Fever: a concept analysis

Impact of an Educational Program on Improving Nurses’ Management of Fever: An Experimental Study

Background: Despite a public information campaign “To Break the Myth of Fever”, nurses continued to overtreat fever. This study hypothesized that the campaign lacked the detailed rationale essential to alter nurses’ attitudes and behaviors. Aim: To evaluate the effect of the educational program on nurses’ knowledge, attitudes, and behaviors related to fever management. Design: A randomized experimental design using a time series analysis. Methods: A random sample of 58 medical/surgical nurses was evenly divided into an intervention and a control group. The intervention group received an educational program on fever and fever management. Both groups completed a pretest and four posttests using investigator-developed instruments: a questionnaire on knowledge and attitudes about fever management and a fever treatment checklist to audit charts. Results: The intervention group had markedly higher knowledge scores and reduced use of ice pillows at all four posttests, as well as lower use of antipyretics overall, except for the first posttest, despite no sustained change in attitude. Conclusions: An educational program for fever management can effectively improve clinical nurses’ knowledge and attitudes about fever management.

Infrared-Emitting Multimodal Nanostructures for Controlled In Vivo Magnetic Hyperthermia

Deliberate and local increase of the temperature within solid tumors represents an effective therapeutic approach. Thermal therapies embrace this concept leveraging the capability of some species to convert the absorbed energy into heat. To that end, magnetic hyperthermia (MHT) uses magnetic nanoparticles (MNPs) that can effectively dissipate the energy absorbed under alternating magnetic fields. However, MNPs fail to provide real-time thermal feedback with the risk of unwanted overheating and impeding on-the-fly adjustment of the therapeutic parameters. Localization of MNPs within a tissue in an accurate, rapid, and cost-effective way represents another challenge for increasing the efficacy of MHT. In this work, MNPs are combined with state-of-the-art infrared luminescent nanothermometers (LNTh; Ag₂ S nanoparticles) in a nanocapsule that simultaneously overcomes these limitations. The novel optomagnetic nanocapsule acts as multimodal contrast agents for different imaging techniques (magnetic resonance, photoacoustic and near-infrared fluorescence imaging, optical and X-ray computed tomography). Most crucially, these nanocapsules provide accurate (0.2 °C resolution) and real-time subcutaneous thermal feedback during in vivo MHT, also enabling the attainment of thermal maps of the area of interest. These findings are a milestone on the road toward controlled magnetothermal therapies with minimal side effects.

Clinical determinants of fever in clozapine users and implications for treatment management: A narrative review

OBJECTIVES

To identify the clinical determinants of fever in clozapine users and their impact on management of clozapine treatment.

METHODS

Articles published in English or French identified with a MEDLINE, Web of Sciences, Cochrane Library and PsycINFO search, from inception through February 2019, using the term "clozapine" in combination with "fever" OR "hyperthermia" OR "body temperature" OR "pyrexia" OR "febrile" OR "heat" OR "thermoregulation". Information extracted for each medical condition were frequency, time to onset after initiation of clozapine treatment, characteristics of fever, associated symptoms, laboratory tests used for diagnosis, course, lethality, discontinuation of clozapine. Data were synthesized narratively.

RESULTS

Our search yielded 394 unique hits published from 1993 to 2018. We included 73 articles in the review: two meta-analyses, 14 reviews, six epidemiological studies, 11 clinical studies and 40 case reports. During clozapine initiation, fever is most frequently benign and transient but should be closely monitored as it may be the first stage of potentially life-threatening adverse drug reactions (ADR) (agranulocytosis, neuroleptic malignant syndrome myocarditis, hepatitis, pancreatitis, nephritis, colitis, etc.). Other ADR associated with fever are independent of duration of exposure to clozapine (heat stroke, pneumonia, pulmonary embolism, necrotizing colitis). If fever is due to intercurrent infection, therapeutic drug monitoring is recommended to adjust clozapine daily dosage.

CONCLUSION

Benign causes of fever are much more frequent than life-threatening ADR during clozapine treatment. Discontinuation should not be considered as automatic in the event of fever, especially during the early phase of clozapine initiation.

Patient reported symptoms, body temperature and hospital mortality: an observational study in a low resource healthcare environment

BACKGROUND

Fever is a common presenting complaint of patients, especially in sub-Saharan Africa. Although most medical authorities consider fever to be synonymous with an elevated body temperature the relationship of the complaint of fever made by patients to temperature has not been well defined.

AIM

This study examined the relationship of the complaint of fever to temperature on and after admission and in-hospital mortality.

METHOD

Observational study in a low-resource Ugandan mission hospital.

RESULTS

Out of 2122 alert patients admitted between 9 August 2016 and 5 January 2018, 349 (16.4%) complained of fever: these patients were no more likely to have an abnormal temperature or die in-hospital than those not complaining of fever. Of the 707 alert patients admitted after 1 July 2017, 422 were interviewed in detail about their symptoms: only rigors, feeling intermittently hot and cold, and anorexia were statistically related to the complaint of fever, and only rigors to an admission temperature >38°C. No symptom or sign was associated with a temperature ≤36°C: cold and clammy skin was the only finding associated with in-hospital death. On logistic regression the only independent predictors of mortality were: the National Early Warning Score, impaired mobility on presentation and cold and clammy skin.

CONCLUSION

In this study, the term fever used by patients and raised body temperature were not synonymous. Although fever and related symptoms reported by patients are common presenting complaints only the finding of cold and clammy skin was associated with in-hospital mortality.

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

Background:

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

Objective:

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

Design:

A prospective observational study.

Method:

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

Results:

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

Conclusions:

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

Febrile illness in the athlete

CONTEXT

Acute febrile illnesses are common in athletes over the course of training and competition seasons. Complete recovery and rapid yet safe return to participation are critical for competitive athletes. Alterations in thermoregulation, metabolism, fluid homeostasis, muscle strength, and endurance, as well as potential complications for the athlete and others, must be considered.

EVIDENCE ACQUISITION

The PubMed database was searched (1970-2013) for all English-language articles related to febrile illness in sport, using the keywords fever, febrile, body temperature, thermoregulation, infection, illness, disease, exercise, athlete, sport, performance, return to play, metabolism, hydration, and dehydration.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Limited data confirm that febrile illness is correlated with alterations in the body's thermoregulatory system, with increases in metabolic rate, and with effects in fluid homeostasis. Human and animal studies demonstrate a decrease in muscle strength and endurance secondary to muscle catabolism in febrile illness. However, indirect evidence suggests that regular exercise enhances the immune response. No strong clinical research has been published on return to play during or following acute febrile illness, excluding mononucleosis and myocarditis.

CONCLUSION

Fever is correlated with an increase in insensible fluid losses, dehydration, metabolic demands, and dysregulation of body temperature. Fever can have detrimental effects on the musculoskeletal system, including decreasing strength and endurance, generalized muscle catabolism, and increase in perceived fatigue. Participating in strenuous exercise during febrile illness can worsen the illness and has demonstrated increased lethality in animal models. No consensus recommendations support return to activity before resolution of fever, and training should be resumed gradually once fever and dehydration have resolved.

Stability in intensive psychiatry: a concept analysis

PURPOSE

The aim of this concept analysis is to describe, explore, and explain stability in the context of mental health nursing in intensive psychiatry.

DESIGN AND METHODS

A modified version of Wilson's method of concept analysis was used.

FINDINGS

Stability is the ability to be resistant to changes. Stability can take different directions after a distortion: re-gaining, neo-gaining, and apo-gaining. Stability may also be achieved through active (adding or using power, making adjustments, parrying, and idling) and passive systems (environmental conditions and constituent materials).

PRACTICE IMPLICATIONS

This article contributes by providing knowledge and insight for nurses on the roles they play in intensive psychiatry as stabilizers.

The incidence of fever in US Critical Care Air Transport Team combat trauma patients evacuated from the theater between March 2009 and March 2010

INTRODUCTION

Most critically ill injured patients are transported out of the theater by Critical Care Air Transport Teams (CCATTs). Fever after trauma is correlated with surgical complications and infection. The purposes of this study are to identify the incidence of elevated temperature in patients managed in the CCATT environment and to describe the complications reported and the treatments used in these patients.

METHODS

We performed a retrospective review of available records of trauma patients from the combat theater between March 1, 2009, and March 31, 2010, who were transported by the US Air Force CCATT and had an incidence of hyperthermia. We then divided the cohort into 2 groups, patients transported with an elevation in temperature greater than 100.4°F and patients with no documented elevation in temperature. We used a standardized, secure electronic data collection form to abstract the outcomes. Descriptive data collected included injury type, temperature, use of a mechanical ventilator, cooling treatment modalities, antipyretics, intravenous fluid administration, and use of blood products. We also evaluated the incidence of complications during the transport in patients who had a recorded elevation in temperature greater than 100.4°F.

RESULTS

A total of 248 trauma patients met the inclusion criteria, and 101 trauma patients (40%) had fever. The mean age was 28 years, and 98% of patients were men. The mechanism of injury was an explosion in 156 patients (63%), blunt injury in 11 (4%), and penetrating injury in 45 (18%), whereas other trauma-related injuries accounted for 36 patients (15%). Of the patients, 209 (84%) had battle-related injuries and 39 (16%) had non-battle-related injuries. Traumatic brain injury was found in 24 patients (24%) with an incidence of elevated temperature. The mean temperature was 101.6°F (range, 100.5°F-103.9°F). After evaluation of therapies and treatments, 80 trauma patients (51%) were intubated on a mechanical ventilator (P < .001). Of the trauma patients with documented fever, 22 (22%) received administration of blood products. Nineteen patients received antipyretics during their flight (19%), 9 received intravenous fluids (9%), and 2 received nonpharmacologic cooling interventions, such as cooling blankets or icepacks. We identified 1 trauma patient with neurologic changes (1%), 6 with hypotension (6%), 48 with tachycardia (48%), 33 with decreased urinary output (33%), and 1 with an episode of shivering or sweating (1%). We did not detect any transfusion reactions or deaths during flight.

CONCLUSION

Fever occurred in 41% of critically ill combat-injured patients evacuated out of the combat theater in Iraq and Afghanistan. Fewer than 20% of patients with a documented elevated temperature received treatments to reduce the temperature. Intubation of patients with ventilators in use during the transport was the only factor significantly associated with fever. Serious complications were rare, and there were no deaths during these transports.

Approach to the febrile patient in the ICU

Fever is a normal adaptive brain response to infectious and noninfectious causes involving a cytokine-mediated response, the generation of acute phase reactants, and the activation of numerous physiologic, endocrinologic and immunologic systems. Ninety percent of patients with severe sepsis in the intensive care unit (ICU) will experience fever during their hospitalization, while the half of the new detected febrile episodes are of noninfectious origin. In the ICU, fever should be treated in cardiorespiratory and neurosurgical patients and in those in whom temperature exceeds 40 degrees C (104 degrees F). Antipyretic therapy must be justified regardless of the metabolic cost (if fever exceeds its physiologic benefit), the result (if the symptomatic relief adversely affects the course of the febrile illness) and the side effects.

The "con" of concept analysis A discussion paper which explores and critiques the ontological focus, reliability and antecedents of concept analysis frameworks

This paper draws on the work of Paley and Duncan et al in order to extend and engender debate regarding the use of Concept Analysis frameworks. Despite the apparent plethora of Concept Analysis frameworks used in nursing studies we found that over half of those used were derived from the work of one author. This paper explores the suitability and use of these frameworks and is set at a time when the numbers of published concept analysis papers are increasing. For the purpose of this study thirteen commonly used frameworks, identified from the nursing journals 1993 to 2005, were explored to reveal their origins, ontological and philosophical stance, and any common elements. The frameworks were critiqued and links made between their antecedents. It was noted if the articles contained discussion of any possible tensions between the ontological perspective of the framework used, the process of analysis, praxis and possible nursing theory developments. It was found that the thirteen identified frameworks are mainly based on hermeneutic propositions regarding understandings and are interpretive procedures founded on self-reflective modes of discovery. Six frameworks rely on or include the use of casuistry. Seven of the frameworks identified are predicated on, or adapt the work of Wilson, a school master writing for his pupils. Wilson's framework has a simplistic eleven step, binary and reductionist structure. Other frameworks identified include Morse et al's framework which this article suggests employs a contestable theory of concept maturity. Based on the findings revealed through our exploration of the use of concept analysis frameworks in the nursing literature, concerns were raised regarding the unjustified adaptation and alterations and the uncritical use of the frameworks. There is little evidence that these frameworks provide the necessary depth, rigor or replicability to enable the development in nursing theory which they underpin.

Evaluation and treatment of fever in intensive care unit patients

Fever is a common complaint in hospitalized patients, with estimates that more than 30% of ward patients and as much as 90% of critically ill patients will experience fever. Much of the treatment of fever, however, is based on tradition and the belief the fever is harmful to the patient rather than on scientific evidence. There is a need to determine via analysis of the literature the best evidence-based approach to the identification and treatment of fever with attention to appropriate measurement of body temperature, diagnostic evaluation, changing of indwelling catheters, administration of antipyretics, and alteration in antimicrobial therapy. The advanced practice nurse is uniquely capable of gathering this evidence and implementing a plan of care that meets the individual needs of the patient, family, nursing staff, and healthcare system.