Fever in trauma patients: evaluation of risk factors, including traumatic brain injury

Temperature Control in Acute Brain Injury: An Update

Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.

Burden of fever and hospital mortality in patients admitted to the intensive care unit with isolated traumatic brain injury-A retrospective cohort study using continuous temperature data

BACKGROUND

Fever has been shown to be associated with poor outcomes in patients with traumatic brain injury. Earlier studies have used peak daily temperature to derive the burden of fever. The association between hospital mortality and fever burden calculated as the area under the temperature-time curve for the entire duration of intensive care unit (ICU) stay has not been studied before.

OBJECTIVES

The objective of this study was to investigate the association between the burden of fever and hospital mortality in patients with isolated traumatic brain injury admitted to the ICU.

METHODS

We conducted this retrospective cohort study using an electronic database in a tertiary ICU in Sydney. We included all adult patients admitted to the ICU with isolated traumatic brain injury over 3 years from 1 July 2017 to 30 June 2020. We collected data on demographics, clinical characteristics, and interventions for all patients. We defined the burden of fever as an area under the temperature-time curve above 37 °C. The primary outcome was hospital mortality. We used multivariable logistic regression to determine the association between burden of fever and hospital mortality. We assessed the importance of the burden of fever in a predictive model using machine-learning methods (Bagging and Random Forest).

RESULTS

A total of 88 patients (76% males, mean age: 54 ± 23 years, mean Acute Physiology and Chronic Health Evaluation [APACHE] II score: 15 ± 7) were included in the study, and 18 (20.5%) of the 88 patients died in hospital. Compared to survivors, the nonsurvivors had lower mean Glasgow Coma Scale (GCS) score at the scene, higher mean APACHE II and III scores, and higher rates of intracranial pressure monitoring, surgery, mechanical ventilation, use of vasopressors, and cooling. On multivariable logistic regression, age (odds ratio: 1.05, 95% confidence interval: 1.02-1.09, p = 0.01) was found to be an independent predictor of hospital mortality. A higher GCS score at the scene (odds ratio: 0.81, 95% confidence interval: 0.66-0.98, p = 0.03) was associated with survival. The burden of fever was not associated with hospital mortality. The top three important variables in the predictive model were APACHE III, GCS score at scene, and age.

CONCLUSION

The burden of fever was not an independent predictor of hospital mortality. The results of this study need to be confirmed in a large multicenter study.

Effect of Fever on the Clinical Outcomes of Traumatic Brain Injury by Age

Background and objective: Fever is a common symptom in patients with traumatic brain injury (TBI). However, the effect of fever on the clinical outcomes of patients with TBI is not well characterized. Our study aims to determine the impact of fever on the clinical outcomes of patients with TBI and test the interaction effect of fever on study outcomes according to age group. Materials and methods: Our retrospective study included adult patients with TBI who were transported to a level 1 trauma center by the emergency medical services (EMS) team. The main exposure is fever, defined as a body temperature of 38 °C or above, in the emergency department (ED). The primary outcome was mortality at hospital discharge. We conducted a multivariable logistic regression analysis to estimate the effect sizes of fever on study outcomes. We also conducted an interaction analysis between fever and age group on study outcomes. Results: In multivariable logistic regression analysis, patients with TBI who had fever showed no significant difference in mortality at hospital discharge (aOR, 95% CIs: 1.24 (0.57−3.02)). Fever significantly increased the mortality of elderly patients (>65 years) with TBI (1.39 (1.13−1.50)), whereas there was no significant effect on mortality in younger patients (18−64 years) (0.85 (0.51−1.54)). Conclusions: Fever was associated with mortality only in elderly patients with TBI.

Post-craniotomy fever and its associated factors in patients with traumatic brain injury

BACKGROUND

Fever frequently occurs in patients with traumatic brain injury and can cause secondary damage to the brain. Critical care nurses play essential roles in assessing and managing fever in these patients.

AIM

The study aimed to (a) examine the fever causes in and condition of neurosurgical patients with traumatic brain injury in intensive care, (b) identify the factors associated with fever, and (c) determine the effects of fever on hospital stay and prognosis.

STUDY DESIGN

This study is a retrospective observational design.

METHODS

Data were collected through chart reviews of 93 traumatic brain injury patients admitted to a teaching hospital's intensive care unit for postoperative care. Fever was defined as at least one episode of body temperature >38°C.

RESULTS

Of the 93 patients, 76 developed a fever within 1-week post-craniotomy. Of these, 49 were infection-related and 27 were unexplained. Results of logistic regression showed that the preoperative Glasgow coma scale score (ß = -.323; P = .013) and length of intubation (ß = .480; P = .005) were the key predictors of unexplained post-craniotomy fever, and these two variables (ß = -.494; P < .001 and ß = .479; P = .006, respectively) were also the key predictors of infection-related fever.

CONCLUSION

A significant portion of patients developed a fever during the first post-craniotomy week. Patients with a lower pre-craniotomy Glasgow coma scale score and a longer intubation length were at a greater risk for both infection-related fever and unexplained fever. Patients with fever had a bad outcome score.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses should closely monitor traumatic brain injury patients' body temperatures and employ evidence-based infection prevention and control measures to minimize their infection risks. Respiratory care and intensive care unit Liberation Bundle should be reinforced to liberate these patients from mechanical ventilation and its associated complications.

Impact of screening COVID-19 on orthopedic trauma patients at the emergency department: A consecutive series from a level I trauma center

BACKGROUND

Coronavirus disease 2019 (COVID-19) posed a major threat to the clinical practice of orthopedic surgeons, especially in the emergency department. We aim to present: (1) the criteria established by the Surgery Management Committee of Taipei Veterans General Hospital in response to COVID-19 and (2) the impact of COVID-19 screening on orthopedic trauma patients in the emergency department.

METHODS

From April 1 to April 30, 2020, all orthopedic trauma patients in the emergency department were screened for COVID-19 if they fulfilled any of the following: (1) travel from abroad within 14 days, (2) high-risk occupation, (3) contact or cluster history with a COVID-19-positive patient, and (4) any associated symptom, including fever up to 38°C, cough, sore throat, rhinorrhea, loss of taste or smell, muscle soreness, malaise, or shortness of breath. We recorded details on the injury, fever, management, and associated outcomes.

RESULTS

Of the 163 orthopedic trauma patients presenting to the emergency department, 24 were screened for COVID-19; of these, 22 received surgery. Sixty-two patients received surgery without screening for COVID-19. Fever was the most common reason to screen for COVID-19 (N = 20; 83.3%). No patients were COVID-19 positive. Screened patients had a significantly longer mean interval from presentation to the emergency department to surgery (2.7 ± 2.5 vs. 1.5 ± 0.8 days, p = 0.037). Of the 20 patients screened because of fever, the focus was not identified in 12 (60.0%) patients. The other eight had urinary tract infection (N = 6; 27.2%), septic hip (N = 1; 4.6%), and concomitant pneumonia and urinary tract infection (N = 1; 4.6%). The mean duration of fever and hospital stay was 4.3 ± 4.6 and 8.7 ± 4.9 days, respectively. There were no thromboembolic events, surgical complications, or in-hospital mortality.

CONCLUSION

We developed safe and reliable screening criteria for this COVID-19 pandemic. The delay in surgery was reasonable and did not adversely affect in-patient outcomes.

Temperature management in acute brain injury: A systematic review of clinical evidence

Temperature alterations in neurocritical care settings are common and have a striking effect on brain metabolism leading to or exacerbating neuronal injury. Hyperthermia worsens acute brain injury (ABI) patients outcome. However conclusive evidence linking control of temperature to improved outcome is still lacking. This review article report an update -results from clinical studies published between March 2006 and March 2020- on the relationship between hyperthermia or Target Temperature Management and functional outcome or mortality in ABI patients.

MATERIALS AND METHODS

A systematic search of articles in PubMed and EMBASE database was accomplished. Only complete studies, published in English in peer-reviewed journals were included.

RESULTS

A total of 63 articles into 5 subchapters are presented: acute ischemic stroke (17), subarachnoid hemorrhage (14), brain trauma (14), intracranial hemorrhage (8), and mixed acute brain injury (10). This evidence confirm and extend the negative impact of hyperthermia in ABI patients on worse functional outcome and higher mortality. In particular "early hyperthermia" in AIS patients seems to have a protective role have as promoting factor of clot lysis but no conclusive evidence is available. Normothermic TTM seems to have a positive effect on TBI patients in a reduced mortality rate compared to hypothermic TTM.

CONCLUSIONS

Hyperthermia in ABI patients is associated with worse functional outcome and higher mortality. The use of normothermic TTM has an established indication only in TBI; further studies are needed to define the role and the indications of normothermic TTM in ABI patients.

Body temperature and in-hospital mortality in trauma patients: analysis of a nationwide trauma database in Japan

PURPOSE

Avoiding body temperature (BT) abnormalities has been emphasized in trauma care, and BT correction in the initial treatment period may improve patient outcome. However, the effect of hyperthermia at hospital arrival on mortality in trauma patients is unclear. This study aimed to identify the association between BT and in-hospital mortality among adult trauma patients.

METHODS

This was a retrospective analysis of a multi-centre prospective cohort study. Data were obtained from the Japan Trauma Data Bank (JTDB). Adult trauma patients who were transferred directly from the scene of injury to the hospital and registered in the JTDB between January 2004 and December 2017 were included. The primary outcome was the association between BT at hospital arrival and in-hospital mortality. BT at hospital arrival was classified by 1 °C strata. We conducted multivariable logistic regression analyses to calculate the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality for each BT group using 36.0-36.9 °C as a reference.

RESULTS

Overall, 153,117 patients were included. The total mortality rate was 7% (n = 10,118). The adjusted OR for in-hospital mortality for < 35.0 °C was 1.65 (95% CI 1.51-1.79, p < 0.001), 35.0-35.9 °C was 1.33 (95% CI 1.25-1.41, p < 0.001), 37.0-37.9 °C was 0.99 (95% CI 0.91-1.07, p = 0.639), 38.0-38.9 °C was 1.30 (95% CI 1.08-1.56, p = 0.007) and > 39.0 °C was 1.62 (95% CI 1.18-2.22, p = 0.003) compared to that for normothermia.

CONCLUSIONS

Our results reveal that hypothermia and hyperthermia at hospital arrival are associated with increased in-hospital mortality in adult trauma patients.

Seven-point Checklist: Have You Prepared Sufficiently for the COVID-19 Crisis in Your Neurosurgery Department?

Coronavirus disease 2019 (COVID-19) is a novel infectious disease caused by severe acute respiratory syndrome coronavirus 2. COVID-19 was initially detected in Wuhan, China, in late 2019, and has now rapidly spread worldwide. Departments of Neurosurgery are required to employ an acute response against this pandemic. In this article, we discuss the important factors that neurosurgeons need to consider when managing their departments during the COVID-19 pandemic. We have summarized perspectives of the articles published on COVID-19, as well as the suggestions from neurosurgical societies in highly infected regions. We have proposed a seven-point checklist for neurosurgery departments: (1) networking among medical institutions; (2) coordinating teams within each institution; (3) prevention of infection within the department; (4) perioperative management; (5) triage; (6) changing subspecialty management protocols; and (7) psychological support for medical staff and patients.

Fever Is Associated with Reduced Mortality in Trauma and Surgical Intensive Care Unit-Acquired Infections

Background: Fever is a common response to both infectious and non-infectious physiologic insults in the critically ill, and in certain populations it appears to be protective. Fever is particularly common in trauma patients, and even more so in those with infections. The relationship between fever, trauma status, and mortality in patients with an infection is unclear. Patients and Methods: A review of a prospectively maintained institutional database over a 17-year period was performed. Surgical and trauma intensive care unit (ICU) patients with a nosocomial infection were extracted to compare in-hospital mortality among trauma and non-trauma patients with and without fever. Univariable analyses compared patient and infection characteristics between trauma and non-trauma patients. A multivariable logistic regression model was created to identify predictors of in-hospital mortality, with a focus on fever and trauma status. Results: Nine hundred forty-one trauma patients and 1,449 non-trauma patients with ICU-acquired infections were identified. Trauma patients were younger (48 vs. 59, p < 0.001), more likely to be male (73% vs. 56%, p < 0.001), more likely to require blood transfusion (74% vs. 47%, p < 0.001), had lower Acute Physiology and Chronic Health Evaluation (APACHE) II scores (18 vs. 19, p = 0.02), and had lower rates of comorbidities. Trauma patients were more likely to develop a fever (72% vs. 43%, p < 0.001) and had lower in-hospital mortality (9.6% vs. 22.6%, p < 0.001). In multivariable analysis, non-trauma patients with fever had a lower odds of mortality compared with non-trauma patients without fever (odds ratio [OR] 0.63, p = 0.004). Trauma patients with fever had the lowest odds ratio for mortality when compared to non-trauma patients without fever (OR 0.25, p < 0.001). Conclusions: In this large cohort of trauma and surgical ICU patients with ICU-acquired infections, fever was associated with a lower odds of mortality in both trauma and non-trauma patients. Further investigation is needed to determine the mechanisms behind the interplay between trauma status, fever, and mortality.

Effectiveness of a bundled approach to reduce urinary catheters and infection rates in trauma patients

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are common nosocomial infections. In 2015, the Centers for Medicare and Medicaid Services began imposing financial penalties for institutions where CAUTI rates are higher than predicted. However, the surveillance definition for CAUTI is not a clinical diagnosis and may represent asymptomatic bacteriuria. The objective of this study was to compare rates of urinary catheterization and CAUTI before and after the implementation of a bundled intervention.

METHODS

This retrospective review evaluated trauma patients from January 2013-January 2015. The bundled intervention optimized the urinary catheterization process and culturing practices to reduce false positives. The CAUTI rate was defined as a positive surveillance CAUTI divided by total catheter days multiplied by 1,000 days.

RESULTS

A total of 6,236 patients were included (pre: n = 5,003; post: n = 1,233). Fewer patients in the post bundle group received a urinary catheter (pre: 25% vs post: 16%; P < .001). After bundle implementation, the CAUTI rate reduced over one third (pre: 4.07 vs post: 2.56; incidence rate ratio, 0.63; 95% confidence interval, 0.19-2.07).

CONCLUSIONS

Although the number of patients exposed to urinary catheters and catheter days was decreased, optimization of culturing practices was essential to prevent the CAUTI rate from increasing from a reduced denominator. Implementation of a CAUTI prevention bundle works synergistically to improve patient safety and hospital performance.

Early fever after trauma: Does it matter?

BACKGROUND

Fever is strongly associated with poor outcome after traumatic brain injury (TBI). We hypothesized that early fever is a direct result of brain injury and thus would be more common in TBI than in patients without brain injury and associated with inflammation.

METHODS

We prospectively enrolled patients with major trauma with and without TBI from a busy Level I trauma center intensive care unit (ICU). Patients were assigned to one of four groups based on their presenting Head Abbreviated Injury Severity Scale scores: multiple injuries: head Abbreviated Injury Scale (AIS) score greater than 2, one other region greater than 2; isolated head: head AIS score greater than 2, all other regions less than 3; isolated body: one region greater than 2, excluding head/face; minor injury: no region with AIS greater than 2. Early fever was defined as at least one recorded temperature greater than 38.3°C in the first 48 hours after admission. Outcome measures included neurologic deterioration, length of stay in the ICU, hospital mortality, discharge Glasgow Outcome Scale-Extended, and plasma levels of seven key cytokines at admission and 24 hours (exploratory).

RESULTS

Two hundred sixty-eight patients were enrolled, including subjects with multiple injuries (n = 59), isolated head (n = 97), isolated body (n = 100), and minor trauma (n = 12). The incidence of fever was similar in all groups irrespective of injury (11-24%). In all groups, there was a significant association between the presence of early fever and death in the hospital (6-18% vs. 0-3%), as well as longer median ICU stays (3-7 days vs. 2-3 days). Fever was significantly associated with elevated IL-6 at admission (50.7 pg/dL vs. 16.9 pg/dL, p = 0.0067) and at 24 hours (83.1 pg/dL vs. 17.1 pg/dL, p = 0.0025) in the isolated head injury group.

CONCLUSION

Contrary to our hypothesis, early fever was not more common in patients with brain injury, though fever was associated with longer ICU stays and death in all groups. Additionally, fever was associated with elevated IL-6 levels in isolated head injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological study, level III.