Fever

Fever is an often raised problem in neurocritical care and stroke medicine. Here are some notes from todays lecture.

Distinguish

  • Infectious causes
  • Drugs (PHE, allopurinol, heparin, minocycline, neuroleptics, serotonergic)
  • other central fever forms (in particular in SAH: impending vasospasm), localizing to the hypothalamus, the third ventricle or the pons.

Management. Regardless of your threshold for fever or hyperthermia, you need to work it up systematically.

  • History: course of fever, is it still rising, drugs
  • Examination: is the body trying to heat or cool (is it fever or hyperthermia?)
  • Examination: sources of infection
  • Labs: apart from the obvious, think of troponin and procalcitonin (the latter if sepsis is assumed)

Therapy. There are some contexts in which fever or hyperthermia is not to be tolerated: stroke, MI, non-stable tachyarrhythmia. Remember that in the case of sepsis, it is probably better tolerated.

In the case of stroke, we know the following:

  • temperature is bad (outcome and mortality-wise)
  • it is safe to try to lower temperature (cf. PAIS study)
  • it is hard to lower temperature (the Kallmünzer/Kollmar publications)

It is not really clear

  • whether it really helps to lower temperature
  • what threshold to use
  • what methods are efficient

In our Stroke Unit, we decided to introduce a 3 layer approach:

  • 37,5°C: low-dose paracetamol or metamizol (4 x 500 mg)
  • 38°C: physical cooling and high dose (4 x 1000 of either)
  • 38,5°C: combination therapy and forced physical cooling
  • 39,5°C: desperate measures

Desperate measures, in particular for central dangerous fever (> 40°C)

  • Dantrolen
  • Baclofen
  • Lytic cocktail (block any neurotransmitter that might be involved in fever generation; since we don’t know which might be, block all of them) using anticholinergically acting neuroleptics + antihistamines + antiserotonergics + pethidine
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