Neutropaenic Fever Hot Case
GENERAL APPROACH
Infectious
- community acquired
- nosocomial (surgical site, lines, chest, urine, sinusitis)
Non-infectious
- head injury
- DVT -> PE
- drug/toxin
- SIRS (post surgery, trauma, aspiration, pancreatitis)
- Hypermetabolic syndromes
-> thyroid storm
-> NMS
-> MH
-> heat stroke
-> phaeo
-> liver failure
-> burns
-> cocaine toxicity
-> serotonin syndrome
Occult Fever
- ophthalmitis
- indwelling line sepsis
- colitis
- graft vs host disease
INTRODUCTION
CUBICLE
- isolation (MDRO)
- long stay patient (new problem -> nosocomial infection)
INFUSIONS
- antibiotics (MDRO)
- noradrenaline (sepsis)
- heparin (DVT -> PE)
- blood products (febrile reactions)
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)
- intercostals drains (number, bubbling, drainage)
- urine (colour, output, myoglobin, microscopy)
QUESTION SPECIFIC EXAMINATION
- hands/arms -> head -> chest -> abdo -> legs/feet -> back
-> cardiovascular
-> respiratory
-> abdominal
-> haematological
- neurological
-> paralysed
-> quick examination
-> unconscious
-> conscious
- 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
- My approach to fever in this patient is to look at Infectious and Non-infectious causes
- I believe that this patient has multiple possible causes for fever:
- List headings of causes -> clinical signs associated with list
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a 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 three amazing children.
On Twitter, he is @precordialthump.
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