Fevers In CCU

[Nursingbride12]

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?

[Sugarcoma, RN]

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]

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]

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]

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]

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]

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?

[MunoRN, RN]

Tylenol and NSAIDS are approved by the FDA as antipyretics. The FDA approves what medications can be marketed for, not what they can be used for, so if it says "fever reducer" on the label (which is what the FDA governs), then it is FDA approved for that purpose.

[Esme12, ASN, BSN, RN]

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??

Albumin level that is 60? Did you mean Ammonia level?

Here are some normal values......

[TABLE=class: style3]

[TR]

[TD=class: style7, width: 199]Albumin[/TD]

[TD=class: style7, width: 327, colspan: 2]3.2 - 5 g/dl[/TD]

[/TR]

[TR]

[TD=class: style7, width: 199]Alkaline phosphatase

(Adults: 25-60)[/TD]

[TD=class: style7, width: 327, colspan: 2]33 - 131 IU/L[/TD]

[/TR]

[TR]

[TD=class: style7, width: 199] Adults > 61 yo:[/TD]

[TD=class: style7, width: 327, colspan: 2]51 - 153 IU/L[/TD]

[/TR]

[TR]

[TD=class: style7, width: 199]Ammonia[/TD]

[TD=class: style7, width: 327, colspan: 2]20 - 70 mcg/dl[/TD]

[/TR]

[TR]

[TD=class: style7, width: 199]Bilirubin, direct[/TD]

[TD=class: style7, width: 327, colspan: 2]0 - 0.3 mg/dl[/TD]

[/TR]

[TR]

[TD=class: style7, width: 199]Bilirubin, total[/TD]

[TD=class: style7, width: 327, colspan: 2]0.1 - 1.2 mg

[/TD]

[/TR]

[/TABLE]

[Nursingbride12]

Yes I meant ammonia. My phone autocorrected me :)

[Ivanna_Nurse, BSN, RN]

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?

Rubbing alcohol needs to be used judiciously, as it can be absorbed systemically. ~Ivanna

[limaRN, BSN, RN]

Nursingbride12-

We used Tylenol at around temp 101.5 and several hours later at temp 103. At temp 103 I discussed with the PA the possibility of a cooling blanket. She wasn't to keen on the idea since the pt had just been made a DNR and was not expected to make it. (The pt was having long runs of vtach, labs had been checked and were fine, and was In a SIRS state on extremely high doses of levo, neo, vaso barely making bp goals). At temp 103 I give the pt a bath left her skin out in the air, used ice, washed their hair, and gave them some meds to prevent shivering. I checked temp 1.5 hours later and it was 106 we then put the pt on a cooling blanket which took nearly 12 hours to get the temp down past 105.

[Esme12, ASN, BSN, RN]

Yes I meant ammonia. My phone autocorrected me :)

That's better.....I would be cautious with alcohol baths or cool baths for they can cause the patient to chill and shiver which will raise the temperature.

I can see no Tylenol with the ammonia level that high.....but ibuprofen can be used even a cooling blanket.