention n=50; male n=59; median age 68years) with complete TEG during follow-up were included. At enrollment, 3%, 38%, and 59% had a hypocoagulable, normocoagulable, and hypercoagulable TEG clot strength (MA), respectively. In the hypothermia group, functional coagulopathy improved during the hypothermia phase, measured by R and MA, in patients with hypercoagulation as well as in patients with hypocoagulation (correlation between ΔR and initial R: rho=-0.60, p<0.0001 and correlation between ΔMA and initial MA: rho=-0.50, p=0.0002). Similar results were not observed in the control group neither for R (rho=-0.03, p=0.8247) nor MA (rho=-0.15, p=0.3115).

CONCLUSION

Mild induced hypothermia did seem to improve functional coagulopathy in septic patients. This improvement of functional coagulopathy parameters during the hypothermia intervention persisted after rewarming. Randomized trials are warranted to determine whether the positive effect on sepsis-related coagulopathy can be transformed to improved survival.

Hypothermia in Adult ICUs: Changing Incidence But Persistent Risk Factor for Mortality

BACKGROUND

This study examined whether hypothermia (< 36.0°C) incidence among critically ill patients varied over time, the determinants of change, and the associated risk for ICU mortality.

METHODS

Interrupted time series analysis among adults admitted to ICUs in Calgary, Canada over 8.5 years. Changes in the incidence of hypothermia within the first 24 hours of ICU admission were modelled using segmented regression.

RESULTS

Among 15,291 first admissions to ICU, hypothermia incidence decreased from 29% to 21% during the study period. Implementation of a new temporal artery thermometer (TAT) was associated with the majority of the decrease in incidence (10%; 95% CI 7.1-13%; P < .0001). However, subgroup analysis revealed important differences between medical and surgical patients. Hypothermia incidence decreased among surgical patients before TAT implementation (0.4% per quarter, 95% CI 0.1-0.7%, P = .009), but not after, whereas in medical patients, the incidence increased after (1.0% per quarter, 95% CI 0.6-1.4%, P < .0001) but not before TAT implementation. Segmented logistic regression suggested that increases in the proportion of patients with non-traumatic neurologic admission diagnoses were associated with hypothermia incidence among medical patients, whereas there was no measurable clinical factor associated with the observed time trends among surgical patients. Hypothermia at ICU admission was independently associated with ICU mortality in medical and surgical patients throughout the entire study.

CONCLUSION

The incidence of hypothermia at ICU admission was dependent on medical versus surgical status, and the method of non-invasive temperature measurement, but was persistently associated with ICU mortality.

Correlation Between Body Temperature and Survival Rate in Patients With Hospital-Acquired Bacteremia

Background:

Fever is a complex and major sign of a patient’s acute response to infection. However, analysis of the risks and benefits associated with the change in body temperature of an infected host remains controversial.

Objective:

To examine the relationship between the intensity of the change in body temperature and the mortality of patients with hospital-acquired bacteremia.

Design:

A prospective observational study.

Method:

Subjects were hospitalized adult patients who developed clinical signs of infection 48 hr or more after admission and had documented bacterial growth in blood culture. The maximum body temperature (maxTe) during the early period of infection measurements (i.e., the day before, the day of, and 2 days after the day of blood culture) was used to indicate the intensity of the body temperature response. Patients were categorized as discharged alive or died in hospital. Cox regression analysis was employed to analyze the data.

Results:

The cohort consisted of 502 subjects. The mean maxTe of subjects was 38.6°C, and 14.9% had a maxTe lower than 38.0°C. The in-hospital mortality rate was 18.9%. The highest in-hospital mortality was found in subjects with a maxTe lower than 38°C (30.7%). Multivariate Cox regression analysis determined that the maxTe and the severity of comorbidity are the two variables associated with in-hospital mortality.

Conclusions:

Lack of a robust febrile response may be associated with greater risk of mortality in patients with bacteremia. Clinicians must be vigilant in identifying patients at risk for a blunted febrile response to bacteremia for more intensive monitoring.

Fever is associated with delayed ventilator liberation in acute lung injury

BACKGROUND

Acute lung injury (ALI) is characterized by inflammation, leukocyte activation, neutrophil recruitment, endothelial dysfunction, and epithelial injury, which are all affected by fever. Fever is common in the intensive care unit, but the relationship between fever and outcomes in ALI has not yet been studied. We evaluated the association of temperature dysregulation with time to ventilator liberation, ventilator-free days, and in-hospital mortality.

METHODS

Analysis of a prospective cohort study, which recruited consecutive patients with ALI from 13 intensive care units at four hospitals in Baltimore, Maryland. The relationship of fever and hypothermia with ventilator liberation was assessed with a Cox proportional hazards model. We evaluated the association of temperature during the first 3 days after ALI with ventilator-free days, using multivariable linear regression models, and the association with mortality was evaluated by robust Poisson regression.

MEASUREMENTS AND MAIN RESULTS

Of 450 patients, only 12% were normothermic during the first 3 days after ALI onset. During the first week post-ALI, each additional day of fever resulted in a 33% reduction in the likelihood of successful ventilator liberation (95% confidence interval [CI] for adjusted hazard ratio, 0.57 to 0.78; P < 0.001). Hypothermia was independently associated with decreased ventilator-free days (hypothermia during each of the first 3 d: reduction of 5.58 d, 95% CI: -9.04 to -2.13; P = 0.002) and increased mortality (hypothermia during each of the first 3 d: relative risk, 1.68; 95% CI, 1.06 to 2.66; P = 0.03).

CONCLUSIONS

Fever and hypothermia are associated with worse clinical outcomes in ALI, with fever being independently associated with delayed ventilator liberation.

Fetal outcome in the critically ill pregnant woman

Management of the critically ill pregnant woman is complicated by potential adverse effects of both maternal illness and ICU interventions on the fetus. This paper reviews the potential risks to the fetus of maternal critical illness, including shock, hypoxemia, and fever, as well as the effects of critical care management, such as drug therapy and radiological investigations. The authors’ recommended approach to management is provided. Prior publications and new data presented identify that there is insufficient information to prognosticate accurately on fetal outcome after maternal critical illness, although maternal shock, hypoxemia and early gestational age are likely significant risk factors.

Fever management in intensive care patients with infections

With great interest we read the article by Dr Schoeneberg and colleagues regarding gender-specific differences with respect to outcome in patients with severe traumatic injury. The authors show that, apart from the acute phase after trauma, women have a more favorable trauma severity-adjusted outcome, with shorter ICU and hospital stay and lower sepsis rates. However, a possible mechanism of action behind this difference was not suggested. We hypothesize that, in view of the fact that morbidity and mortality in the post-acute phase after trauma are often caused by infectious complications, gender differences in immunity might explain the observed differences.

Body temperature abnormalities in non-neurological critically ill patients: a review of the literature

Body temperature abnormalities, which occur because of several infectious and non-infectious etiologies, are among the most commonly noted symptoms of critically ill patients. These abnormalities frequently trigger changes in patient management. The purpose of this article was to review the contemporary literature investigating the definition and occurrence of body temperature abnormalities in addition to their impact on illness severity and mortality in critically ill non-neurological patients, particularly in patients with severe sepsis. Reports on the influence of fever on outcomes are inconclusive, and the presence of fever per se may not contribute to increased mortality in critically ill patients. In patients with severe sepsis, the impacts of elevated body temperature and hypothermia on mortality and the severity of physiologic decline are different. Hypothermia is significantly associated with an increased risk of mortality. In contrast, elevated body temperature may not be associated with increased disease severity or risk of mortality. In patients with severe sepsis, the effect of fever and fever control on outcomes requires further research.

Fever in sepsis: is it cool to be hot?

Changes in body temperature are a characteristic feature of sepsis. The study by Kushimoto and colleagues in a recent issue of Critical Care demonstrates that hypothermia is a very important manifestation of infection associated with very high mortality. Combined with recent data suggesting that febrile patients with infections have the lowest mortality risk, the study raises the question of whether inducing therapeutic hyperthermia might be beneficial in this patient group. Body temperature is easily measured and manipulated in the ICU, and interventional trials defining the most appropriate temperature targets in ICU patients with infections are urgently needed. One such study is in progress.

Heat shock protein 72 expressing stress in sepsis: unbridgeable gap between animal and human studies--a hypothetical "comparative" study

Heat shock protein 72 (Hsp72) exhibits a protective role during times of increased risk of pathogenic challenge and/or tissue damage. The aim of the study was to ascertain Hsp72 protective effect differences between animal and human studies in sepsis using a hypothetical “comparative study” model. Forty-one in vivo (56.1%), in vitro (17.1%), or combined (26.8%) animal and 14 in vivo (2) or in vitro (12) human Hsp72 studies (P < 0.0001) were enrolled in the analysis. Of the 14 human studies, 50% showed a protective Hsp72 effect compared to 95.8% protection shown in septic animal studies (P < 0.0001). Only human studies reported Hsp72-associated mortality (21.4%) or infection (7.1%) or reported results (14.3%) to be nonprotective (P < 0.001). In animal models, any Hsp72 induction method tried increased intracellular Hsp72 (100%), compared to 57.1% of human studies (P < 0.02), reduced proinflammatory cytokines (28/29), and enhanced survival (18/18). Animal studies show a clear Hsp72 protective effect in sepsis. Human studies are inconclusive, showing either protection or a possible relation to mortality and infections. This might be due to the fact that using evermore purified target cell populations in animal models, a lot of clinical information regarding the net response that occurs in sepsis is missing.

Fever Management in Intensive Care Patients with Infections

Fever is one of the cardinal signs of infection and, nearly 120 years after William Osler’s statement in his address to the 47^th annual meeting of the American Medical Association [1], infectious diseases remain a major cause of morbidity and mortality. Despite this, it is unclear whether fever itself is truly the enemy or whether, in fact, the febrile response represents an important means to help the body fight infection. Furthermore, it is unclear whether the administration of antipyretic medications or physical cooling measures to patients with fever and infection is beneficial or harmful [2, 3]. Here, we review the biology of fever, the significance of the febrile response in animals and humans, and the current evidence-base regarding the utility of treating fever in intensive care patients with infectious diseases.

Diagnosis and management of temperature abnormality in ICUs: a EUROBACT investigators' survey

Introduction

Although fever and hypothermia are common abnormal physical signs observed in patients admitted to intensive care units (ICU), little data exist on their optimal management. The objective of this study was to describe contemporary practices and determinants of management of temperature abnormalities among patients admitted to ICUs.

Methods

Site leaders of the multi-national EUROBACT study were surveyed regarding diagnosis and management of temperature abnormalities among patients admitted to their ICUs.

Results

Of the 162 ICUs originally included in EUROBACT, responses were received from 139 (86%) centers in 23 countries in Europe (117), South America (8), Asia (5), North America (4), Australia (3) and Africa (2). A total of 117 (84%) respondents reported use of a specific temperature threshold in their ICU to define fever. A total of 14 different discrete levels were reported with a median of 38.2°C (inter-quartile range, IQR, 38.0°C to 38.5°C). The use of thermometers was protocolized in 91 (65%) ICUs and a wide range of methods were reportedly used, with axillary, tympanic and urinary bladder sites as the most common as primary modalities. Only 31 (22%) of respondents indicated that there was a formal written protocol for temperature control among febrile patients in their ICUs. In most or all cases practice was to control temperature, to use acetaminophen, and to perform a full septic workup in febrile patients and that this was usually directed by physician order. While reported practice was to treat nearly all patients with neurological impairment and most patients with acute coronary syndromes and infections, severe sepsis and septic shock, this was not the case for most patients with liver failure and fever.

Conclusions

A wide range of definitions and management practices were reported regarding temperature abnormalities in the critically ill. Documenting temperature abnormality management practices, including variability in clinical care, is important to inform planning of future studies designed to optimize infection and temperature management strategies in the critically ill.

Beyond intuition: patient fever symptom experience

CONTEXT

Fever is an important sign of inflammation recognized by health care practitioners and family caregivers. However, few empirical data obtained directly from patients exist to support many of the long-standing assumptions about the symptoms of fever. Many of the literature-cited symptoms, including chills, diaphoresis, and malaise, have limited scientific bases, yet they often represent a major justification for antipyretic administration.

OBJECTIVES

To describe the patient experience of fever symptoms for the preliminary development of a fever assessment questionnaire.

METHODS

Qualitative interviews were conducted with 28 inpatients, the majority (86%) with cancer diagnoses, who had a recorded temperature of ≥38°C within approximately 12 hours before the interview. A semi-structured interview guide was used to elicit patient fever experiences. Thematic analyses were conducted by three independent research team members, and the data were verified through two rounds of consensus building.

RESULTS

Eleven themes emerged. The participants reported experiences of feeling cold, weakness, warmth, sweating, nonspecific bodily sensations, gastrointestinal symptoms, headaches, emotional changes, achiness, respiratory symptoms, and vivid dreams/hallucinations.

CONCLUSION

Our data not only confirm long-standing symptoms of fever but also suggest new symptoms and a level of variability and complexity not captured by the existing fever literature. Greater knowledge of patients' fever experiences will guide more accurate assessment of symptoms associated with fever and the impact of antipyretic treatments on patient symptoms in this common condition. Results from this study are contributing to the content validity of a future instrument that will evaluate patient outcomes related to fever interventions.

The impact of body temperature abnormalities on the disease severity and outcome in patients with severe sepsis: an analysis from a multicenter, prospective survey of severe sepsis

INTRODUCTION

Abnormal body temperatures (Tb) are frequently seen in patients with severe sepsis. However, the relationship between Tb abnormalities and the severity of disease is not clear. This study investigated the impact of Tb on disease severity and outcomes in patients with severe sepsis.

METHODS

We enrolled 624 patients with severe sepsis and grouped them into 6 categories according to their Tb at the time of enrollment. The temperature categories (≤ 35.5 °C, 35.6-36.5 °C, 36.6-37.5 °C, 37.6-38.5 °C, 38.6-39.5 °C, ≥ 39.6 °C) were based on the temperature data of the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring. We compared patient characteristics, physiological data, and mortality between groups.

RESULTS

Patients with Tb of ≤ 36.5 °C had significantly worse sequential organ failure assessment (SOFA) scores when compared with patients with Tb >37.5 °C on the day of enrollment. Scores for APACHE II were also higher in patients with Tb ≤ 35.5 °C when compared with patients with Tb >36.5 °C. The 28-day and hospital mortality was significantly higher in patients with Tb ≤ 36.5 °C. The difference in mortality rate was especially noticeable when patients with Tb ≤ 35.5 °C were compared with patients who had Tb of >36.5 °C. Although mortality did not relate to Tb ranges of ≥ 37.6 °C as compared to reference range of 36.6-37.5 °C, relative risk for 28-day mortality was significantly greater in patients with 35.6-36.5 °C and ≤ 35.5 °C (odds ratio; 2.032, 3.096, respectively). When patients were divided into groups based on the presence (≤ 36.5 °C, n = 160) or absence (>36.5 °C, n = 464) of hypothermia, disseminated intravascular coagulation (DIC) as well as SOFA and APACHE II scores were significantly higher in patients with hypothermia. Patients with hypothermia had significantly higher 28-day and hospital mortality rates than those without hypothermia (38.1% vs. 17.9% and 49.4% vs. 22.6%, respectively). The presence of hypothermia was an independent predictor of 28-day mortality, and the differences between patients with and without hypothermia were observed irrespective of the presence of septic shock.

CONCLUSIONS

In patients with severe sepsis, hypothermia (Tb ≤ 36.5 °C) was associated with increased mortality and organ failure, irrespective of the presence of septic shock.

TRIAL REGISTRATION

UMIN-CTR ID UMIN000008195.

The PIRO (predisposition, insult, response, organ dysfunction) model: toward a staging system for acute illness

Multimodal therapy for diseases like cancer has only become practicable following the development of staging systems like the TNM (tumor, nodes, metastases) system. Staging enables the identification of subgroups of patients with a disease who not only have a differing prognosis, but who are also more likely to benefit from a specific therapeutic modality. Critically ill patients represent a highly heterogeneous population for whom multiple therapeutic options are potentially available, each carrying not only the potential for differential benefit, but also the potential for differential harm. The PIRO system (predisposition, insult, response, organ dysfunction) is a template proposal for a staging system for acute illness that incorporates assessment of pre-morbid baseline susceptibility (predisposition), the specific disorder responsible for acute illness (insult), the response of the host to that insult, and the resulting degree of organ dysfunction. However the creation of a valid, robust, and clinically useful system presents significant challenges arising from the complexity of the disease state, the lack of a clear phenotype, the confounding influence of the effects of therapy and of cultural and socio-economic factors, and the relatively low profile of acute illness with clinicians and the general public. This review summarizes the rationale for such a model of illness stratification and the results of preliminary cohort studies testing the concept. It further proposes two strategies for building a staging system, recognizing that this will be a demanding undertaking that will require decades of work.

Admission factors associated with prolonged (>14 days) intensive care unit stay

PURPOSE

To describe the admission factors associated with prolonged (>14 days) intensive care unit (ICU) stay (PIS).

MATERIALS AND METHODS

Retrospective analysis of 3257 admissions during a 1.5-year period in a tertiary hospital. We tested the association between clinically relevant variables and PIS (>14 days) through binary logistic regression using the backward method. A Kaplan-Meier curve and the log-rank test were used to compare hospital outcomes for ICU survivors between patients with and without PIS.

RESULTS

In total, 6.6% of all admissions had a prolonged stay, consuming over 40% of all ICU bed-days. Illness severity; respiratory support at admission; performance status; readmission; admission from a ward, emergency room or other hospital; admission due to intracranial mass effect; severe chronic obstructive pulmonary disease; and the temperature at admission were all associated with PIS in a multivariate analysis. The created model had a good area under the curve (0.82) and was calibrated (Hosmer-Lemeshow test p = 0.431). Post hoc analysis on ICU survivors on in patients with at least two days of ICU stay yielded similar results. Hospital survival after ICU discharge was similar for patients with and without PIS (log-rank test p = 0.50).

CONCLUSION

A small number of ICU admissions consume a great proportion of ICU bed-days. Illness severity, a need for support and performance status are important predictors of PIS. Patients who survive a PIS have similar hospital mortality to patients with a shorter stay.