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Feverinthecontextofcriticalillnessisafrequentoccur-renceandcanraisetheconcernthataninfectionorotherinammatoryprocess,suchaspancreatitis,ispresent.
Inthissituation,theevaluativeprocessforthecauseoffevermayresultinimportantmodicationsintreatment,includinginitiationoralterationinantimicrobialtherapy.
Feverscanalsobeamanifestationofdrugreactions,promptingthediscontinuationofsuspectedagents.
However,inmanycases,feverinacriticallyillpatientisnotassociatedwithatreatableetiologyandisconsideredsimplyasymptomthataccompaniestheorgandysfunc-tionthatbroughtthepatienttotheintensivecareunit(ICU).
TheoptimalapproachtofeverintheICUhasnotbeenresolved.
Whilereducingfevercanimprovepatientcomfort,decreasetheriskoffebrileseizuresinthepredisposedpatient,andlowermetabolicrate,itremainsunclearwhetherantipyreticsactuallyaectpatientout-comeinclinicallymeaningfulways.
Nevertheless,theuseofacetaminophen(paracetamol),ibuprofen,andotheroralagentsremainsacommonpracticeinbothout-patientandinpatientsettings.
However,therearelimitedoptionsavailableforloweringtemperatureincriticallyillpatientsinwhomtheenteralroutecannotbeused.
Externalcoolingmeasureshaveonlymodesteects,especiallyifthereisperipheralvasoconstriction,andtheuseofinvasivetechniques,includingchilledintravenousuidsandperitonealorextracorporealcoolingmeasures,isgenerallynotindicatedforthemodesthyperthermiacommonlypresentintheICU.
InthepreviousissueofCriticalCare,aclinicaltrialreportedbyMorrisandcolleagues[1]showsthatintravenousibuprofenismoreeectivethanplaceboinloweringtemperaturetolessthan101°Cinbothcriticallyillandnon-criticallyillpatients.
Althoughtheredidnotappeartobeanincreasedincidenceofadverseeventsinthepatientswhoreceivedintravenousibuprofen,thisstudywassmall,withjust53criticallyillpatients,andspecicallyexcludedgroupsofpatientscommonlyseenintheICU,suchasthoseimmediatelypost-surgery,thosewithcreatinineofgreaterthan3mg/dL,orthosereceivingdialysisorcorticosteroidtherapy.
Therefore,claimsofsafetyfortheuseofintravenousibuprofenincriticallyillpatientsneedtobewellestablishedwithlargerstudiesbeforesuchtherapycanbeconsideredforroutineuse.
ConcernsabouttheuseofintravenousibuprofenintheICUarefurthermagniedbythelackofanysuggestionofclinicalbenetwithsuchtherapy.
AlthoughastudybyBernardandcolleagues[2]showedthatintravenousibuprofenwaseectiveindiminishingtheseverityofhyperthermiainpatientswithacutelunginjury,theredidnotappeartobeanybenecialeectsonsurvivalorothermeaningfulclinicaloutcomes.
Thesafetyconcernswiththeuseofibuprofenincriticallyillpatientsshouldnotbeunderestimated.
Eveninhealthypatients,ibuprofenandsimilarnonsteroidalanti-inammatoryagentsareassociatedwithrenaldysfunction,particularlyinpatientswithbaselineevidenceofrenalcompromise[3].
Owingtorenalhypoperfusionassociatedwithsepsis,hypovolemia,ordiminishedcardiacoutputorinresponsetonephrotoxicdrugs,suchasaminoglycosides,whicharefrequentlyusedincriticallyillpatients,acutekidneyinsuciencyisacommonoccurrenceintheICU.
InthestudybyMorrisandcolleagues[1],intravenousibuprofenwasadminis-teredoveronlya24-hourperiod.
AsfeverisoftenaAbstractFeverisacommonoccurrenceintheintensivecareunit,andpharmacologicapproachesarelimited,particularlyinpatientsunabletotolerateenteralmedications.
AlthoughastudybyMorrisandcolleaguesinthepreviousissueofCriticalCaresuggeststhatintravenousibuprofenissafeandeffectiveincriticallyillpatients,thestudyissmallandthedrugwasgivenoveronlya24-hourperiod.
Additionalstudieswillneedtobeperformedtodemonstratethesafetyandefficacyofintravenousibuprofenincriticallyillpatients.
2010BioMedCentralLtdHottimesintheintensivecareunitEdwardAbraham*SeerelatedresearchbyMorrisetal.
,http://ccforum.
com/content/14/3/R125COMMENTARY*Correspondence:eabraham@uab.
eduDepartmentofMedicine,UniversityofAlabamaatBirminghamSchoolofMedicine,420BoshellBuilding,18087thAvenueSouth,Birmingham,AL35294,USAAbrahamCriticalCare2010,14:178http://ccforum.
com/content/14/4/1782010BioMedCentralLtdpersistentproblemincriticallyillpatients,occurringovermanydays,thepotentialuseofintravenousibuprofenisunlikelytobelimitedtoonly24hours.
Althoughthepresentstudyappearstoshowthataverylimitedexposuretointravenousibuprofeninpatientswithoutevidenceofsignicantrenaldysfunctionisnotassociatedwithsignicantharm,wereallyneedtobeassuredofthesafetyofthisinterventionoveramoreprolongedperiodandinmoretypicalICUpopulationsbeforeitsroutineusecanbeconsidered.
Thequestionofwhetherweshouldbetreatingfeveratallremains.
Althoughtheremaybesomereasontobelievethatmassiveandprolongedhyperpyrexiaisharmful,thereislittleevidencethatthemoremodestfeverscommonlyseeninICUpatientsaecttheirclinicaloutcomes.
Untilwehavesuchdata,thereseemstobelittleuseintreatingfeveratall,especiallyasthedevelopmentoffevermayprovideanimportantcluealertingustotheneedformodifyingtherapyforpatho-physiologicprocesses,suchasanewinfection,thatreallycandeterminetheoutcomeforapatient.
AbbreviationICU,intensivecareunit.
CompetinginterestsTheauthordeclaresthathehasnocompetinginterests.
Published:19July2010References1.
MorrisPE,PromesJT,GuntupalliKK,WrightPE,AronsMM:Amulti-center,randomized,double-blind,parallel,placebo-controlledtrialtoevaluatetheefficacy,safety,andpharmacokineticsofintravenousibuprofenforthetreatmentoffeverincriticallyillandnon-criticallyilladults.
CritCare2010,14:R125.
2.
BernardGR,WheelerAP,RussellJA,ScheinR,SummerWR,SteinbergKP,FulkersonWJ,WrightPE,ChristmanBW,DupontWD,HigginsSB,SwindellBB:Theeffectsofibuprofenonthephysiologyandsurvivalofpatientswithsepsis.
TheIbuprofeninSepsisStudyGroup.
NEnglJMed1997,336:912-918.
3.
AmerM,BeadVR,BathonJ,BlumenthalRS,EdwardsDN:Useofnonsteroidalanti-inflammatorydrugsinpatientswithcardiovasculardisease:acautionarytale.
CardiolRev2010,18:204-212.
doi:10.
1186/cc9092Citethisarticleas:AbrahamE:Hottimesintheintensivecareunit.
CriticalCare2010,14:178.
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