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Fevers In CCU

Posted

Specializes in Cardiac, Transplant, Vascular, NICU. Has 4 years experience.

I am a new grad in a CCU and we deal with post surgical as well as transplant patients. Needless to say I'm always trying to learn more thing in my position!

So my patient has Clebsiella pneumonia following an ECMO de-canulation and continues to have a fever of 103. I've already given Tylenol and want an order for something else so my patients fever doesn't get even higher.

Call doc on infectious disease following them and the doc says that they are not going to treat a fever. That its the bodies reaction and needs to be that high. They'd actually rather me not even give the Tylenol because the Tylenol should just be used for analgesic use and not for fever when the patient is incubated and on IV meds for pain.

My preceptor and I were very surprised by this little lesson and I want to know if anyone else has had experience with this?? Or any other experience with docs like this?

danmarin_99

Specializes in CCU.

I don't know... As a new grad in my ccu, I'd be having the same reaction although, I would look for an alternative in this case such as a hyperthermia blanket. If the doc wants no pharmacological Tx, there must be a darn good reason with a fever at that level. I understand that they not want to mask it, but it's getting dangerous at that point.

Some of our patients are allowed to run high, but not that high. I agree with the previous poster though, this is a time to use nursing measures. In my state you need an order for a cooling blanket, but ice packs are open game. A fan and a wet head works fairly quickly too, just don't let the temp go too low. Fevers are good when controlled.

Cooling blanket. I had a septic patient that got up to 104. I was nervous but with tylenol suppository and cooling blanket, it took all shift for the temp to climb back down. I thought we wanted to bring fever down, so we don't fry the patient's brain.

Sun0408, ASN, RN

Specializes in Trauma Surgical ICU. Has 4 years experience.

Treating fevers is tricky.. The main reason is what the ID doc told you. Many don't want a fever treated. We have one doc that will not order tylenol unless the fever is greater than 103.9. A fever is the body's natural defense and a fever of under 104 will not fry the brain in an adult pt (not sure about peds). However the pt should have been pan cultured and antibiotics started.

Sugarcoma, RN

Specializes in Trauma/Tele/Surgery/SICU. Has 2 years experience.

I agree with Sun, treating fevers is tricky business. I assume this patient had been pan-cultured and was on ABX. That said Klebsiella is a nasty bug that basically destroys the lungs. It is also becoming more resistant to carbipenem (sp?) which is the ABX of last resort. I can see the ID docs rationale in wanting to use the fever to help kill the bug.

Critical patient's are just ripe for colonization. Did the pt. just begin spiking fevers or have they been febrile for awhile? How old are the cultures? Is it possible they may have picked up yet another bug? Just some food for thought.

If the patient was hemo-dynamically stable I would have probably followed the ID docs order but I would have asked him/her at what number do we start treating this fever? Also and I am not saying this is the case in this situation it has been my experience that specialists sometimes only treat their specialty and not the whole picture. I may have ran this by the intensivist to see if they agree with this approach.

Sounds like you had a super sick patient on your hands!

Nursingbride12

Specializes in Cardiac, Transplant, Vascular, NICU. Has 4 years experience.

The patient was cultured and nothing new grew. Nice thing is I had the patient again today and of course talked to the same ID doc.

When I asked about parameters, he said: I'm not going to treat a symptom with a drug that is not used for treating fevers.

My preceptor introduced me to the delightful Rubbing Alcohol bath?? This was the first time I'd heard of this and surprisingly it brought my patients fever from 103 to 99. So much for old wives tales! Has anyone heard about this??

amoLucia

Specializes in LTC.

An oldie but goodie remedy comes through again!!!

Just be careful about you and your pt inhaling the fumes. Nasty!

umcRN, BSN, RN

Has 4 years experience.

interesting. I work peds and was always taught that fever increases metabolic & myocardial demand and to reduce them as much as possible. Start with tylenol, cool washcloths, ice packs and resort to a cooling blanket if necessary

amoLucia

Specializes in LTC.

Ibuprofen is also an antipyretic - don't know about its use in peds though. But I've been liking it better than tylenol for a while.

The idea of letting a fever run its course as a therapeutic approach makes sense. As it was once explained to me, an elevated temp will kill' the 'bad' germs. Germs need a favorable environment in which to survive. Their temperature range window cannot allow much room for variation. Raise the temp and it's like 'cooking' the germs and thus destroying them.

Kinda like cooking chicken to kill off salmonella!!!

At least that was the way it was explained to me a looooong time ago. I know in LTC, many of our standing orders for tylenol require a temp above 101. It's the MD's call when the temp gets really high.

I'm a little surprised that ID doc said it like that. I'd understand letting a patient have a slight fever, but your patient's hemodynamics are priority. Fever & sepsis causes increased metabolic demand, and eventually cause other hemodynamic changes i.e. hyperdynamic state... low BP/SVR vasodilation, crazy high CO, high SVO2 r/t decrease oxygen extraction by tissues, shifts in your oxyhemoglobin diss. curve etc. Also, in a CCU, increased metabolic demand causing tachycardia is prob not the best thing for that person's cardiac function.... not sure about the specifics w/your patient. In the end it depends on whether that fever is high enough to start causing the patient to become unstable. If the pt is unstable, and the doc was still adamant about not tx the fever, I'd advocate, and if no result would then seek higher powers.

danmarin_99

Specializes in CCU.

This is why I love coming here for info... All of these different perspectives are a great resource! I've never even heard of a rubbing alcohol bath! In my unit, we have pretty strict parameters for everything so we're rarely left trying to figure this sort of thing out. Anything over 101 gets Tylenol where I'm at. This seems like a good place to start a policy/procedure discussion with your unit manager if there's nothing on the books already so if a similar case appears in the future, there won't be any question about it maybe.

Edited by danmarin_99

Sugarcoma, RN

Specializes in Trauma/Tele/Surgery/SICU. Has 2 years experience.

The patient was cultured and nothing new grew. Nice thing is I had the patient again today and of course talked to the same ID doc.

When I asked about parameters, he said: I'm not going to treat a symptom with a drug that is not used for treating fevers.

My preceptor introduced me to the delightful Rubbing Alcohol bath?? This was the first time I'd heard of this and surprisingly it brought my patients fever from 103 to 99. So much for old wives tales! Has anyone heard about this??

Hmmm, Tylenol is not used for treating fevers? That is news to me. Almost all of our tylenol orders say prn for pain or fever. We have trouble getting Ibuprofen out of docs, but never tylenol. I wonder if this is an older doc? I remember when my kids were little and had fevers my mother always encouraged rubbing alcohol baths. At one point my pediatrician recommended against it, but I cannot remember why.

Did the doc recommend the alcohol bath? I only ask because if he ordered the bath to lower the fever what is the difference between lowering it with the bath or with medication?

limaRN, BSN, RN

Specializes in ICU/CCU/CVICU. Has 3 years experience.

Interesting to hear so many different perspectives. I also with in an ICU/ CTICU. I've never heard of a rubbing alcohol bath so I looked it up and found some very interesting info... Here quoted from a website

"Isopropyl alcohol is quickly absorbed through the skin, and large amounts applied topically can be inhaled, which can lead to alcohol poisoning and other problems. A number of case reports in the medical literature describe small children who slipped into comas after a caregiver tried to reduce their fevers with alcohol. Other reports have described cases in which adults suffered cardiac and neurological problems after using alcohol-soaked towels to cool down or ease pain."

http://www.nytimes.com/2008/10/07/health/07real.html?_r=0

It may not be an issue if your pt is intubated but may cause problems for you and might be unsafe!

I agree with the other posters about treating the pt if they are unstable.

I recently had a pt with temps up to 106-107!!! Highest I've ever seen.. They're likely related to a neurological injury not an infectious process. We did give Tylenol and used a cooling blanket.

Nursingbride12

Specializes in Cardiac, Transplant, Vascular, NICU. Has 4 years experience.

Thanks for all the topics again!

We have orders for Tylenol greater than 38.1, but the issue was that my PTs Albumin levels were in the 60's!! So I called the doc because I didn't want one more thing to dig at this PTs liver.

That's when he came back and informed us that Tylenol is not approved by the FDA for anti-pyretic use but for analgesic. AND he only likes giving the patient Tylenol if the patient is extubated and complaining of pain.

He didnt recommend the alcohol bath my preceptor tried it to see if it would work... And laughed and said "I don't do this all the time but I thought it might help!"

106-107 would FREAK me out!!! I would have fans and cooling blankets and ice surrounding that patient! What did you end up doing??

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

You want to start trying to control a temp of 103 (102-102.5 even), we learned this the hard way. We had a patient who was young, a father of 2 little girls, his temp went uncontrolled because the Doc thought it was a good thing (which is it but only to a point), now this young man is doomed to spend the rest of his life in a nursing home, wheelchair bound, and severely neurologically disabled. Kill bacteria with antibiotics, not an uncontrolled temp.

You also have to remember that in a patient who is febrile due to sepsis for instance, end organ perfusion is a concern. The higher the temp, the higher the metabolic demand, and the more pronounced the end organ failure may be, so zero tolerance of a fever might be a good call in that instance.

Sugarcoma, RN

Specializes in Trauma/Tele/Surgery/SICU. Has 2 years experience.

Thanks for all the topics again!

We have orders for Tylenol greater than 38.1, but the issue was that my PTs Albumin levels were in the 60's!! So I called the doc because I didn't want one more thing to dig at this PTs liver.

That's when he came back and informed us that Tylenol is not approved by the FDA for anti-pyretic use but for analgesic. AND he only likes giving the patient Tylenol if the patient is extubated and complaining of pain.

He didnt recommend the alcohol bath my preceptor tried it to see if it would work... And laughed and said "I don't do this all the time but I thought it might help!"

106-107 would FREAK me out!!! I would have fans and cooling blankets and ice surrounding that patient! What did you end up doing??

I had no idea that tylenol wasn't approved as an anti-pyretic by the FDA. I am going to have to look that up. Very interesting. I personally prefer ibuprofen for fever but I can never get a doc to order it. Even when BUN, CR, coags, and other labs are normal.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Tylenol is approved for fever by the FDA they have issued warning for organ specific diseases. I have no idea what this MD is saying. anyone have any references that tylenol is not approved for antipyretic use?