Evaluation of In-Patients With Fever
Evaluation of In-Patients With Fever
Evaluation of In-Patients With Fever
# Nosocomial Fever
#1 #2 #3 #4
Shock? Sepsis?
Hx
PE
Lab
Shock ?
Hx ซึม?
ปํ สสาวะ
PE BP, ?HR,
RR
Cold
skin?
Lab CO2 content
Sepsis ???
Sepsis syndrome
(Bone RC : Crit Care Med 1989;17:389)
- No of patients = 191
- 41% were bacteremic
- 36% were in septic shock on study entry
- An additional 23% later developed shock;
70% within 24 hr of study entry
- 13% mortality in patients without shock
- 27.5% mortality in patients with shock on admission
- 43.2% mortality in patients with shock post admission
- 25% developed ARDS
Sepsis?
= Infection PLUS Systemic Inflammatory Response Syndrome
(SIRS)
= > 2 of -oral temp > 38oC or < 36oC
- HR > 90/min.
- RR > 24/min. (or pCO2 < 32 mmHg)
- WBC > 12,000 or < 4,000 (or band > 10%)
Ref : Bone RC, Chest 1992:101:1644.
# Nosocomial Fevers
#3 #4
Shock? Sepsis?
Hx ซึม?
ปํ สสาวะ
PE BP, ?HR, Fever or Subtemp
RR Tachycardia?
Cold Tachypnea?
skin?
CO2 content Leucocytosis?
Lab
Leucopenia?
Blood pH
Take home message 1
What to do next???
“
“Normal body temperature is generally
considered to be 37.0°C (98.6°F). In
healthy individuals, this temperature
varies by 0.5 to 1.0°C, according to
circadian rhythm and menstrual cycle.”
“As a broad generalization, it is
reasonable in many ICUs to
consider everyone with a temp.
of >38.3°C (>101°F) to be febrile
and to warrant special attention
to determine whether infection is
present.”
Take home message 2
Where ???
Source of infection
Source Episodes Percent(%)
ต่อให้ม ี pyuria,ถ้าผู ป
้ ่ วยไม่มอ
ี าการ จง
อย่า treat
Antibiotics prescribed for PSU-UTIs
Appropriate Empirical Antibiotics afebrile in 7 days
Yes = 42/92 (45.7%) episodes 30/42(71%)
No = 50/92 (54.3%) episodes 27/50(54%)*
P=0.040
Why were the empirical Rx for
nosocomial UTIs in PSU Hospital
so inaccurate?
Organisms
1. E coli = 30/92 ( 32.6%)
How ???
Only one out of 67 patients with various
bacteriuria had “ yeast” in urine
reported in routine urinalysis done by
PSU technicians.
( specificity=66/67= 98%)
Only one of 21 patients,who had “yeast”
reported as seen in the urinalysis did not
grew Candida in his urine. ( positive
predictive value = 20/21=95%)
•- after 96 hours
likely to represent
infection
– Wind,
– Water,
– Wound,
– Walk,
– Wonder drugs
Acute Postoperative Fever
• Fever in days 5-7
• Wound. Most wound infections occur here.
Surgical wound infections relating to specific
operations generally present 3–7 days
postoperatively for example the failure of a bowel
anastomosis, with fistula formation and leakage
• Intra-abdominal sepsis from abscess is
considered after the 5th–7th postoperative day.
A rectal examination is performed.
Some fullness posteriorly and the
anastomosis cannot be felt.
What is your diagnosis and what should
you do?
The patient is returned to the operating room
and the abscess drained per rectum.
Source of PSU
Nosocomial Bacteremia
Source Episodes Percent(%)
Urinary tract 40 21.2
Gastrointestinal tract 31 16.4
Lower respiratory
28 14.8
tract
Skin and soft tissue 26 13.8
Catheter-related 19 10.1
Unknown source 32 16.9
?Pneumonia
Why important?
“Respiratory tract infections
accounted for 49% of all antibiotics
prescribed in the ICU; 63% of the
antibiotics used, however, were for
clinically suspected and not proven
respiratory tract infections.”
Bergmans DC et al. JAC 1997;39:227
How to Dx VAP?
NNIS Criteria for Defining Nosocomial Pneumonia
At least one of:
Fever or WBC<4000 or >=12,000
And >= 2 of:
Purulent sputum (>=25 PMNs and <=10 epithelials
Per low power field )
New cough or dyspnea or RR>25/min
Rales or bronchial breath sound
Worsening gas exchange
Take home message 7:
Always pneumonia ?
Any other D/Dx s ?
?Pneumonia vs. Atelectasis
– Postoperative atelectasis generally occurs
within 48 hours.
•
Daily incidence of lobar atelectasis after open
heart surgery
Day 0 Day 1 Day2
Left lung 2% 4% 20%
Right lung 0% 0% 3%
Both lungs 0% 0% 1%
Onset of bacteremia:
Median = 10 d. after central lines were inserted.
(range = 3-47)
95% occurred after Day 3
78% occurred after Day 5
Take home message 9: