Fever Hot Case

GENERAL APPROACH

Infectious

  • community acquired
  • nosocomial (surgical site, lines, chest, urine, sinusitis)
  • ‘hidden’ sepsis (endocarditis, neuraxial infection, retroperitoneum, sinusitis)

Non-infectious

  • head injury
  • VTE
  • drug/toxin
  • SIRS (post surgery, trauma, burns, ICH, aspiration, pancreatitis, CTD)
  • Hypermetabolic syndromes (e.g. thyroid storm, NMS, MH, heat stroke, pheochromocytoma)

INTRODUCTION

CUBICLE

  • isolation (multi-drug resistant organisms, MDRO)
  • long stay patient (new problem -> nosocomial infection)

INFUSIONS

  • antibiotics (MDRO) – ask! (may not be running)
  • noradrenaline (sepsis)
  • heparin (VTE, MI, vascular occlusion, systemic anticoagulation for CVVH)
  • blood products (febrile reactions)
  • TPN (pancreatitis, intra-abdominal sepsis, line sepsis)

VENTILATOR

  • level of support
  • level of oxygenation (FiO2, PEEP)
  • disease specific questions (ARDS: plateau pressure, bronchospasm: dynamic hyperinflation, intrinsic PEEP)

MONITOR

  • temperature
  • tachycardia (SIRS)
  • ETCO2 (hypermetabolic syndrome)
  • CVP (number, waveform)
  • arterial trace (pressure, swing, pulsus paradoxus)

EQUIPMENT

  • intra-abdominal drains (fluid, amount)
  • EVD (recent cell count and culture)
  • rectal tube (diarrhoea)
  • active cooling (severe hyperthermia)
  • epidural (inspect site and examine neurology)
  • intercostal drains (number, bubbling, drainage)
  • urine (colour, output, myoglobin, microscopy)

QUESTION SPECIFIC EXAMINATION

  • hands/arms -> head -> chest -> abdo -> legs/feet -> back

-> cardiovascular
-> respiratory
-> abdominal (cholecystitis, pancreatitis, collections)
-> haematological (bleeding, organomegaly, bone tenderness, lymphadenopathy)

  • neurological

-> paralysed
-> quick examination
-> unconscious
-> conscious

  • scars, wounds, cellulitis
  • prosthetic devices
  • track marks
  • ask to see under bandages
  • meningism
  • otoscopy (otitis media)
  • fundoscopy (Roth spots, chorioretinitis, endophthalmitis)
  • check for signs of endocarditis
  • limbs for DVT (esp if long-term lines) and tone (MH, serotonin syndrome)
  • vaginal examination for retained tampon
  • age of lines
  • recent anaesthetics (MH)
  • recent antibiotic exposure (drug fever)

RELEVANT INVESTIGATIONS

  • CXR
  • FBC: WCC
  • microbiology: sputum, blood cultures, urine, line cultures, intra-abdominal samples
  • burn biopsy

OPENING STATEMENT

  • I believe that this patient has multiple possible causes for fever:
  • List headings of causes and provide evidence/ clinical signs associated with list
  • Infectious causes…
  • Non-infectious causes…
  • To confirm or rule out these suspected diagnoses I would…:

DISCUSSION

  • activated protein C (now unlikely)
  • vasopressin in refractory septic shock
  • corticosteroids in septic shock
  • role of double GNB cover in gram negative sepsis
  • MROs in ICU
  • VTE management
  • care bundles
  • neutropenic sepsis
  • hyperthermia
  • heat stroke

References and Links

  • Foote C, Steel L, Vidhani K, Lister B, MacPartlin M, Blackwell N. Examination Intensive Care Medicine (2nd Edition), Elsevier 2011. [Google Books Preview]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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