AACN News—August 2002—Practice

AACN News Logo

Back to AACN News Home

Vol. 19, No. 8, AUGUST 2002


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.