Intensive care unit management of fever following traumatic brain injury

Abstract

SummaryFever, in the presence of traumatic brain injury (TBI), is associated with worsened neurologic outcomes. Studies prior to the publication of management guidelines revealed an undertreatment of fever in patients with neurologic insults. Presently the adult TBI guidelines state that maintenance of normothermia should be a standard of care therefore improvement in management of fever in these patients would be expected. The specific aims of the study were to: 1) determine the incidence of fever (T> 38.5° C) in a population of critically ill patients with TBI. 2) describe what interventions were recorded by intensive care unit (ICU) nurses in managing fever. 3) ascertain the rate of adherence with published normothermia guidelines. Medical record review of available hospital records was conducted on patients admitted to a level I trauma center following severe TBI (N=108) from the parent study. Temperature data was abstracted and contemporaneous nursing documentation was examined for evidence of intervention for fever and adherence with published standards. Data analyses were performed that included descriptive statistics. Seventy-nine percent of TBI patients (85/108) had at least one recorded fever event while in the ICU. However in only 31% of events did the patient receive any documented intervention by nursing staff for the elevated temperature. The most frequently documented intervention was pharmacologic (358/1166 elevations). Other nursing actions (e.g. use of fan) accounted for a minority (<1%) of nursing interventions documented. Patients were more likely to have a high temperature that exceeded 40°C (13%) than a temperature that was normothermic (5%). There continues to be an under treatment of fever in patients with TBI by critical care nurses despite our knowledge of its negative effects on outcomes. There remains a gap in translation between patient outcomes research and bedside practice that needs to be overcome, thus research efforts need to now focus on understanding nurses' decision-making processes and the best methods of fever reduction in patients with TBI.

Judgments of Critical Care Nurses About Risk for Secondary Brain Injury

“…However, marked gaps still remain between best evidence and nursing practice. 72,73 In our study, only 27% of nurses were aware of evidencebased guidelines for managing physiological parameters in TBI patients. Of those nurses who responded that they were aware of guidelines, not 1 nurse was able to cite the name of guidelines established by the BTF, 11 which are the current standard of evidencebased care for TBI patients.…”

“…Nationally, nurses vary in how they define elevated temperature (fever) and determine appropriate interventions. 72,73 Currently, no evidence-based standards of care for temperature management are available, particularly for TBI patients. Although fever in TBI patients has been associated with poor outcomes, 9,52,53 to what extent nurses are aware of this information when determining risk for secondary brain injury is not clear.…”

A Systematic Review of the Effects of Body Temperature on Outcome After Adult Traumatic Brain Injury

“…However, many interventions to treat fever are not aggressive (Thompson, Kirkness, & Mitchell, 2007). Recent investigation of 33°C versus 36°C in cardiac arrest patients (Nielsen et al, 2013) supports the hypothesis that fever avoidance may be the highest yield intervention in TTM (Rittenberger & Callaway, 2013), but this is not translatable directly to TBI and requires further investigation in this population.…”

Clinical management of fever by nurses: doing what works

“…Nurses frequently must manage the problem of fever in these populations as its prevalence is high in the acute phase (Childs et al. 2005, McIlvoy 2007, Thompson et al. 2007b, Kirkness et al.…”