All medical and nursing staffs involved in the management of acute Stroke patients at Salford Royal Hospital. Acute Stroke Management of Fever

Transcription

1 Acute Stroke Management of Fever Classification: Clinical Guideline Lead Author: Dr Amir Ahmad Additional author(s): Dr Jouher Kallingal, Professor Pippa Tyrrell Authors Division: Neurosciences and Renal Services Unique ID: TWCG03(14) Issue number: 3 Expiry Date: September 2020 Contents Section Page Who should read this document 1 Key Messages 2 Background 2 Guideline Definition Effects of fever in stroke outcome Causes of fever in acute stroke Treatment of fever Monitoring and treatment of raised body temperature 3 Standards 4 References and Supporting Documents 4 Roles and Responsibilities 5 Appendix 1 Protocol for monitoring and treating Fever in Acute Stroke 6 Document control information (Published as separate document) Document Control Policy Implementation Plan Monitoring and Review Endorsement Who should read this document? All medical and nursing staffs involved in the management of acute Stroke patients at Salford Royal Hospital. Page 1 of 6

2 Key Messages All stroke patient have a baseline temperature recorded on admission to stroke unit and then if they are pyrexial continue to record four hourly for the first 72 hours following admission. When fever is identified assessment to find the underlying cause of the fever and prompt treatment should instituted. Background About a third of patients admitted with stroke will have fever (temperature 37.5 ºC) within the first few days after stroke onset. It is often under recognised and assessed inadequately. Various studies have shown that fever is associated with poor outcome in stroke patients. Identifying presence of fever, the underlying cause and prompt treatment is a vital component in the effective management of stroke patients. This protocol is aimed to guide appropriate assessment and management of fever in acute stroke patients. Guideline 1.1 Definition: There is no universal cut off temperature above which it is defined as fever. In general it is characterized by an elevation of body temperature above the normal range of C due to an increase in the temperature regulatory set-point. A temperature of 37.5 ºC or more is referred to as fever in this protocol. 1.2 Effects of fever in stroke outcome Patients with acute stroke who develop fever are far more likely to die within the first 10 days after a stroke than those with lower temperature. 1 Data from various studies show that body temperature higher than 37.5 ºC significantly correlates with poor outcome. 2 Two separate meta-analyses showed that febrile stroke patients have significantly higher morbidity and mortality rates compared to nonfebrile patients, independent of the cause of the temperature elevation. 3, 4 The relationship between stroke outcome or infarct volume and intensity of fever is strongest within the first 24 hours. The earlier the fever develops, the worse the cerebral damage is expected to be. 2, 5 High body temperature in preclinical studies has been shown to cause transformation of ischemic penumbra into infarction and apoptosis. In a recently reported study, patients with poor functional outcome (modified Rankin Score, mrs 3) at 90 days had higher admission and peak temperatures than patients with good outcome (mrs 2). In 69% of pyrexial stroke patients no source of infection was detected, and no alternative cause of pyrexia other than the stroke itself in 44%. 6 Fever also has been shown to confer poor prognosis in acute ischemic stroke patients who are thrombolysed: body temperature of 37 ºC at 24 hours was associated with Page 2 of 6

3 a lack of recanalization, greater hypodensity volume and worse outcome in 9, 10 stroke patients treated with t-pa. 1.3 Causes of fever in acute stroke The treating physician should investigate the source of fever. Fever may be secondary to the cause of stroke (e.g. Infective endocarditis), may be a response to the stroke itself (central fever) or may represent a complication such as aspiration, pneumonia, urinary tract infection or other causes of sepsis.7 In most cases infection is the cause of fever after stroke. Most fever (83%) can be attributed to infections or chemical aspiration. Pneumonitis after aspiration is frequently followed by early bacterial infection within the first 48 hours. 2, 8 Massive tissue necrosis in severe stroke can elevate body temperature. 2 Haemorrhage in the brain is another cause of non infective fever. Lysis of blood cells leads to accumulation of haemoglobin degradation products which can provoke fever. 11 Distinguishing between infective and non infective fever following stroke can be difficult at times especially when investigations are negative for an underlying cause. Some studies suggest that timing of fever can indicate origin. Fever resulting from stroke related pathologic process starts with 24 hours of stroke symptoms while fever due to infections emerges at later time periods. This implies that if pre-existing infection is excluded, 5, 12 early fever in patients with stroke can indicate a neurologic origin. 1.4 Treatment of fever The European Stroke Initiative s recommendations for stroke management include treating body temperatures higher than 37.5 ºC, searching for a possible infection and starting tailored antibiotic treatment. Similarly the recommendations of the European Stroke Organisation are to monitor body temperature and begin a search for concurrent infection when temperature is above 37 ºC. Both groups recommend paracetamol to treat fever without specific doses mentioned. 2, 13 The American Stroke Association guidelines recommend antipyretic agents if the body temperature is higher than 38 ºC. The Australian Quality in Acute Stroke Care (QASC) protocol recommends prompt treatment of a temperature 37.5 ºC or greater in the first 72 hours Monitoring and treatment of raised body temperature (see Appendix 1): Record baseline temperature on admission to stroke unit and for the first 72 hours following admission Monitor and record temperature every four hours if patient is febrile. If temperature 37.5 ºC, remove blankets and any heaters Administer oral paracetamol 1 gm. If patient is not able to swallow safely, administer paracetamol 1 gm via nasogastric tube (NG), per rectum (PR) or intravenously (IV). Continue to monitor and record temperature four hourly If continues to spike temperature ( 37.5 ºC) or initial temperature 38 ºC Page 3 of 6

4 o Inform medical team o Consider sepsis screen Mid Stream Urine sample Chest X-ray Blood tests for inflammatory markers Blood cultures as per infection control and blood culture policy ( o Continue to monitor temperature four hourly Standards All stroke patient have a baseline temperature recorded on admission to stroke unit and then if they are pyrexial continue to record four hourly for the first 72 hours following admission. After this period it should be recorded as per routine observation recording. Monitor and record temperature every four hours for 72 hours from admission if patient has fever ( 37.5ºC) When fever is identified assessment to find the underlying cause of the fever should be made Prompt treatment should be given if an acute stroke patient develops fever. Explanation of terms & Definitions Terms explained in the document. References and Supporting Documents 1. Azzimondi G, Bassein L, Nonino F et al. Fever in acute stroke worsens prognosis; a prospective study. Stroke 1995; 26: Wrotek SE, Kozak WE, Hess DC et al. Treatment of fever after stroke: conflicting evidence. Pharmacotherapy 2011; 31 : Hajat C, Hjat S, Sharma P. Effects of post stroke pyrexia on stroke outcome. a meta-analysis of studies in patients. Stroke 2003;31: Greer DM, Funk SE, Reaven NL et al. Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive metaanalysis. Stroke 2008;39: Castillo J, Davalos A, Marraget J, Noya M. Timing for fever related brain damage in acute ischemic stroke. Stroke 1998;29: Karaszewski B, Thomas R, Dennis MS, Wardlaw JM. Temporal profile of body temperature in acute ischemic stroke: relation to stroke severity and outcome. BMC Neurology 2012;12: Jauch EC, Saver JL, Adam HP et al. Guidelines for the early management of patients with acute ischemic stroke: a guidance for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44: Page 4 of 6

5 8. Grau AJ, Buggle F, Schnitzler P et al. Fever and infection early after ischemic stroke. J Neurol Sci 1999;171: Millan M, Grau L, Castellenos M et al. Body temperature and response to thrombolytic therapy in acute ischemic stroke. Eur J Neurol 2008;15: Ernon L, Schrooten M, Thijs V. Body temperature and outcome after stroke thrombolysis. Acta Neurol Scand 2006; 114: Wu J, Hua Y, Keep RF et al. Oxidative brain injury from extravasated erythrocytes after intracerebral haemorrhage. Brain Res 2002;953: Boysen G, Christansen H. Stroke severity determines body temperature in acute stroke. Stroke 2001;32: Leys D, Ringelstam EB, Kaste M et al. for the European Stroke Initiative Executive committee. The main components of stroke unit care: results of a European expert survey. Cerebrovas Dis 2007;23: Middleton S, Mcelduff P, Ward J et al. Implementation of evidence based treatment protocols to manage fever, hyperglycemia and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011;12: Roles and responsibilities Acute Stroke Unit Ward managers and Consultants; to ensure all medical and trained nursing staff are familiar with, and comply with this policy, in accordance with agreed competencies set-out for nursing and medical staff. Page 5 of 6

6 Appendix 1: Protocol for monitoring and treating Fever in Acute Stroke Page 6 of 6