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Research Corner: Myth vs.
Reality�Should You Treat Fever?
By Betsy L. George, RN, PhD, CCRN
Research Work Group
As a standard of practice, critical care nurses
monitor their patients� body temperatures as an indicator of infection. However,
the definition of fever varies. Some literature defines fever as core
temperature greater than 38.0�C (100.4�F). Another definition is two consecutive
temperature elevations greater than 38.3�C (101� F).1
Numerous biological processes, both infectious
and noninfectious, can cause temperature elevation. Although fever is often
considered to be a host defense response to infection,2 not all infected
patients are feverish. A common practice in critical care is to reduce fever by
administering antipyretic or applying physical cooling. However, because
scientific support is limited, the question of whether to treat fever in
critically ill patients continues to be an area for debate.
The physiology of fever is poorly understood,
and this clinical picture is further confused by contradictory evidence. Current
data are conflicting on whether fever is harmful or beneficial. Both sides of
the argument have data to support their contentions about the benefit or harm of
fever and its treatment.
Beneficial?
Fever may be beneficial for enhancing the host
defenses. Animal studies have demonstrated that fever imparts additional host
defenses and improves survival.2 In patients with sepsis, fever has been linked
to decreased mortality.3 Elevated body temperatures are thought to impair the
growth of bacteria.4 Fever will also decrease the normal affinity that exists
between oxygen and hemoglobin and decrease the oxy-hemoglobin binding,5 which
results in increased oxygen unloading at the tissue level.
Harmful?
Some studies have highlighted the physiological
demands of fever. For example, fever can cause hyperventilation.6 Studies in
humans with fever have demonstrated increases in cardiovascular demands and
metabolic rates. There is a 7% increase in metabolic rate for each increase of 1
degree Fahrenheit.6 Revhaug and colleagues7 documented increases in oxygen
consumption, heart rate, serum epinephrine and norepinephrine levels in 13
healthy subjects when fever to a mean of 38.5�C was induced via injection of
endotoxin. Another study showed that increases in cardiac output (compared to
nonfebrile baseline) in seven patients with fever were due to bacteria or viral
causes.8 Haupt and Rackow9 found significantly higher heart rates in critically
ill patients with temperatures greater than 37.8�C than in patients with
temperatures less than 37.8�C. Obviously, these increases in energy consumption
may be a problem for a compromised, critically ill patient.
Another factor to consider is patient comfort.
Potentially adverse symptoms of fever include tachycardia, tachypnea, warm skin,
flushed appearance and restlessness. Increased body temperature can have varying
and individualized effects, depending on patient condition, the cause of fever
and the duration of fever. On the other hand, potential adverse changes
associated with physical cooling include shivering and decreased blood flow to
the skin.
Special Populations
Reducing fever in patients with severe
neurotrauma10 or in patients who cannot tolerate the increased oxygen
consumption of fever can be useful.11 However, there is no evidence of
usefulness in other types of patients. Gozzoli et al12 randomized 38 critically
ill surgical patients with fever to receive either external cooling (n=18) or no
antipyretic treatment (n=20). The groups, which were similar in age, sex
distribution and simplified acute physiologic scores, did not differ in vital
signs, organ dysfunction, level of sedation or laboratory values, both prefever
and 24 hours later. The mean temperature significantly decreased in both the
treatment group (P<.001) and the group without treatment (P<.001). In addition,
the recurrence of fever at 24 hours did not differ in the two groups. This study
suggests that treatment of fever may not be indicated in all critically ill
patients.
Recommendations
Although it is recognized that treatment of body
temperature greater than 41�C is clinically warranted, treatment of body
temperatures less than 41�C remains controversial. To evaluate the impact on
patient outcomes, research is still needed to further examine physiological
response to fevers and fever treatment. Research is also needed to determine
treatment protocols. Current practice should be based on the individual
patient�s clinical condition and the origin of body temperature elevation to
determine if, when and how fever should be treated.
References
1. O�Grady NP, Barie PS, Barlett J. Bleck T,
Garvey G, Jacobi J, Linden P, Maki D, Nam M, Pasculle W, Pasquale MD, Tribett D,
Masur H. Practice parameters for evaluating new fever in critically ill adult
patients. Crit Care Med. 1998;26:392-408.
2. Henker R. Evidence-based practice:
Fever-related interventions. Am J Crit Care. 1999;8:481-487.
3. Clemmer TP, Fisher CJ, Bone RC, Slotman GJ,
Metz CA, Tomas FA. The Methylprednisolone Severe Sepsis Study Group: hypothermia
in the sepsis syndrome and clinical outcome. Crit Care Med. 1992;20:1395-1401.
4. Kluger MI. Is fever beneficial? Yale J Biol
Med. 1986;59:89-95.
5. Thelan LA, Davie JK, Urden LD . Textbook of
Critical Care Nursing. St. Louis, Mo: C.V. Mosby; 1990:392.
6. Potter PA, Perry AG. Fundamentals of Nursing.
4th edition. St. Louis, Mo: C.V. Mosby; 1997:611.
7. Revhaug A, Michie HR, Manson JM, et al.
Inhibition of cyclo-oxygenase attenuates: the metabolic response to endotoxin in
humans. Arch Surg. 1988;123:162-170.
8. Weinberg JR, Innes JA, Thomas K, Tooke JE,
Guz A. Studies on the circulation in normotensive febrile patients. Q J Exp
Physiol. 1989;74:301-310.
9. Haupt MT, Rackow E. Adverse effects of
febrile state on cardiac performance. Am Heart J. 1983;105:763-768.
10. Marion DW, Penrod LE, Kelsey SF, et al.
Treatment of traumatic brain injury with moderate hypothermia. N Engl J Med.
1997;336:540-546.
11. Manthous CA, Hall JB, Olson D, et al. Effect
of cooling on oxygen consumption in febrile critically ill patients. Am J Respir
Crit Care Med. 1995;151:10-14.
12. Gozzoli V, Schollker P, Suter PM, Ricou B.
Is it worth treating fever in intensive care unit patients? Preliminary results
from a randomized trial of the effect of external cooling. Arch Intern Med.
2001;1616(1):121-123.
2002 Research and Creative Solutions
Abstracts Now Online
Sept. 1 Is Deadline to Submit 2003
Abstracts
Research and creative solutions abstracts from
AACN�s 2002 National Teaching Institute and Critical Care Exposition in Atlanta,
Ga., are now available online. A total of 150 posters and 24 oral abstracts are
featured at
http://www.aacn.org
> Clinical Practice > Research >
NTI Abstracts.
Call for 2003 Abstracts
Forms to submit research and creative solutions
abstracts for the 2003 NTI in San Antonio, Texas, are also available in this
area. The deadline to submit abstracts is Sept. 1.
Research abstracts can focus on any aspect of
critical care nursing research, including reports of research studies or reports
of research utilization. Only abstracts of completed projects will be accepted.
Abstracts reporting research studies must address the purpose, background and
significance, methods, results, and conclusions.
Creative solutions abstracts should focus on
specific strategies and practice innovations that are used by nurses to solve
difficult, unique or interesting problems in patient care, nursing practice,
nursing management or nursing education. The creative solution must have been
implemented, with outcomes evaluated. Abstracts must address the purpose of the
project and include a description of the creative solution, as well as
evaluation and outcomes.
Abstracts must be relevant to the care of the
acute and critically ill or critical care nursing and must be noncommercial in
nature. The first author must be a nurse holding current AACN membership. Only
completed research and finished projects are eligible, and abstracts must not
have been previously published or presented nationally.
The designated presenters of accepted abstracts
receive a $75 reduction in NTI registration fees. All other expenses are the
responsibility of the presenter, who can be either the first author or a
designate of the author. Presenters who have multiple abstracts accepted will be
eligible for only one reduction in NTI registration.
In addition, four awards will be presented for
oral research abstracts reflecting outstanding original research, replication
research or research utilization. Each of these awards provides an additional
$1,000 toward NTI expenses.
Abstract forms can also be obtained by calling
(800) 899-AACN (2226) and requesting Item #6007.
Check Out These New Pediatric Resources
AACN has developed two new pediatric nursing
resources.
One is a laminated wall chart on the
compatibility of common pediatric IV medications. The content of this chart is
reprinted from �Compatibility of Commonly Used IV Infusions in a Pediatric ICU�
by Cynthia A. Wedekind, PharmD, and Brook D. Fidler, PharmD, which appeared in
the August 2001 issue of Critical Care Nurse. The price is $12 for members and
$15 for others (Item #128624).
The other is a 120-page collection of nine
articles on pediatric advanced practice that were published in AACN Clinical
Issues. Topics include dysrhythmias after heart surgery, evidence-based
practice, asthma, nutrition, SIDS, airway management and heart transplantation.
The price is $12 for members and $15 for others (Item # 128625).
To order, call (800) 899-2226 or visit the AACN
online Bookstore at
http://www.aacn.org.
Grants
Oct. 1, 2002, is the deadline to apply for three
nursing research grants that are available through AACN:
AACN Clinical Practice Grant�This grant awards
up to $6,000 to support research focused on one or more of AACN�s research
priorities.
AACN-Sigma Theta Tau Critical Care
Grant�Cosponsored by Sigma Theta Tau, this grant awards up to $10,000.
Recipients must be members of either AACN or Sigma Theta Tau.
Evidence-Based Clinical Practice Grant�This
grant awards up to $1,000 for research that includes research utilization
studies, CQI projects or outcome evaluation studies. Collaborative research
teams are encouraged.
To find out more about AACN�s research
priorities and grant opportunities, visit the AACN Web site at
http://www.aacn.org. The
grants handbook is also available from AACN Fax-on-Demand at (800) 222-6239
(Canada call 949-448-7315), Request Document #1013.
Critical Care Across the Continuum: Award
Recognizes Excellence in Nontraditional Settings
Following are excerpts from exemplars
submitted in connection with the Excellence in Clinical Practice�Non-Traditional
Setting Award for 2002. Part of the AACN Circle of Excellence recognition
program, this award recognizes excellence in the care of critically ill patients
in environments outside of the traditional ICU/CCU setting. Recipients were
given complimentary registration, airfare and hotel accommodations for AACN�s
National Teaching Institute and Critical Care Exposition in Atlanta, Ga.
John Kelly, RN, BSN, CCRN, CFRN, CEN, EMT-P
Auburn, Mass.
Hartford Hospital
Working as a flight nurse has been the most
demanding and challenging work that I have done. My ICU is the helicopter in
which I fly. Unlike a traditional ICU, we have no patient assignment when we get
to work. Instead, we check our equipment and participate in a shift briefing
with our partner respiratory therapist, the pilot and the communicator. There is
no age limit for patients in our ICU. Following is just one example of my
practice.
Our last request came early in the evening when
we responded to the scene of a motor vehicle crash. A 15-year-old patient was
the passenger in a car traveling about 100 mph when it left the roadway and
rolled several times. Thrown partly out of the car, she was unresponsive when
ground EMS providers removed her from the vehicle. When we assessed her, she was
obtunded with a large scalp laceration and skull fracture, an open fracture to
her left upper arm, and shallow respiration.
After our assessment, we gave the patient
medications for an RSI intubation and I intubated her. Eight minutes after
arriving at the scene, we were loading her into the helicopter. During the
transport to a pediatric trauma center, we monitored her vital signs, oximetry
and capnography; inserted an OG tube; and I put in an 8 French left subclavian
line for better vascular access and fluid resuscitation.
The patient was at the trauma center 32 minutes
after we arrived at the scene. We were privileged to care for Laura in her
golden hour. We are prepared to meet the needs of other patients like her, when
time and care are critical.
Nancy R. Simpson, RN, MSN, CCRN, EMT
Loudon, Tenn.
University of Tennessee Medical Center
I was on a mission trip to Quito, Ecuador, when
two sisters arrived at our clinic to urgently beg the doctor to come see their
mother, Maria, who had been run over by a car. Left with serious wounds, both
her legs were broken. She was ashen and lethargic, but responsive.
Maria�s wounds were several weeks old. She
appeared septic and dehydrated, with only central pulses palpable, a warm trunk
and cool extremities. None of us had anticipated how necrotic her flesh would be
under the splint. We cleaned with peroxide, debrided, cleaned again with
betadine and redressed without painful response from Maria. I was praying for
her healing. She held on to me with surprising strength. �Have mercy, Lord,� I
was repeating through my tears. I had no real faith that Maria would survive.
About six weeks after leaving Ecuador, I learned
that Maria had not only survived, but was up walking and praising God for having
been healed. A dying woman in a remote and primitive equatorial village reminded
me that I can only do so much, but I am not in this alone. Emmanuel: �God is
with us.�
Olinda Pando Spitzer, RN, BSN, CCRN
McKinney, Texas
North Central Medical Center
When I close my eyes and think of the
Netherlands, where my husband was stationed with the Air Force, I can still see
Joyce. She was one-week postoperative from an exploratory laparatomy when her
husband, Bill, asked me to care for her at her residence. Joyce was pale and
weak, and her incision line was open. Her immune system was depressed due to the
Prednisone she was taking for her arthritis. She was having diarrhea and was
very dehydrated. Another nurse and I took turns caring for her. Changing the
abdominal dressing with a sterile technique using European supplies was a
challenge.
One week later, Bill called me early at home and
asked me to come to see Joyce right away. She was crying, scared that she was
dying and worrying about leaving Bill and her 11-year-old daughter, Bridget,
behind. It was obvious her condition was worsening and that something needed to
be done immediately. Bill called the USAF clinic in Germany and asked me to
explain to the medivac doctor Joyce�s deteriorating condition. The Air Force
commander decided to evacuate her to the U.S. military hospital in Germany the
next day. It took Joyce one month to recover.
I was able to use my nursing skills to care for
Joyce in this nontraditional setting, where not only was the language a barrier,
but the standards of care were also very different. The many obstacles that
needed to be overcome to care for her presented a great nursing challenge. She
owes her health to her caring husband and to the USAF medivac team, but I feel
that I made a difference in her life, too.
Practice Resource Network: Numerous
Progressive Care Resources Are Available
Q:
We are setting up a progressive care or
step-down unit. Can you direct us to resources that will help us in this
process?
A:
AACN has many resources relevant to progressive
care or step-down units. AACN believes that acute and critically ill patients,
who five to 10 years ago would have been placed in critical care units, are now
cared for throughout the hospital. Therefore, many nurses who work outside the
ICU need to meet the same educational standards as those who work in an ICU.
Although a section of the AACN Resource Catalog
is geared specifically to progressive care nurses, many products in other
sections are appropriate for progressive care.
For example, fully researched practice protocols
include Protocols for Practice: Noninvasive Monitoring, Medication
Administration, Care of the Cardiovascular Patient and Creating a Healing
Environment. Topics covered in the Noninvasive Monitoring series include
�Bedside Cardiac Monitoring,� �Non-Invasive Blood Pressure Monitoring,� �Pulse
Oximetry,� �Respiratory Inductive Plethysmography� and �Continuous Airway
Pressure Monitoring.� Included in the Care of the Cardiovascular Patient series
are topics related to the �Care of the Cardiac Patient in Rehabilitation and
Recovery,� �Care of the Patient With a Ventricular Assist Device,� �Care of the
Patient With an Arrhythmia� and �Care of the Patient With Heart Failure.�
In addition, the AACN Procedure Manual (Item
#128150) is full of procedures performed in progressive care units. A companion
to this resource is the AACN Critical Care Procedures Performance Evaluation
Checklist CD-ROM (Item #128151).
Also of interest is �Continuum of Care
Monitoring�Its Time Has Come,� an ECRI survey of hospital telemetry monitoring
practices. This resource (Item #1105) is free to members and can be ordered by
calling (800) 899-2226. For additional information on technology assessments,
the ECRI Web site is
http://www.ecri.org.
You can obtain a catalog by calling (800)
899-2226. Request Item #1001. These resources can also be accessed online at
http://www.aacn.org
The AACN Web site also includes an area offering
myriad resource links and educational and career information related to
progressive care.
http://www.aacn.org
. For example, the Society of Critical Care Medicine has admission and discharge
criteria: titled �Guidelines for Admission/Discharge for Adult Intermediate Care
Units.�
In addition, the Standards for Acute and
Critical Care Nursing Practice is available on the AACN Web site
http://www.aacn.org. However,
access to these resources is available only to members and requires a password.
If you have forgotten your AACN member password, call (800) 899-2226.
AACN has endorsed a six-part progressive care
series that is being published in Nursing Management. These articles provide an
overview of progressive care; the patient and care delivery team; staff
education and competency; discuss technology; regulatory compliance; safety
issues; and outcome measures. For information on these articles, e-mail
nursingmanagement@lww.com or visit the publication Web site at
http://www.nursingmanagement.com.
AACN is preparing to launch a Web-based basic orientation program called
Essentials of Critical Care Orientation that will apply to the progressive care
setting.
Finally, AACN has established a Progressive Care
Task Force, as well as a Progressive Care Advisory Team, to help in meeting the
needs of progressive care nurses. Task force members are writing articles for
AACN News to offer helpful tips related to progressive care. Topics include
continuum of critical care; educational needs and standards; management and
inclusive leadership; critical thinking in progressive care; resources to
support care; mentoring and partnership of ICU and progressive care staffs; and
the future of progressive care.
The articles, which debuted in the May 2002
issue of AACN News, are available in the �Progressive Care/Telemetry� area of
the AACN Web site.
In the Circle: Award Recognizes Excellence
in Precepting
Following are excerpts from exemplars
submitted in connection with the Eli Lilly-AACN Excellent Preceptor Award for
2002, sponsored by Eli Lilly & Company. Part of the AACN Circle of Excellence
recognition program, this award recognizes preceptors who demonstrate the key
components of the preceptor role, including teacher, clinical role model,
consultant, and friend or advocate. Recipients were provided complimentary
registration, airfare and hotel accommodations for the NTI.
Carl Deal, RN, BSN, CCRN
West Salisbury, Pa.
West Virginia University Hospital
Lisa was a new graduate nurse in the ICU.
Because, after weeks of orientation, she was unable to function in any nursing
role, let alone a critical care setting, I obtained permission from our nurse
manager to precept her.
I had had the pleasure of precepting most of the
staff that worked night shift. However, nothing had prepared me for Lisa. Her
self-confidence was low and, unsure of her nursing skills, she felt unprepared
to care for patients. My approach was that we were a team that works toward a
goal. Our goal was to have Lisa care for patients proficiently, professionally
and confidently. I assured her that team members support each other and that I
would never let her down.
We assessed, planned and implemented care each
night, evaluating the care outcomes and her growing skills and confidence. I
planned conferences to discuss her progress, how to improve on areas of weakness
and our patient�s condition and progress. Each shift we worked I saw improvement
and reinforced that she was making steps toward our goal.
At the end of her orientation, I was proud when
our nurse manager expressed surprise and pleasure at what we accomplished. I
knew Lisa met and exceeded our goals and would continue to grow as a nurse and a
person. Lisa was proud and happy, her self-confidence was restored, and she was
doing what she loved. Lisa and I continued working together for many nights, not
as preceptor, but as peers and friends.
Lisa Marie Noe, RN
Philadelphia, Pa.
Hospital of the University of Pennsylvania
When I transferred to the ICU from a
medical-surgical unit seven years ago, I was scared and uncertain if I had made
the right decision. My preceptor was great and helped me every step of the way.
Five years ago, I became a preceptor.
Although I precept nurses with different skill
levels and experience, I feel a special connection to nurses like Julie, who
transfer from the general care floors. Julie transferred to the ICU from a
general surgical unit. She was excited and enthusiastic, but also nervous. I
told her about my own experience and how my fear and doubt changed to confidence
and self-assurance. After discussing our expectations, we tailored Julie�s
orientation to best meet her needs. We started slowly, adding new experiences
every few days so she would not be overwhelmed.
On one of her first days, a patient in the unit
�coded� and died. Afterward, Julie was quiet. She expressed that one of her
primary fears was having one of her patients code when no one else was around. I
tried to allay her fears by reassuring her that there would always be someone
around to help.
Throughout her orientation we openly discussed
problems or issues that arose. When we both felt she was ready, I stepped back
and let Julie assume the primary role in an effort to instill a level of
confidence that would allow her to grow after orientation was complete. By the
end of orientation, she was caring for the most critical patients with little or
no assistance. Julie is now one of the best and brightest nurses I work with. I
am proud to say that I helped her through her career transition.
Eugenia C. Welch, RN, CCRN
Combine, Texas
Presbyterian Hospital of Dallas
As a registered nurse since June 1988 and a
critical care nurse for all but one of those years, I have enjoyed my journey. I
was molded in my early years by many wonderful clinicians and make every attempt
to remain cognizant of how I felt as a new nurse entering the profession.
With this in mind, I approach each individual
and situation with the tools that my preceptors used with me. I have each new
preceptee express what they feel their strengths and weaknesses are and what
they want to gain from the experience. I encourage questions and strive to be
alert to new learning situations. Following is one story that reflects how I
have made my optimal contribution:
Sarah came to me as a graduate nurse. She seemed
to absorb everything I said and everything she observed like a sponge. During
one of our shifts, we received a patient from another facility, with CPR in
progress. Sarah jumped onto the stretcher without hesitation to continue the
CPR. Following the unsuccessful resuscitation of the patient, we began to
perform the postmortem care. Sarah continued with eagerness in this experience
as well. We talked at length, sorting the clinical aspects of what happened.
After the long discussion, I asked Sarah what she was feeling after her first
�code� and her first direct experience with death. She replied, �Isn�t that what
I am trained to do?�
With each new �Sarah,� I grow and become a
better nurse myself. I cherish each new precepting experience as a true learning
experience for me and, I hope, for each new nurse who comes into my path.
AACN Online Quick Poll
Under what circumstances are critical care
nurses allowed to IV push anesthesia agents (eg, etomidate) for IV sedation in
your facility?
Never 40%
In emergent cardioversion, rapid sequence
intubation and other situations 25%
In both emergent cardioversion and rapid
sequence intubation 16%
During rapid sequence intubation 14%
Allowed, but not in any of the above situations
3%
In emergent cardioversion 2%
Number of Responses: 1477
The AACN Online Quick Poll is a voluntary survey
on a variety of topics and is not scientifically projectable to any other
population. AACN presents these surveys to give our users an opportunity to
share their opinions on particular topics. Participate by visiting the AACN Web
site at
http://www.aacn.org.
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