51
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Park DW, Egi M, Nishimura M, Chang Y, Suh GY, Lim CM, Kim JY, Tada K, Matsuo K, Takeda S, Tsuruta R, Yokoyama T, Kim SO, Koh Y. The Association of Fever with Total Mechanical Ventilation Time in Critically Ill Patients. J Korean Med Sci 2016; 31:2033-2041. [PMID: 27822946 PMCID: PMC5102871 DOI: 10.3346/jkms.2016.31.12.2033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/06/2016] [Indexed: 01/30/2023] Open
Abstract
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.
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Affiliation(s)
- Dong Won Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Masaji Nishimura
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chae Man Lim
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Yeol Kim
- Department of Pulmonary and Critical Care Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Keiichi Tada
- Department of Anesthesiology and Intensive Care Medicine, Hiroshima City Hospital, Hiroshima, Japan
| | - Koichi Matsuo
- Division of Intensive Care Unit, New Tokyo Hospital, Tokyo, Japan
| | - Shinhiro Takeda
- Division of Intensive and Coronary Care Unit, Nippon Medical School Hospital, Tokyo, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Takeshi Yokoyama
- Intensive Care Unit, Department of Anesthesiology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Seon Ok Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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52
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Chiumello D, Gotti M, Vergani G. Paracetamol in fever in critically ill patients-an update. J Crit Care 2016; 38:245-252. [PMID: 27992852 DOI: 10.1016/j.jcrc.2016.10.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/20/2016] [Accepted: 10/31/2016] [Indexed: 11/26/2022]
Abstract
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).
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Affiliation(s)
- D Chiumello
- Dipartimento di Emergenza-Urgenza, ASST Santi Paolo e Carlo, Milan, Italy; Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy.
| | - M Gotti
- Dipartimento di Emergenza-Urgenza, ASST Santi Paolo e Carlo, Milan, Italy
| | - G Vergani
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
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53
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Doyle JF, Schortgen F. Should we treat pyrexia? And how do we do it? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:303. [PMID: 27716372 PMCID: PMC5047044 DOI: 10.1186/s13054-016-1467-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- James F Doyle
- Department of Intensive Care Medicine and Surrey Peri-Operative Anaesthesia and Critical Care Collaborative Research Group, Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, Surrey, UK.
| | - Frédérique Schortgen
- Service de Réanimation Médicale, Groupe Hospitalier Henri Mondor-APHP, 94000, Créteil, France
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54
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Abstract
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.
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Affiliation(s)
- Edward James Walter
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK.
| | - Mike Carraretto
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK
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55
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Walter EJ, Hanna-Jumma S, Carraretto M, Forni L. The pathophysiological basis and consequences of fever. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:200. [PMID: 27411542 PMCID: PMC4944485 DOI: 10.1186/s13054-016-1375-5] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Edward James Walter
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK.
| | - Sameer Hanna-Jumma
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK
| | - Mike Carraretto
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK
| | - Lui Forni
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK
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56
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Abstract
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.
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Affiliation(s)
- Kevin Meier
- 1 Department of Neurosurgery, The University of Texas Medical School at Houston, Houston, TX, USA
| | - Kiwon Lee
- 1 Department of Neurosurgery, The University of Texas Medical School at Houston, Houston, TX, USA
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57
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Nakajima Y. Controversies in the temperature management of critically ill patients. J Anesth 2016; 30:873-83. [PMID: 27351982 DOI: 10.1007/s00540-016-2200-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 06/04/2016] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Yasufumi Nakajima
- Department of Anesthesiology and Intensive Care, Kansai Medical University, Shinmachi 2-3-1, Hirakata, Osaka, 573-1191, Japan.
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58
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Axelrod DM, Alten JA, Berger JT, Hall MW, Thiagarajan R, Bronicki RA. Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference. World J Pediatr Congenit Heart Surg 2016; 6:575-87. [PMID: 26467872 DOI: 10.1177/2150135115598211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- David M Axelrod
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jeffrey A Alten
- Section of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - John T Berger
- Division of Critical Care Medicine, George Washington University School of Medicine, Children's National Health System, Washington, DC, USA Division of Cardiology, George Washington University School of Medicine, Children's National Health System, Washington, DC, USA
| | - Mark W Hall
- The Ohio State University College of Medicine, Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ravi Thiagarajan
- Intensive Care Unit, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Ronald A Bronicki
- Section of Critical Care Medicine and Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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59
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Yamamoto S, Yamazaki S, Shimizu T, Takeshima T, Fukuma S, Yamamoto Y, Tochitani K, Tsuchido Y, Shinohara K, Fukuhara S. Body Temperature at the Emergency Department as a Predictor of Mortality in Patients With Bacterial Infection. Medicine (Baltimore) 2016; 95:e3628. [PMID: 27227924 PMCID: PMC4902348 DOI: 10.1097/md.0000000000003628] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Shungo Yamamoto
- From the Department of Healthcare Epidemiology (SY, SY, TT, SF, YY, SF), School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto; Division of Infectious Diseases (SY), Kobe University Hospital, Hyogo; Current affiliation: Center for Environmental Health Sciences (SY), National Institute for Environmental Studies, Ibaraki; Department of Infectious Diseases (TS, KT, YT, KS), Kyoto City Hospital, Kyoto; Division of Community and Family Medicine (TT), Center for Community Medicine, Jichi Medical University, Tochigi; Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE) (SF, SF), Fukushima Medical University, Fukushima; Department of Clinical Laboratory Medicine (current affiliation for YT), Graduate School of Medicine, Kyoto University, Kyoto; and Disease Control and Prevenion Center (current affiliation for KS), National Center for Global Health and Medicine, Tokyo, Japan
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60
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Duffin R, O'Connor RA, Crittenden S, Forster T, Yu C, Zheng X, Smyth D, Robb CT, Rossi F, Skouras C, Tang S, Richards J, Pellicoro A, Weller RB, Breyer RM, Mole DJ, Iredale JP, Anderton SM, Narumiya S, Maizels RM, Ghazal P, Howie SE, Rossi AG, Yao C. Prostaglandin E₂ constrains systemic inflammation through an innate lymphoid cell-IL-22 axis. Science 2016; 351:1333-8. [PMID: 26989254 PMCID: PMC4841390 DOI: 10.1126/science.aad9903] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Rodger Duffin
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Richard A O'Connor
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Siobhan Crittenden
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Thorsten Forster
- Division of Pathway Medicine, Edinburgh Infectious Diseases, The University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Cunjing Yu
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Xiaozhong Zheng
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Danielle Smyth
- Institute for Immunology and Infection Research, The University of Edinburgh, Edinburgh EH9 3JT, UK
| | - Calum T Robb
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Fiona Rossi
- MRC Centre for Regenerative Medicine, The University of Edinburgh, Edinburgh EH16 4UU, UK
| | - Christos Skouras
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Shaohui Tang
- Department of Gastroenterology, First Affiliated Hospital of Jinan University, Guangzhou 510630, China
| | - James Richards
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Antonella Pellicoro
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Richard B Weller
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Richard M Breyer
- Department of Veterans Affairs, Tennessee Valley Health Authority, Nashville, TN 37212, USA. Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Damian J Mole
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - John P Iredale
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Stephen M Anderton
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Shuh Narumiya
- Center for Innovation in Immunoregulative Technology and Therapeutics (AK Project), Kyoto University Graduate School of Medicine, Kyoto 606-8501, Japan. Core Research for Evolutional Science and Technology (CREST), Japan Science and Technology Agency (JST), Tokyo 102-0075, Japan
| | - Rick M Maizels
- Institute for Immunology and Infection Research, The University of Edinburgh, Edinburgh EH9 3JT, UK
| | - Peter Ghazal
- Division of Pathway Medicine, Edinburgh Infectious Diseases, The University of Edinburgh, Edinburgh EH16 4SB, UK. Centre for Synthetic and Systems Biology (SynthSys), The University of Edinburgh, Edinburgh EH9 3JD, UK
| | - Sarah E Howie
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Adriano G Rossi
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Chengcan Yao
- Medical Research Council (MRC) Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK.
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Seguin P, Launey Y, Nesseler N, Malledant Y. [Is control fever mandatory in severe infections?]. MEDECINE INTENSIVE REANIMATION 2016; 25:266-273. [PMID: 32288743 PMCID: PMC7117820 DOI: 10.1007/s13546-015-1168-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 12/22/2015] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- P. Seguin
- Service d’anesthésie-réanimation 1, réanimation chirurgicale, hôpital Pontchaillou, 2, rue Henri-Le-Guilloux, F-35000 Rennes, France
| | - Y. Launey
- Service d’anesthésie-réanimation 1, réanimation chirurgicale, hôpital Pontchaillou, 2, rue Henri-Le-Guilloux, F-35000 Rennes, France
| | - N. Nesseler
- Service d’anesthésie-réanimation 1, réanimation chirurgicale, hôpital Pontchaillou, 2, rue Henri-Le-Guilloux, F-35000 Rennes, France
| | - Y. Malledant
- Service d’anesthésie-réanimation 1, réanimation chirurgicale, hôpital Pontchaillou, 2, rue Henri-Le-Guilloux, F-35000 Rennes, France
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62
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Makino S, Egi M. Acetaminophen for febrile patients with suspected infection: potential benefit and further directions. J Thorac Dis 2016; 8:E111-4. [PMID: 26904236 DOI: 10.3978/j.issn.2072-1439.2016.01.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Shohei Makino
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Hyogo 650-0017, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Hyogo 650-0017, Japan
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63
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Beverly A, Walter E, Carraretto M. Management of hyperthermia and hypothermia in sepsis: A recent survey of current practice across UK intensive care units. J Intensive Care Soc 2016; 17:88-89. [PMID: 28979467 PMCID: PMC5606379 DOI: 10.1177/1751143715601124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- A Beverly
- Intensive Care Unit, Royal Surrey County Hospital, Guildford, UK
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64
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Kudenchuk PJ, Sandroni C, Drinhaus HR, Böttiger BW, Cariou A, Sunde K, Dworschak M, Taccone FS, Deye N, Friberg H, Laureys S, Ledoux D, Oddo M, Legriel S, Hantson P, Diehl JL, Laterre PF. Breakthrough in cardiac arrest: reports from the 4th Paris International Conference. Ann Intensive Care 2015; 5:22. [PMID: 26380990 PMCID: PMC4573754 DOI: 10.1186/s13613-015-0064-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 08/18/2015] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy.
| | - Hendrik R Drinhaus
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Alain Cariou
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris, France.
- Paris Descartes University and Sorbonne Paris Cité-Medical School and INSERM U970 (Team 4), Cardiovascular Research Center, European Georges Pompidou Hospital, Paris, France.
| | - Kjetil Sunde
- Division of Emergencies and Critical Care, Department of Anaesthesiology, Surgical Intensive Care Unit Ullevål, Oslo University Hospital, Oslo, Norway.
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Vienna General Hospital, Medical University Vienna, Vienna, Austria.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Laboratoire de Recherche Experimentale, Erasme Hospital, Brussels, Belgium.
| | - Nicolas Deye
- Medical Intensive Care Unit, AP-HP, Lariboisière University Hospital, Inserm U942, Paris, France.
| | - Hans Friberg
- Anaesthesiology and Intensive Care Medicine, Skåne University Hospital, Lund University, Lund, Sweden.
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Centre, University of Liège and Liège 2 Department of Neurology, University Hospital of Liège, Liège, Belgium.
| | - Didier Ledoux
- Coma Science Group, Cyclotron Research Centre, University of Liège and Department of Intensive Care Medicine, University Hospital of Liège, Liège, Belgium.
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, CHUV-University Hospital, Lausanne, Switzerland.
| | - Stéphane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles, Le Chesnay, France.
| | - Philippe Hantson
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Jean-Luc Diehl
- Medical Intensive Care Unit, AP-HP, European Georges Pompidou Hospital, Paris Descartes University and Sorbonne Paris Cité-Medical School, Paris, France.
| | - Pierre-Francois Laterre
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Brussels, Brussels, Belgium.
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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. BIOMED RESEARCH INTERNATIONAL 2015; 2015:806042. [PMID: 26550577 PMCID: PMC4621332 DOI: 10.1155/2015/806042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/23/2015] [Accepted: 08/31/2015] [Indexed: 12/29/2022]
Abstract
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.
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66
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Golding R, Taylor D, Gardner H, Wilkinson JN. Targeted temperature management in intensive care - Do we let nature take its course? J Intensive Care Soc 2015; 17:154-159. [PMID: 28979480 DOI: 10.1177/1751143715608642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Robert Golding
- Northampton General Hospital, Cliftonville, Northampton, UK
| | - Daniel Taylor
- Northampton General Hospital, Cliftonville, Northampton, UK
| | - Hannah Gardner
- Northampton General Hospital, Cliftonville, Northampton, UK
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67
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Affiliation(s)
- Martin Richardson
- Department of Paediatrics, Peterborough & Stamford Hospitals NHS Foundation Trust, Peterborough, UK
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68
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Chhangani NP, Amandeep M, Choudhary S, Gupta V, Goyal V. 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. Indian J Crit Care Med 2015; 19:462-5. [PMID: 26321805 PMCID: PMC4548415 DOI: 10.4103/0972-5229.162463] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- N P Chhangani
- Department of Paediatrics, Umaid Hospital, Dr. S N Medical College, Jodhpur, Rajasthan, India
| | - Minhas Amandeep
- Department of Paediatrics, Umaid Hospital, Dr. S N Medical College, Jodhpur, Rajasthan, India
| | - Sandeep Choudhary
- Department of Paediatrics, Umaid Hospital, Dr. S N Medical College, Jodhpur, Rajasthan, India
| | - Vidit Gupta
- Department of Paediatrics, Umaid Hospital, Dr. S N Medical College, Jodhpur, Rajasthan, India
| | - Vishnu Goyal
- Department of Paediatrics, Umaid Hospital, Dr. S N Medical College, Jodhpur, Rajasthan, India
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69
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Schortgen F, Charles-Nelson A, Bouadma L, Bizouard G, Brochard L, Katsahian S. Respective impact of lowering body temperature and heart rate on mortality in septic shock: mediation analysis of a randomized trial. Intensive Care Med 2015. [PMID: 26202042 DOI: 10.1007/s00134-015-3987-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
| | - Anaïs Charles-Nelson
- Unité de recherche clinique, Hôpital Européen Georges Pompidou-APHP, Paris, France.,INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Lila Bouadma
- Réanimation médicale et infectieuse, Hôpital Bichat-Claude Bernard-APHP, Paris, France
| | - Geoffray Bizouard
- Unité de recherche clinique, Hôpital Henri Mondor-APHP, Créteil, France
| | - Laurent Brochard
- Keenan Research Centre, St Michael's Hospital, Toronto, Canada.,Interdepartmental Division of Critical care, University of Toronto, Toronto, Canada
| | - Sandrine Katsahian
- Unité de recherche clinique, Hôpital Européen Georges Pompidou-APHP, Paris, France.,INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
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70
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Saxena M, Young P, Pilcher D, Bailey M, Harrison D, Bellomo R, Finfer S, Beasley R, Hyam J, Menon D, Rowan K, Myburgh J. Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection. Intensive Care Med 2015; 41:823-32. [PMID: 25643903 PMCID: PMC4414938 DOI: 10.1007/s00134-015-3676-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 01/20/2015] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Manoj Saxena
- Critical Care and Trauma Division, George Institute for Global Health, Sydney, NSW, Australia,
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71
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Abstract
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.
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Affiliation(s)
- Edward Walter
- Intensive Care Unit, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Mike Carraretto
- Intensive Care Unit, Royal Surrey County Hospital, Guildford, Surrey, UK
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72
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Suzuki S, Eastwood GM, Bailey M, Gattas D, Kruger P, Saxena M, Santamaria JD, Bellomo R. Paracetamol therapy and outcome of critically ill patients: a multicenter retrospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:162. [PMID: 25879463 PMCID: PMC4411740 DOI: 10.1186/s13054-015-0865-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/09/2015] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Satoshi Suzuki
- Austin Hospital, 145 Studley Rd, Heidelberg, Victoria 3084, Australia. .,Okayama University Hospital, 700-0082 Okayama Prefecture, Okayama 1-1-1, Japan.
| | - Glenn M Eastwood
- Austin Hospital, 145 Studley Rd, Heidelberg, Victoria 3084, Australia.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Alfred Centre, 53 Commercial Rd, Melbourne, Victoria 3004, Australia.
| | - David Gattas
- Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia.
| | - Peter Kruger
- Princess Alexandra Hospital, 237 Ipswich Rd, Wooloongabba, QLD 4102, Australia.
| | - Manoj Saxena
- St George Hospital, Gray St, Kogarah, NSW 2217, Australia.
| | - John D Santamaria
- St Vincent's Hospital, 59 Victoria Parade, Fitzroy, Victoria 3065, Australia.
| | - Rinaldo Bellomo
- Austin Hospital, 145 Studley Rd, Heidelberg, Victoria 3084, Australia. .,Australian and New Zealand Intensive Care Research Centre, Alfred Centre, 53 Commercial Rd, Melbourne, Victoria 3004, Australia.
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73
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Schell-Chaple HM, Puntillo KA, Matthay MA, Liu KD. Body temperature and mortality in patients with acute respiratory distress syndrome. Am J Crit Care 2015; 24:15-23. [PMID: 25554550 DOI: 10.4037/ajcc2015320] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Hildy M. Schell-Chaple
- Hildy M. Schell-Chaple is a clinical nurse specialist and PhD candidate at the University of California, San Francisco (UCSF) School of Nursing. Kathleen A. Puntillo is a professor emerita at the UCSF School of Nursing. Michael A. Matthay is a professor of medicine and anesthesia and Kathleen D. Liu is an associate professor at the UCSF School of Medicine
| | - Kathleen A. Puntillo
- Hildy M. Schell-Chaple is a clinical nurse specialist and PhD candidate at the University of California, San Francisco (UCSF) School of Nursing. Kathleen A. Puntillo is a professor emerita at the UCSF School of Nursing. Michael A. Matthay is a professor of medicine and anesthesia and Kathleen D. Liu is an associate professor at the UCSF School of Medicine
| | - Michael A. Matthay
- Hildy M. Schell-Chaple is a clinical nurse specialist and PhD candidate at the University of California, San Francisco (UCSF) School of Nursing. Kathleen A. Puntillo is a professor emerita at the UCSF School of Nursing. Michael A. Matthay is a professor of medicine and anesthesia and Kathleen D. Liu is an associate professor at the UCSF School of Medicine
| | - Kathleen D. Liu
- Hildy M. Schell-Chaple is a clinical nurse specialist and PhD candidate at the University of California, San Francisco (UCSF) School of Nursing. Kathleen A. Puntillo is a professor emerita at the UCSF School of Nursing. Michael A. Matthay is a professor of medicine and anesthesia and Kathleen D. Liu is an associate professor at the UCSF School of Medicine
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74
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Association between early peak temperature and mortality in neutropenic sepsis. Ann Hematol 2014; 94:857-64. [DOI: 10.1007/s00277-014-2273-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/02/2014] [Indexed: 10/24/2022]
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75
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Serpa Neto A, Pereira VGM, Colombo G, Scarin FCDLC, Pessoa CMS, Rocha LL. Should we treat fever in critically ill patients? A summary of the current evidence from three randomized controlled trials. ACTA ACUST UNITED AC 2014; 12:518-23. [PMID: 25628209 PMCID: PMC4879924 DOI: 10.1590/s1679-45082014rw2785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 12/01/2013] [Indexed: 11/22/2022]
Abstract
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.
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76
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Johansen ME, Jensen JU, Bestle MH, Ostrowski SR, Thormar K, Christensen H, Pedersen HP, Poulsen L, Mohr T, Kjær J, Cozzi-Lepri A, Møller K, Tønnesen E, Lundgren JD, Johansson PI. Mild induced hypothermia: effects on sepsis-related coagulopathy--results from a randomized controlled trial. Thromb Res 2014; 135:175-82. [PMID: 25466837 DOI: 10.1016/j.thromres.2014.10.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 09/27/2014] [Accepted: 10/29/2014] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Maria E Johansen
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark.
| | - Jens-Ulrik Jensen
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Anesthesia and Intensive Care, Nordsjaellands hospital, Denmark
| | - Sisse R Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Denmark
| | - Katrin Thormar
- Department of Anesthesia and Intensive Care, Bispebjerg Hospital, Denmark
| | - Henrik Christensen
- Department of Anesthesia and Intensive Care, University Hospital Herlev, Denmark
| | | | - Lone Poulsen
- Department of Anesthesia and Intensive Care, University Hospital Køge, Denmark
| | - Thomas Mohr
- Department of Anesthesia and Intensive Care, University Hospital Gentofte, Denmark
| | - Jesper Kjær
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark
| | - Alessandro Cozzi-Lepri
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark; Department of Virology, Royal Free and University College Medical School London, United Kingdom
| | - Kirsten Møller
- Neurointensive Care Unit 2093, Department of Neuroanaesthesiology, University Hospital Rigshospitalet, Denmark
| | - Else Tønnesen
- Department of Anaesthesia and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | - Jens D Lundgren
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Denmark; Department of Surgery, University of Texas Medical School at Houston, TX, USA
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77
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Niven DJ, Stelfox HT, Laupland KB. Hypothermia in Adult ICUs: Changing Incidence But Persistent Risk Factor for Mortality. J Intensive Care Med 2014; 31:529-36. [PMID: 25336679 DOI: 10.1177/0885066614555491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 09/03/2014] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Daniel J Niven
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada Department of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Kevin B Laupland
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada Department of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada Department of Medicine, Royal Inland Hospital, Kamloops, British Columbia, Canada
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78
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Dai YT, Lu SH, Chen YC, Ko WJ. Correlation Between Body Temperature and Survival Rate in Patients With Hospital-Acquired Bacteremia. Biol Res Nurs 2014; 17:469-77. [DOI: 10.1177/1099800414554683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Yu-Tzu Dai
- Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Hua Lu
- School of Nursing, China Medical University, Taichung, Taiwan
- Department of Nursing, China Medical University Hospital, Taichung, Taiwan
| | - Yee-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-Je Ko
- Department of Cardiovascular Surgery, National Taiwan University, Taipei, Taiwan
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79
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Branco LG, Soriano RN, Steiner AA. Gaseous Mediators in Temperature Regulation. Compr Physiol 2014; 4:1301-38. [DOI: 10.1002/cphy.c130053] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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80
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Abstract
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.
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Champion S. Diuretics or ultrafiltration in acute heart failure syndrome? Or two inadequate answers to the main question? Int J Cardiol 2014; 174:404-5. [PMID: 24768462 DOI: 10.1016/j.ijcard.2014.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Sébastien Champion
- Service de Réanimation Polyvalente, Centre Hospitalier Universitaire de la Réunion, 97400, Saint Denis, France.
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Aoyama K, Seaward PG, Lapinsky SE. Fetal outcome in the critically ill pregnant woman. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:307. [PMID: 25042936 PMCID: PMC4056043 DOI: 10.1186/cc13895] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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83
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Knapp J, Bernhard M, Hofer S, Popp E, Weigand M. Update Intensivmedizin. Anaesthesist 2014; 63:429-38. [DOI: 10.1007/s00101-014-2321-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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84
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Taccone FS, Saxena M, Schortgen F. What's new with fever control in the ICU. Intensive Care Med 2014; 40:1147-50. [PMID: 24691575 DOI: 10.1007/s00134-014-3277-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 03/20/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme Université Libre de Bruxelles, Bruxelles, Belgium
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85
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Young PJ, Saxena M. Fever management in intensive care patients with infections. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:206. [PMID: 25029624 PMCID: PMC4056101 DOI: 10.1186/cc13773] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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86
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Management of severe infections: A time to keep a cool head or a hot topic for clinical trials? CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2014; 25:9-10. [PMID: 24634680 DOI: 10.1155/2014/129710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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87
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Shen HN. Fever Control and Sepsis Mortality. Chest 2014; 145:666-667. [DOI: 10.1378/chest.13-2644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Kushimoto S, Yamanouchi S, Endo T, Sato T, Nomura R, Fujita M, Kudo D, Omura T, Miyagawa N, Sato T. Body temperature abnormalities in non-neurological critically ill patients: a review of the literature. J Intensive Care 2014; 2:14. [PMID: 25520830 PMCID: PMC4267592 DOI: 10.1186/2052-0492-2-14] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 02/07/2014] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi, 980-8574 Japan ; Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
| | - Satoshi Yamanouchi
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi, 980-8574 Japan ; Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
| | - Tomoyuki Endo
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
| | - Takeaki Sato
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
| | - Ryosuke Nomura
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
| | - Motoo Fujita
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
| | - Daisuke Kudo
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
| | - Taku Omura
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
| | - Noriko Miyagawa
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
| | - Tetsuya Sato
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Seiryo-machi 1-1, Aoba-ku, Sendai, 980-8574 Japan
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89
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Abstract
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.
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90
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Heat shock protein 72 expressing stress in sepsis: unbridgeable gap between animal and human studies--a hypothetical "comparative" study. BIOMED RESEARCH INTERNATIONAL 2014; 2014:101023. [PMID: 24524071 PMCID: PMC3912989 DOI: 10.1155/2014/101023] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 10/05/2013] [Indexed: 01/30/2023]
Abstract
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.
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91
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Mohr NM, Doerschug KC. Point: Should antipyretic therapy be given routinely to febrile patients in septic shock? Yes. Chest 2014; 144:1096-1098. [PMID: 24081339 DOI: 10.1378/chest.13-0916] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, Division of Critical Care, Department of Anesthesia, Iowa City, IA.
| | - Kevin C Doerschug
- Division of Pulmonary Diseases, Critical Care and Occupational Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
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Vincent JL. Fever Management in Intensive Care Patients with Infections. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2014 2014. [PMCID: PMC7122612 DOI: 10.1007/978-3-319-03746-2_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Fever is one of the cardinal signs of infection and, nearly 120 years after William Osler’s statement in his address to the 47th 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.
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93
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Niven DJ, Laupland KB, Tabah A, Vesin A, Rello J, Koulenti D, Dimopoulos G, de Waele J, Timsit JF. Diagnosis and management of temperature abnormality in ICUs: a EUROBACT investigators' survey. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R289. [PMID: 24326145 PMCID: PMC4057370 DOI: 10.1186/cc13153] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 12/10/2013] [Indexed: 01/26/2023]
Abstract
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.
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Ames NJ, Peng C, Powers JH, Leidy NK, Miller-Davis C, Rosenberg A, VanRaden M, Wallen GR. Beyond intuition: patient fever symptom experience. J Pain Symptom Manage 2013; 46:807-16. [PMID: 23742739 PMCID: PMC3830719 DOI: 10.1016/j.jpainsymman.2013.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 02/05/2013] [Accepted: 02/18/2013] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Nancy J Ames
- National Institutes of Health, Clinical Center, Bethesda, Maryland, USA.
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Kushimoto S, Gando S, Saitoh D, Mayumi T, Ogura H, Fujishima S, Araki T, Ikeda H, Kotani J, Miki Y, Shiraishi SI, Suzuki K, Suzuki Y, Takeyama N, Takuma K, Tsuruta R, Yamaguchi Y, Yamashita N, Aikawa N. 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. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R271. [PMID: 24220071 PMCID: PMC4057086 DOI: 10.1186/cc13106] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 10/31/2013] [Indexed: 01/08/2023]
Abstract
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.
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96
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Marshall JC. The PIRO (predisposition, insult, response, organ dysfunction) model: toward a staging system for acute illness. Virulence 2013; 5:27-35. [PMID: 24184604 PMCID: PMC3916380 DOI: 10.4161/viru.26908] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- John C Marshall
- Departments of Surgery and Critical Care Medicine; University of Toronto; Toronto, ON Canada; The Keenan Research Centre of the Li Ka Shing Knowledge Institute; St. Michael's Hospital; University of Toronto; Toronto, ON Canada; The Interdepartmental Division of Critical Care Medicine; University of Toronto; Toronto, ON Canada
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Zampieri FG, Ladeira JP, Park M, Haib D, Pastore CL, Santoro CM, Colombari F. Admission factors associated with prolonged (>14 days) intensive care unit stay. J Crit Care 2013; 29:60-5. [PMID: 24268622 DOI: 10.1016/j.jcrc.2013.09.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 09/19/2013] [Accepted: 09/21/2013] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Fernando Godinho Zampieri
- Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil; Intensive Care Unit, Emergency Medicine Discipline, University of São Paulo, São Paulo, Brazil.
| | - José Paulo Ladeira
- Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil; Intensive Care Unit, Emergency Medicine Discipline, University of São Paulo, São Paulo, Brazil
| | - Marcelo Park
- Intensive Care Unit, Emergency Medicine Discipline, University of São Paulo, São Paulo, Brazil
| | - Douglas Haib
- Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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Mohr NM, Doerschug KC. Rebuttal From Drs Mohr and Doerschug. Chest 2013; 144:1101-1102. [PMID: 29852548 DOI: 10.1378/chest.13-0917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA.
| | - Kevin C Doerschug
- Division of Pulmonary Diseases, Critical Care and Occupational Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
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Drewry AM, Hotchkiss RS. Counterpoint: Should antipyretic therapy be given routinely to febrile patients in septic shock? No. Chest 2013; 144:1098-1101. [PMID: 24081340 PMCID: PMC3787912 DOI: 10.1378/chest.13-0918] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO.
| | - Richard S Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO; Department of Surgery, Washington University School of Medicine, St. Louis, MO; Department of Medicine, Washington University School of Medicine, St. Louis, MO
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100
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Lillie P, Allen J, Hall C, Walsh C, Adams K, Thaker H, Moss P, Barlow G. Long-term mortality following bloodstream infection. Clin Microbiol Infect 2013; 19:955-60. [DOI: 10.1111/1469-0691.12101] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 11/05/2012] [Accepted: 11/07/2012] [Indexed: 11/27/2022]
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