More guidelines! Today we'll walk through some interesting bits of the new IDSA/SCCM guideline on evaluation of new fever in the adult ICU patient (available free here).
how should temperature be evaluated?
- This is frankly a mess.
- Bladder catheter or esophageal probe are best, but usually not used.
- Rectal temperature is 2nd best, but unwieldy (especially for serial measurements).
- Oral measurement is 3rd best (but not possible for patients who are intubated or uncooperative).
- Axillary or temporal membrane is the least accurate… but this is sometimes what we are left with due to necessity.
chest radiograph is recommended to evaluate fever
- I'm down for this.
- Pneumonia or aspiration pneumonitis are super common in ICU, so this makes sense.
- Beware that atelectasis is also very common – so be prepared to ignore chest radiographs which are only mildly abnormal.
limit the RUQUS ruckus
- Right upper quadrant ultrasound (pronounced “ruckus” by those in the know) is not recommended routinely for fever evaluation.
- Overall, the guidelines seem to point more towards CT imaging for patients with suspected intra-abdominal infection (e.g., status post abdominal surgery with persistent and unexplained fever).
- RUQUS in ICU patients is very frequently abnormal, due to 3rd spacing of fluid that causes gallbladder edema. It's easy for this to create a slippery slope whereby patients receive unnecessary scans (and sometimes unnecessary gallbladder drains!). So curbing the RUQUS makes sense.
change the Foley catheter before obtaining a urine culture
- The entire approach to diagnosing CAUTI (catheter-associated urinary tract infection) in the ICU is deeply problematic. We over-diagnose this a lot (because available tests lack specificity).
- In general, a well-functioning Foley catheter is rarely a source of fever in the ICU, so focusing on CAUTI during the first pass of your fever evaluation may not be high-yield.
- If urinary cultures are desired, the IDSA/SCCM recommends inserting a fresh Foley prior to obtaining cultures. That seems reasonable. If anything, this may force people stop and think before culturing every body fluid in sight.
- Below is one approach to the diagnosis of CAUTI in the ICU:
consider testing for COVID and/or extended respiratory virus PCR panel
- Unfortunately, these may be acquired nosocomially.
- COVID testing depends on epidemiologic prevalence in the community.
- Respiratory virus panel PCR may be indicated based on signs/symptoms of respiratory infection (including both upper and lower respiratory tract symptoms).
- Beware that the presence of a respiratory virus doesn't necessarily mean that it is the cause of the patient's fever and/or pneumonia. For example, the patient could be co-infected with viral and bacterial pathogens.
consider checking CRP and/or procalcitonin
- Guidelines recommend checking a procalcitonin and/or CRP (C-reactive protein) among patients with low-to-intermediate likelihood of infection.
- Wow, I'm surprised they went here.
- This will be super controversial. Currently I don't think there is any definitive answer to the role of procalcitonin and/or CRP here (nor do the author guideline's authors seem to – this recommendation is qualified as a weak recommendation based on very low-quality evidence).
- I think this is a reasonable approach but:
- (1) Intermediate values need to be ignored. For example, if the procalcitonin is 10 ng/mL, that suggests the presence of infection. But if the procalcitonin is 0.666 ng/mL that probably doesn't mean much of anything.
- (2) It must be noted that elevated procalcitonin isn't necessarily an indicator of septic shock that requires broad-spectrum antibiotics. If the patient is otherwise stable, an elevated procalcitonin should probably be just an indicator to evaluate more closely for infection.
- (3) Investigation should be carefully tailored to the individual patient. Obtaining a procalcitonin on every febrile ICU patient probably isn't wise, but there may be situations where checking a procalcitonin would be helpful.
- In practice, I fear that these labs will probably be used unwisely, leading to patient harm.
Overall I think these are helpful guidelines.
The IBCC chapter on approach to fever in ICU has been updated based on these guidelines, it's here.
Opening image: Photo by Matteo Fusco on Unsplash
Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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The gallbladder spiral is a common rant I have about how more consultants often leads to worse care. Usually someone orders the US from critical care. then someone (ID or GI) usually writes “possible chole” and recs that someone consult surgery. Surgery writes “not the gall bag, consider HIDA to rule it out officially” …… then the HIDA is ordered for 3 days before someone realizes that at best HIDA is stupid, and at worst sending a sick patient to nuc med is dangerous… so then someone has the bright idea to consult IR, who will put a tube in… Read more »
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