Persistent Fever in the ICU.pdf

Postgraduate Education Corner CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE CHEST 158 Postgraduate Education Corner Fever is a ubiquitous fi nding among patients admitted to the ICU. The clinical signifi cance of fever var- ies with its context. On one hand, fever may represent a response to a serious perturbation in the steady state, such as when an infection is present. On the other, fever may occur as a nonspecifi c physical sign accompanying critical illness, as is often the case in postoperative patients. Single temperature elevations that resolve without treatment are seldom of signifi - cance; however, persistently elevated temperature has major implications for the care of critically ill patients. 1 Not infrequently, the fi nding of fever in the ICU trig- gers an unfocused, multimodal diagnostic workup and empirical dispensation of antimicrobial agents. Such an approach contributes to disruption of care, patient discomfort, antimicrobial resistance, and increased cost. 2 This article recapitulates the salient aspects of febrile critical illness; discusses recent advances in its epidemiology, evaluation, and treatment; and advocates for a rational approach to its management. Pathophysiology of Thermoregulation As homeothermic organisms, humans must tightly regulate their core body temperature to maintain opti- mal conditions for fundamental biologic processes. 3 The target temperature that the thermoregulatory sys- tem aims to achieve (ie, the set point) is determined in the preoptic region of the hypothalamus. To mini- mize variation from the set point, the hypothalamus integrates processes that generate, conserve, or dissi- pate heat to the environment. Abnormally elevated body temperature can result from two pathophysiologically distinct disorders of thermoregulation: 1. Fever results from an upward adjustment in the thermoregulatory set point. Pyrogens (eg, bacte- rial lipopolysaccharide, tumor necrosis factor- a , IL