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ntensive and Critical Care Nursing (2007) 23, 91—96

RIGINAL ARTICLE

ntensive care unit management of feverollowing traumatic brain injury

ilaire J. Thompsona,∗, Catherine J. Kirknessa, Pamela H. Mitchell b

Biobehavioral Nursing and Health Systems, The University of Washington, United StatesSchool of Nursing, University of Washington, United States

Accepted 15 November 2006

KEYWORDSHead injury;Hyperthermia;Normothermia;Clinical decision making;Evidence-based practice

Summary Fever, in the presence of traumatic brain injury (TBI), is associated withworsened neurologic outcomes. Studies prior to the publication of managementguidelines revealed an undertreatment of fever in patients with neurologic insults.Presently the adult TBI guidelines state that maintenance of normothermia shouldbe a standard of care therefore improvement in management of fever in thesepatients would be expected. The specific aims of the study were to: (1) determinethe 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 inmanaging fever; (3) ascertain the rate of adherence with published normothermiaguidelines. Medical record review of available hospital records was conductedon patients admitted to a level I trauma center following severe TBI (N = 108)from the parent study. Temperature data was abstracted and contemporaneousnursing documentation was examined for evidence of intervention for fever andadherence with published standards. Data analyses were performed that includeddescriptive statistics. Seventy-nine percent of TBI patients (85/108) had at leastone recorded fever event while in the ICU. However in only 31% of events did thepatient receive any documented intervention by nursing staff for the elevatedtemperature. The most frequently documented intervention was pharmacologic(358/1166 elevations). Other nursing actions (e.g. use of fan) accounted for aminority (<1%) of nursing interventions documented. Patients were more likely tohave a high temperature that exceeded 40 ◦C (13%) than a temperature that wasnormothermic (5%). There continues to be an under treatment of fever in patientswith TBI by critical care nurses despite our knowledge of its negative effects onoutcomes. There remains a gap in translation between patient outcomes research

and bedside practice that needs to be overcome, thus research efforts need to nowfocus on understanding nurses’ decision-making processes and the best methods offever reduction in patients with TBI.© 2006 Elsevier Ltd. All rights reserved.

∗ Corresponding author at: Biobehavioral Nursing and Health Systems, The University of Washington, Box 357266, Seattle,A 98195-7266, United States. Tel.: +1 206 616 5641; fax: +1 206 543 4771.

E-mail address: hilairet@u.washington.edu (H.J. Thompson).

964-3397/$ — see front matter © 2006 Elsevier Ltd. All rights reserved.oi:10.1016/j.iccn.2006.11.005

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Introduction

Fever is an adaptive response of the body to aperceived threat that often does not require inter-vention and for which intervention may even beperceived as counterproductive (Holtzclaw, 2002).However in certain patient populations, tempera-ture elevations may be extremely detrimental andintervention is necessary. One such population ispatients with traumatic brain injury (TBI) where thepresence of fever in the acute phase is associatedwith worse outcomes for patients including longerintensive care unit (ICU) stays, increased intracra-nial pressure, lower Glasgow Coma Scale scores,and poorer functional status (Diringer et al., 2004;Jiang et al., 2002; Natale et al., 2000; Stocchettiet al., 2002). In the presence of TBI, fever maybe associated with increased excitatory aminoacid release, increased vasogenic edema, increasedintracranial pressure, and increased metabolicexpenditure, ultimately resulting in increased neu-ronal loss (for review see Thompson et al., 2003b).Fever in the TBI patient may result from a num-ber of sources including infection, drug reactions,deep vein thrombosis, or be central nervous system-mediated as a result of the injury (Thompson et al.,2003a). A recent study reported that more than 80%of critically ill TBI patients experience brain tem-peratures over 38 ◦C in the first 3 days followinginjury (Childs et al., 2005).

Even when a protocol is in place, the bed-side nurse is often the primary clinical decisionmaker regarding interventions to instigate for fever(Kilpatrick et al., 2000; O’Donnell et al., 1997),as he/she must determine whether or not to fol-low said protocol. A number of studies conductedprior to the publication of management guide-lines revealed an under treatment of fever inpatients with neurologic insults (Albrecht et al.,1998; Kilpatrick et al., 2000). One study foundthat fourteen percent of neurologically vulnerablefebrile patients did not receive any interventionand some patients received only non-pharmacologicintervention, despite the presence of a manage-ment protocol specifying a first-tier pharmacologictherapy (Kilpatrick et al., 2000). In another study,only 7% of closed head injury patients receivedantipyretic medications in doses appropriate totreat fever (Albrecht et al., 1998). A third studyshowed that only 59% of patients experiencing feverwere treated appropriately by nurses on a mixedacute care unit (Grossman et al., 1995).

Initially published in 1996, the TBI man-agement guidelines state that maintenance ofnormothermia should be a standard of care (BrainTrauma Foundation/American Association of

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H.J. Thompson et al.

eurologic Surgeons, 1996; Brain Traumaoundation/American Association of Neurologicurgeons, 2000; Society of Critical Careedicine/World Federation of Pediatric Intensivend Critical Care Societies, 2003); thus improve-ent in achieving normothermia in these patientsould be an expected outcome since the publica-

ion of the guidelines. Control of body temperatureas also been recognized as an important compo-ent of care in the United Kingdom (Johnston etl., 2006).

Therefore the aims of this study were:

1) To determine the incidence of fever in a popu-lation of critically ill patients with TBI.

2) To describe what interventions were recordedby ICU nurses in the management of fever.

3) To ascertain the rate of adherence with pub-lished normothermia guidelines.

ethods

etrospective medical record review of availableospital records was conducted on patients admit-ed over a 2-year period (2000—2002) to a leveltrauma center following a primary diagnosis of

evere TBI (n = 108) enrolled in a parent study.he study was approved by the University’s Institu-ional Review Board under the goals of the parenttudy for which subjects gave informed consent.he goal of the parent study was to examinehe impact of a continuous bedside system oferebral perfusion pressure feedback monitoringn nursing management and its relationship toatient outcomes. For each subject, temperatureata recorded while in the ICU was abstractedrom the electronic medical record for the firsteek post-injury. Data abstracted from the parentata set included demographic data (age, gen-er, race/ethnicity), injury severity (Glasgow Comacale (Teasdale and Jennett, 1974), Injury Sever-ty Score (Baker and O’Neill, 1976)), clinical injuryharacteristics and mechanism of injury. Contem-oraneous nursing documentation was examined inhe medical record using the flowsheet, medicationdministration record, and nursing notes for evi-ence of intervention for fever. Fever was defineds a temperature greater or equal to 38.5 ◦C (eitherympanic or core) as this is the temperature spec-fied within institution-specific protocols. In thisetting, the written ‘‘fever protocol’’ for all ICU

atients consists of assessment of temperature atminimum of every 4 h, orders for administration

f acetaminophen 650 mg every 4 h if the temper-ture is 38.5 ◦C or higher, and reassessment of the

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Table 2 Documented nursing interventions for tem-perature elevations ≥38.5 ◦C by ICU nurses in patientswith traumatic brain injury

Documentedintervention

Type Frequency

None n/a 804

Pharmacologic Acetaminophen 354Ibuprofen 4Total 358

Non-Pharmacologic Fan 2

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ever management

emperature within 2 h after any intervention forlevated temperature. Any additional nursing inter-entions are left to the discretion of the individualurse. Normothermia was defined as a temperaturef 37 ◦C (Hinkle, 2004). At the time of the reviewhere was no specific protocol for fever manage-ent of TBI patients.

esults

atient demographics are presented in Table 1.otor vehicle crashes (48%) and falls (21%) were

he primary mechanism of injury for this pop-lation which is consistent with TBI nationally.eventy-nine percent (85/108) of TBI patients hadt least one recorded fever event while in theCU. The mean maximal temperature of this cohortf critically ill TBI patients was 39.0 ◦C (range7.3—41.8 ◦C). Patients were more likely to have aigh temperature that exceeded 40 ◦C (13%) thantemperature that was normothermic (5%). Theean number of febrile episodes during the firsteek while in the ICU was 4.4 per patient (range—18). However for only 31% of the recorded tem-erature elevations did the patient receive anyocumented intervention for fever by nursing staff.

lthough we consistently found documentationithin the nursing notes that the plan of care was

o ‘‘follow fever protocol’’, this was not actuallymplemented in the majority of cases. Interest-

Table 1 Demographic and clinical characteristics ofsample (N = 108)

Variable

Mean age (S.D.) 38 (19)Mean glasgow coma scale-post

resuscitation (GCS-PR) (S.D.)7.25 (3.1)

Mean injury severity scale (S.D.) 24.9 (9.3)Gender (% male) 78.7

Race/ethnicity (%)Caucasian, non-hispanic 80.6Hispanic/Latino 6.5Black 3.7Asian/Pacific Islander 2.8Native American 2.8Other 3.7

Traumatic brain injury characteristics (% yes)Subdural hematoma 40.7Epidural hematoma 24.1Intracranial hemorrhage 5.6Intraventricular hemorrhage 30.6Subarachnoid hemorrhage 59.3Skull fracture 30.6

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ngly, 20% of acetaminophen doses (91/445) wereiven at temperatures less than 38.5 ◦C. Per docu-ent analysis, delay in implementing the treatmentrotocol occurred in 57.7% of febrile episodes.he most frequently documented intervention washarmacologic (358/1166 elevations) (See Table 2).ther nursing actions (e.g. use of fan) accounted

or a minority (<1%) of nursing interventions doc-mented (Table 2). In 20% of cases, patients wereeceiving regularly ordered medications that couldave altered temperature, including beta-blockers,teroids, levothyroxin, and aspirin.

iscussion

ursing documentation regarding accompanyingigns and symptoms of fever was very limited;herefore, it was difficult to ascertain what role, ifny, these signs and symptoms played in the deci-ion to treat fever. Limitations of this study includehe retrospective nature of the study. It is possi-le that nurses performed interventions for patientemperature elevations that were not documentedn the medical record. Within the nursing notesn all patients, the investigator consistently foundocumentation to follow the institution protocol forever management; however this did not occur. Twoain issues are identified from this study regard-

ng treatment of fever in TBI patients in the ICU:1) there appears to be a lack of intervention byursing for patients with fever and (2) in the major-ty of cases there was a delay in treatment beforentervention was initiated. As this was a retrospec-ive study of the patient medical record, we did notave access to nursing staff data, however, it would

e of particular interest to note if staff variablesuch as time since orientation, years in nursing orducation level correlated with adherence to thenstitution protocol.

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Of particular concern, there was not theexpected improvement of nursing managementof fever following publishing of normothermiaguidelines and additional studies demonstratingdetrimental effects of fever on outcomes afterTBI. The TBI management guidelines are not onlycovered in handouts and discussion at nursing ori-entation, but have been widely discussed in bothmedical and nursing literature, and at neuroscienceand critical care nursing conferences both locallyand nationally, thus nurses would have had expo-sure to these guidelines. On-line access to nursingand medical journals is available throughout theinstitution, and off-campus library access is pro-vided to employees as well. Amount of exposureof individual nurses to this information may havevaried, but due to the study design, we are unableto determine its influence. As such, it is an area forfurther study.

While the overall incidence of fever in this pop-ulation of TBI patients was slightly higher thanpreviously reported (79%), the rate of interventionwas substantially lower (31% versus 86% (Kilpatricket al., 2000)). Pharmacologic therapy was the mostfrequently documented intervention used in thepresent report, which is consistent with previousstudies (Grossman et al., 1995; Johnston et al.,2006; Kilpatrick et al., 2000). Acetaminophen wasthe most frequently used antipyretic agent, withibuprofen being used much less frequently. Judi-cious use of these agents within this population mayhave occurred due to potential for toxicity in theformer and increased bleeding potential of the lat-ter (Holtzclaw, 2002). Other possibilities for choiceinclude usual practices within the environment.

Physical cooling measures (fan) in conjunctionwith pharmacologic therapy were documented inonly two cases. Independent nursing activitiesavailable for use in this setting included ice packs,tepid bathing, and cooling blankets; however doc-umentation of these activities were not foundwithin the medical records reviewed. These inter-ventions have been reported to be ineffective inthe majority of TBI patients (Stocchetti et al.,2002; see review Thompson et al., 2003b), and mayactually be contraindicated as they could induceshivering (Holtzclaw, 2002), increasing metabolicrate and decreasing cerebral oxygenation. How-ever, research in this area has been hampered bymethodological and conceptual characteristics ofthe studies such as definitions of fever, which varygreatly, mixed populations, along with low sam-

ple sizes. Thus further systematic evaluation of theefficacy and side effects of physical cooling mea-sures in TBI patients is warranted. Additionally, thisinstitution did not have a specific protocol in place

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H.J. Thompson et al.

or management of fever in TBI patients. The lackf a systematic approach to this patient manage-ent problem is not uncommon (Johnston et al.,

006; Thompson, Kirkness et al., 2007) and may beeflected in our results.

The major management goal following TBI isrevention of further brain injury from secondarynsults (March et al., 2004), such as fever, whichre often preventable or treatable. As the pres-nce of fever in the patient with a TBI is likelyo have a synergistic effect (Thompson et al.,003b), rather than just an additive effect, thisnsult can be particularly devastating to brain tissuend thus, patient outcomes (March et al., 2004).s a result, nursing management of fever shoulde a priority for TBI patients, as ‘‘time equalsrain’’ in managing secondary insults. As this sam-le represents practice at a single institution, thesendings may not be generalizable to other set-ings. However our confidence in the validity ofhe findings is increased by similar results duringhe primary investigator’s pilot work completed innother region of the US.

The institutional protocol that formed the basisor this analysis defined a fever requiring inter-ention as a temperature equal or greater than8.5 ◦C; however, this temperature is higher thanhat proposed for treatment in the literature.he American Association of Neuroscience Nursesore Curriculum defines pyrexia as a temperaturereater than 38 ◦C (March et al., 2004) and Marion2001) defined hyperthermia in the neuroscienceCU as 37.5 ◦C and recommended that treatment benitiated when temperatures exceed this threshold.n the present study, acetaminophen was availableer orders for pain or temperatures ≥38.5 ◦C, andome nurses administered acetaminophen at tem-eratures between 38 and 38.4 ◦C, although it wasnclear from the documentation the exact rea-on for administration as no signs or symptoms ofain were being exhibited by the patient per doc-mentation either. It is possible, therefore, thaturses were noting the rise in patient temper-ture and administering acetaminophen early inrder to prevent further potential neuronal damageThompson, Webb, Mitchell, 2007). Thus, insti-utional protocols may hamper nurses’ ability tomplement evidence-based practice, but selectedurses may be using ‘‘loopholes’’ within the sys-em in an attempt to circumvent these barriers.here may be other possible explanations for earlydministration that could not be captured in the

resent record-based study that would be impor-ant to explore. As there was not a standardizedrotocol for fever management in TBI patients, thisay have been a useful guide to improve practice.

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ever management

ormothermia is the standard of care for tempera-ure management in severely injured TBI patients,ut the guidelines do not provide specific directionBrain Trauma Foundation/American Association ofeurologic Surgeons, 2000). As yet, appropriateanagement of fever (maintenance of normother-ia) for TBI patients has not been well established

nd further research in this area is clearly needed.Due the retrospective nature of the study, the

ite of temperature measurement in this settingncluded core (pulmonary artery) and tympanic andikely underestimated the degree of fever in theseatients. The temperature of the brain is higherhan core temperature and this temperature gra-ient is larger during periods of pyrexia (Rossi etl., 2001). Future studies of temperature in TBIatients need to incorporate new technology, suchs brain temperature monitoring in centers wheret is available and appropriate to do so. In patientsor whom invasive brain monitoring is not an option,he nurse must be cognizant that the differenceetween pulmonary artery and brain temperatureeasurements is 0.4 ◦C at the peak of fever (Rossi et

l., 2001) and the differences between rectal (Tre)r bladder (Tbl) temperatures and brain (Tbr) tem-eratures are generally larger (Tre—Tbr 0.1—2.0 ◦C;bl—Tbr 0.3—1.9 ◦C) (Henker et al., 1998). A recenttudy by Johnston et al. (2006) noted that the mostommon site of temperature monitoring in neuro-ritical care units in the United Kingdom and Irelandas the groin and axilla, a site not consideredppropriate for assessment of fever in critically illdult patients (O’Grady et al., 1998).

onclusions

here continues to be a high incidence and annder treatment of fever in patients with TBIy nurses despite our knowledge of its negativeffects on outcomes. These findings reveal nomprovement in practice over 10 years despitencreased attention to this issue and publicationf guidelines recommending maintenance of nor-othermia. There remains a gap in translationetween patient outcomes research and bedsideursing practice that needs to be overcome. Asedside nurses make many independent decisionsn this regard, research efforts need to now focusn understanding their decision-making processesnd determining the best methods of fever reduc-

ion in patients with TBI. Further study of bothharmacologic and non-pharmacologic methods forever and hyperthermia reduction in TBI patients isarranted given the dearth of available evidence

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nd plethora of remaining questions, including ifdequate treatment ultimately improves patientutcomes. Institutional protocols may provide bar-iers to implementation of evidence-based practicend need to be examined carefully. Thus, there isneed for a definition of fever from the critical

are nurses’ perspective, an understanding of theirecisions regarding fever management in this pop-lation and clearer understanding of the barrierso evidence-based practice. It is hoped that armedith this knowledge, we can develop and testvidence-based protocols for fever management inBI patients that are both valuable to and fully-

mplemented by critical care nurses. Insomuch asyperthermia is associated with worse outcomes,e should then be able to demonstrate that reduc-

ng pyrexia actually and measurably improves TBIatient outcomes.

cknowledgements

his publication was made possible by Grantumbers R01NR004901-05, T32NR07106 from theational Institute of Nursing Research (NINR), andK12 RR023265-03 from the National Center for

esearch Resources (NCRR), components of theational Institutes of Health (NIH) and a Fellow-hip from the John A. Hartford Building Geriatriccademic Nursing Capacity Program (JAHF). Its con-ents are solely the responsibility of the authorsnd do not necessarily represent the official viewf NINR, NCRR, NIH or JAHF. This paper was pre-ented at the 39th Annual Communicating Nursingesearch Conference/20th Annual WIN Assembly,ponsored by the Western Institute of Nursing.

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