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Fever in the intensive care unit

Authors: Graeme MacLaren, MBBS, MSc, FRACP, FCICM, Denis Spelman, MBBS, FRACP, FRCPA, MPH
Section Editor: Scott Manaker, MD, PhD
Deputy Editor: Geraldine Finlay, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2019. | This topic last updated: Jul 16, 2018.

INTRODUCTION

Fever is a common abnormality in the intensive care unit (ICU), which prompts important
diagnostic and treatment decisions. The definition, differential diagnosis, diagnostic evaluation, and
management of fever in the ICU are reviewed here. The pathophysiology of fever is discussed
separately. (See "Pathophysiology and treatment of fever in adults".)

DEFINITION

Normal body temperature is approximately 37ºC (98.6ºF), although this varies with the time of day
and the method of measurement used. The definition of fever is arbitrary; as the temperature that
defines fever is lowered, its sensitivity increases and its specificity decreases. A joint task force
from the American College of Critical Care Medicine and the Infectious Diseases Society of
America defined fever as a body temperature of 38.3ºC (101ºF) or higher [1]. We adhere to this
definition in this review because it is widely accepted. It is reasonable to use a lower temperature
to define fever in immunocompromised patients.

TEMPERATURE MEASUREMENT

Conventional means of measuring temperature in the ICU include core measurements

(intravascular, intravesicular [ie, bladder], and rectal), and peripheral measurements (, oral and
axillary), the former being more accurate [1-7]. The gold standard is the thermistor on a pulmonary
artery catheter, although these are used infrequently and may give unreliable temperature readings
if the catheter is used to rapidly administer volume [1]. Regardless of which method is chosen, the
same method and site of measurement should be used repeatedly to facilitate the trending of serial
measurements. Alternative methods, such as axillary, temporal artery, tympanic, and chemical dot
monitors, should not be used because they are inaccurate during critical illness [1,6,8-13]. Despite
this inaccuracy, these methods are still in widespread use in many ICUs around the world [14].

EPIDEMIOLOGY

Fever complicates up to 70 percent of all intensive care unit (ICU) admissions and is often due to
an infection or another serious condition [15,16]. In one observational study of 24,204 adult ICU
admissions, fever ≥39.5ºC (103ºF) was associated with an increase in mortality (20 versus 12
percent) [16]. Fever has also been associated with an increased length of stay, increased cost of
care, and poorer outcomes in patients with traumatic head injury, subarachnoid hemorrhage, or
pancreatitis [15,17-23]. The same associations probably exist with other conditions that have not
been studied. Fever may prompt unnecessary investigations and lead to inappropriate antibiotic
use.

The importance of fever as a pathophysiological process is poorly understood. Although regarded

as a sign of clinical deterioration, fever can be an appropriate adaptive response to infection. For
example, one study showed that elevated peak temperatures in ICU patients with infections were
associated with decreased hospital mortality [24]. Compared to patients with peak temperatures
36.5 to 36.9ºC, patients with peak temperatures 39 to 39.4oC had significantly lower hospital
mortality (OR, 0.56; 95% CI 0.48-0.66). However, in non-infectious cases of fever, mortality
increased with rising temperature (OR, 2.07; 95% CI 1.68-2.55).

DIFFERENTIAL DIAGNOSIS

Sources of fever in the ICU may be infectious (table 1) or noninfectious (table 2). The relative
frequency of infectious and noninfectious fevers varies according to the population being studied
and the definition of infection that is used [15]. Distinguishing between infectious and noninfectious
fevers is challenging, but the magnitude of the fever may be helpful [8,25,26]:
 ● Fevers between 38.3ºC (101ºF) and 38.8ºC (101.8ºF) may be infectious or noninfectious. The
differential diagnosis is longest in this range; fortunately, most noninfectious sources of fever
can be excluded by a detailed history and physical examination.

● Fevers between 38.9 (102ºF) and 41ºC (105.8ºF) can be assumed to be infectious.

● Fevers ≥41.1ºC (106ºF) are usually noninfectious. Examples include drug fever, transfusion
reactions, adrenal insufficiency, thyroid storm, neuroleptic malignant syndrome, heat stroke,
and malignant hyperthermia. (See "Severe nonexertional hyperthermia (classic heat stroke) in
adults" and "Neuroleptic malignant syndrome" and "Malignant hyperthermia: Clinical diagnosis
and management of acute crisis".)

Infectious causes — There are many infectious sources of fever (table 1). The most common in
the ICU include ventilator-associated pneumonia, intravascular catheter-related infections, surgical
site infections, catheter-related urinary tract infections, and bacteremia from these and other
sources [8].

● Ventilator-associated pneumonia (VAP) – VAP is usually suspected when a patient who has
been receiving mechanical ventilation for more than 48 hours develops a fever that is
accompanied by a new or progressive pulmonary infiltrate, leukocytosis, and purulent
tracheobronchial secretions. These signs may be accompanied by an increased respiratory
rate, increased minute volume, decreased tidal volume, decreased oxygenation, or the need
for more ventilatory support or inspired oxygen. (See "Clinical presentation and diagnostic
evaluation of ventilator-associated pneumonia".)

● Intravascular catheter-related infection – Intravascular catheter-related infections commonly

present as a fever without localizing symptoms or signs. Alternative presentations include
cellulitis at the insertion site, purulent drainage from the insertion site, incidentally detected
bacteremia, sepsis (fever, tachycardia, tachypnea, leukocytosis), severe sepsis (sepsis plus
organ dysfunction), or septic shock (eg, severe sepsis plus shock). Rarely, a patient may
present with suppurative thrombophlebitis, endocarditis, or septic abscesses. Arterial
catheters have comparable infection rates to central venous catheters [27]. (See "Arterial
catheterization techniques for invasive monitoring", section on 'Infection' and "Intravascular
catheter infection: Epidemiology, pathogenesis, and microbiology", section on 'Epidemiology'
and "Complications of central venous catheters and their prevention", section on 'Catheter-
related infection'.)
 ● Surgical site infection – A surgical site infection should be considered in any postoperative
patient with a fever. Most surgical site infections occur one to four weeks after surgery,
although they may occasionally occur during the first postoperative week or more than a
month after surgery. The clinical manifestations and likely pathogen depend upon the surgical
site. (See "Postoperative fever".)

● Catheter-related urinary tract infections – The incidence of catheter-related urinary tract

infections has probably been overestimated because many studies did not distinguish
asymptomatic bacteriuria from a genuine urinary tract infection [28]. Catheter-related urinary
tract infections may present as a fever without localizing symptoms or signs. They may also
present with symptoms and signs of cystitis (fever, suprapubic pain, hematuria, pyuria),
pyelonephritis (fever, chills, flank pain, costovertebral angle tenderness, nausea, and
vomiting), or urosepsis. (See "Catheter-associated urinary tract infection in adults".)

● Bacteremia – Bacteremia may be secondary to any of the above infections, as well as many
others. Fever may be the only sign of bacteremia, although it can rapidly progress to sepsis,
severe sepsis, or septic shock. Transfusion-transmitted bacterial infection is a rare, but life-
threatening, complication of hospital care that does not always occur during transfusion. (See
"Transfusion-transmitted bacterial infection".)

● Sinusitis – Sinusitis occurs in eight percent of all ICU patients [29], but is more common
among mechanically ventilated patients who have sinus opacification on imaging [30]. It most
typically manifests as fever without localizing symptoms and signs, since most patients are
mechanically ventilated and unable to communicate the presence of a headache and sinus
tenderness. Purulent nasal drainage is occasionally present. (See "Complications of the
endotracheal tube following initial placement: Prevention and management in adult intensive
care unit patients", section on 'Sinusitis'.)

All of the infections described above have the potential to progress to sepsis, severe sepsis, and
septic shock. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation,
diagnosis, and prognosis", section on 'Definitions'.)

Noninfectious causes — There are many noninfectious sources of fever in the ICU (table 2). In
most cases, the fever is not the only sign and, therefore, the cause can usually be identified with a
detailed history and physical examination [8]. The noninfectious causes of fever may be
conceptualized as those that are accompanied by distributive shock and those that are not. (See
"Definition, classification, etiology, and pathophysiology of shock in adults", section on
'Distributive'.)

Noninfectious fever without shock — Noninfectious causes of fever that are usually not
accompanied by shock include transfusion reactions, drug fever, certain intra-abdominal conditions
(eg, acalculous cholecystitis, mesenteric ischemia, pancreatitis), and thromboembolic disease.

● Non-hemolytic transfusion reaction – Fever is the most common sign of a non-hemolytic

transfusion reaction. It generally occurs within one to six hours after the initiation of a
transfusion of red blood cells or platelets and may be accompanied by chills and mild
dyspnea. Non-hemolytic reactions are benign with no lasting sequelae, but can be
uncomfortable. (See "Immunologic transfusion reactions", section on 'Febrile nonhemolytic
reactions'.)

● Drug fever – Drug fever is a diagnostic challenge. It can occur several days after the initiation
of the drug, can take several days to subside after cessation of the drug, and can produce
high fevers (ie, >38.9ºC [102ºF]) without other signs. The true incidence is unknown. It is
essentially a diagnosis of exclusion unless other signs of hypersensitivity (eg, rash) are
present. (See "Drug fever".)

● Acalculous cholecystitis – Acalculous cholecystitis is associated with a variety of clinical

conditions (table 3). It generally presents with fever, leukocytosis, and vague abdominal
discomfort. A right upper quadrant mass may be palpable. An insidious presentation is
associated with gallbladder gangrene and perforation. Acalculous cholecystitis may have a
mortality rate as high as 30 to 40 percent, even with treatment [31-33]. (See "Acalculous
cholecystitis: Clinical manifestations, diagnosis, and management".)

● Mesenteric ischemia – Fever is a late sign in both arterial and venous mesenteric ischemia. It
usually signifies bowel infarction, by which time other signs have usually developed such as
abdominal tenderness, hematochezia, or lactic acidosis [34,35]. The abdominal tenderness is
typically periumbilical, may be severe and out of proportion to the physical exam findings, and
may be accompanied by nausea and vomiting. (See "Overview of intestinal ischemia in
adults".)

● Acute pancreatitis – Acute pancreatitis is typically accompanied by abdominal pain,

tenderness, and distension, as well as nausea and vomiting. Abdominal pain due to
pancreatitis is typically improved by leaning forward. (See "Clinical manifestations and
diagnosis of acute pancreatitis".)
 ● Deep vein thrombosis (DVT) – DVT is common among ICU patients, with an incidence that
has been estimated to be 12 to 33 percent depending upon the patient populations studied
and type of prophylaxis [36,37]. However, DVT is a rare cause of fever. More common
manifestations of DVT include asymmetric extremity edema, pain, or erythema. (See "Clinical
presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of
the lower extremity".)

● Pulmonary embolism (PE) – The Prospective Investigation of Pulmonary Embolism Diagnosis

(PIOPED) study about PE in hospitalized patients (not necessarily ICU patients) detected
fever with the following frequency [38,39] (see "Overview of acute pulmonary embolism in
adults"):

• 14 percent when defined as >37.8ºC (>100ºF)

• 6 percent when defined as >38.3ºC (>101ºF)

• 1.5 percent when defined as >38.9ºC (>102ºF)

Noninfectious fever with shock — Noninfectious causes of fever that are frequently
accompanied by shock include adrenal crisis (ie, acute adrenal insufficiency) [40,41], thyroid storm
[42], and an acute hemolytic transfusion reaction. The fever is often >38.9ºC (>102ºF) and the
shock is distributive, which is characterized by hypotension, warm extremities, a hyperdynamic
precordium (tachycardia, prominent heart sounds), oliguria, altered mental status, and metabolic
acidosis. (See "Definition, classification, etiology, and pathophysiology of shock in adults", section
on 'Distributive'.)

● Adrenal crisis – An adrenal crisis usually occurs in patients with previously undiagnosed
adrenal insufficiency who are subjected to a serious infection or other major stress, patients
with known adrenal insufficiency who do not take more glucocorticoid during a serious
infection or other major stress, patients with acute bilateral adrenal infarction or hemorrhage,
or patients whose chronic glucocorticoid therapy is abruptly withdrawn. Distributive shock is
the predominant manifestation of an adrenal crisis, but fever, nausea, vomiting, abdominal
pain, weakness, fatigue, lethargy, hypoglycemia, confusion, or coma may also be present.
(See "Clinical manifestations of adrenal insufficiency in adults", section on 'Adrenal crisis'.)

● Thyroid storm – Thyroid storm refers to severe, life-threatening thyrotoxicosis. It is often

precipitated by an acute stressor, such as surgery, infection, trauma, or an acute iodine load.
 Clinical manifestations may include severe fever (>40ºC [>104ºF]), distributive shock, severe
tachycardia (>140 beat/min), congestive heart failure, nausea, vomiting, diarrhea, agitation,
delirium, psychosis, stupor, and coma. (See "Thyroid storm".)

● Acute hemolytic transfusion reaction – An acute hemolytic transfusion reaction is a medical

emergency that results from the rapid destruction of donor red blood cells by recipient
antibodies. It is usually due to ABO incompatibility. Some acquired alloantibodies are
occasionally implicated. Common clinical manifestations include fever, chills, distributive
shock, disseminated intravascular coagulation, and acute kidney injury. Flank pain, red or
brown urine, and bleeding occur less often. (See "Immunologic transfusion reactions".)

DIAGNOSTIC APPROACH

A thorough review of the medical history and a full physical examination should be performed
whenever a patient develops an unexplained fever in the ICU. Blood cultures are the only
mandatory diagnostic tests in patients with a new fever; the rationale is that clinical findings cannot
reliably exclude bacteremia and mortality is high without appropriate treatment [43]. Further
investigation may be indicated depending upon the clinical assessment.

● Sputum – Sputum Gram stain and culture are indicated for febrile patients with any of the
following findings: new sputum production; a change in the color, amount, or thickness of their
sputum; a new or progressive pulmonary infiltrate; an increased respiratory rate; an increased
minute volume; a decreased tidal volume; decreased oxygenation; needing more ventilatory
support; or requiring more inspired oxygen. (See "Clinical presentation and diagnostic
evaluation of ventilator-associated pneumonia" and "Epidemiology, pathogenesis,
microbiology, and diagnosis of hospital-acquired and ventilator-associated pneumonia in
adults".)

● Urine – Urinalysis and urine culture are indicated for febrile patients with a urethral catheter,
urinary obstruction, renal calculi, recent genitourinary surgery or trauma, or neutropenia. (See
"Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults".)

● Chest imaging – A chest radiograph is easily obtainable in the ICU and worthwhile in many
patients with respiratory symptoms or signs. It may detect a new or progressive pulmonary
infiltrate, distinguish pneumonia from tracheobronchitis, or identify a respiratory source of
fever other than pneumonia or tracheobronchitis that would otherwise be missed because it is
 not associated with sputum production. However, chest radiographs are less helpful and,
therefore, should be used more judiciously in patients with known pleural effusions, acute lung
injury, or acute respiratory distress syndrome because such abnormalities may obscure other
findings. Computed tomography (CT) should be reserved for the clarification of abnormal
chest radiographic findings.

● Laboratory studies – Transaminase, bilirubin, alkaline phosphatase, amylase, lipase, and

lactate measurements are indicated for patients with abdominal pain or whose abdominal
exam cannot be reliably assessed due to sedation or coma. Serum sodium, potassium,
glucose, and cortisol levels should be drawn if adrenal insufficiency is possible. Thyroid
stimulating hormone (TSH), T3, and T4 levels should be drawn if thyroid storm is possible.
And, blood should be drawn for measurement of direct antiglobulin test, plasma free
hemoglobin, and haptoglobin, as well as a repeat blood type and cross-match if an acute
hemolytic transfusion reaction is suspected.

Procalcitonin (PCT) and the endotoxin activity assay are adjunctive diagnostic tools for
distinguishing fever due to infection from noninfectious fever [1]. We believe that such assays
should be used as a last resort until the benefits of each are clarified, even though several
professional organizations have endorsed them as reasonable measures. Currently, the body
of evidence for PCT testing is conflicting [44,45] and the body of evidence for the endotoxin
activity assay is scarce [46,47]. C-reactive protein (CRP) has also been studied as a
biomarker for identifying infection, but it appears less promising because it lacks specificity
[48,49], rises later than PCT, doesn’t correlate as well with severity of disease [50], and tends
to be lower among patients with liver disease [51]. Both PCT and CRP predict mortality in ICU
patients [52,53].

● Abdominal imaging – Abdominal imaging is indicated for patients with symptoms or signs of
an intraabdominal process, but for whom the laboratory testing has not identified the cause of
the symptoms or signs. It is also indicated for patients who have a reason to have an
intraabdominal infection (eg, recent abdominal surgery) and no alternative source of the fever
has been identified, even if there are no symptoms or signs of an abdominal process. Finally,
abdominal imaging may be indicated if laboratory testing suggests a possible intra-abdominal
process, but the results are insufficient to identify the exact abnormality. As an example, in a
patient with fever, transaminitis, and hyperbilirubinemia, a right upper quadrant ultrasound
exam may determine whether there is acalculous cholecystitis, choledocholithiasis, or a
primary hepatic condition.
 ● Sinus evaluation – Evaluation for sinusitis is appropriate for mechanically ventilated patients
who have purulent nasal drainage or whose evaluation has otherwise been completely
negative. The evaluation begins with a radiographic evaluation looking for sinus opacification
[54,55]. CT is the preferred modality, but sinus radiographs and sinus ultrasound are
reasonable alternatives. Culture of sinus fluid obtained by endoscopic-guided middle meatal
aspiration is indicated for patients with sinus opacification and no other cause for fever.
Interpretation of the culture results and the role of empiric therapy are discussed separately.
(See "Complications of the endotracheal tube following initial placement: Prevention and
management in adult intensive care unit patients", section on 'Sinusitis'.)

It is important for a clinician to keep several things in mind when investigating a fever. First,
clinicians should remain mindful that critically ill patients often have more than one infection.
Second, evidence of infection and inflammation (eg, leukocytosis, pus) may be altered if the
patient is immunosuppressed. Finally, medical technologies (eg, continuous renal replacement
therapy, extracorporeal membrane oxygenation [ECMO]) can modify or mask a fever.

MANAGEMENT

Treatment of fever should be directed at its underlying cause, which is discussed in separate topic
reviews.

Perhaps the two most common clinical decisions that need to be made when a patient develops a
new fever in the intensive care unit (ICU) are whether or not empiric antibiotic therapy is warranted
and whether or not the patient’s intravascular catheters need to be removed:

● The effects of empiric antibiotics initiated for fever in a heterogeneous population of critically ill
patients have not been studied. However, there is evidence in patients with suspected severe
sepsis or septic shock that a shorter time to appropriate antibiotic administration is associated
with lower mortality [43,56]. There is also evidence that appropriate antibiotic therapy
dramatically reduces mortality among patients with neutropenia and fever [57]. Infection of
ventricular assist devices can be catastrophic, as device removal is often not possible without
concurrent transplantation [58]. On the basis of this evidence, we recommend that patients in
the ICU who develop a new fever be treated with empiric antibiotics if they are deteriorating, in
shock, neutropenic, or have a ventricular assist device. We also believe the empiric therapy is
warranted for patients who have a temperature ≥38.9ºC (≥102ºF) because most fevers in this
range will be infectious. For most other patients, further diagnostic work-up with ongoing
 clinical assessment prior to the initiation of antibiotic therapy is reasonable.

● Whether or not to routinely remove an intravascular catheter (or other device) in a febrile
patient is a controversial and evolving issue. Generally speaking, considerations in the
decision include the severity of illness, age of the catheter, and probability that the catheter is
the source of fever. The management of a catheter in the setting of possible intravascular
catheter-related infections is discussed separately. (See "Intravascular catheter-related
infection: Treatment", section on 'Catheter management'.)

Fever itself does not generally require treatment with antipyretics (eg, acetaminophen) or external
cooling (ie, cooling blanket, ice packs) [59-61], and some evidence suggests that the use of
antipyretics may worsen outcomes in sepsis [62]. Exceptions to this are when the fever may be
detrimental to the outcome (eg, increased intracranial pressure) or is ≥41ºC (≥105.8ºF) [63,64]. If
body temperature exceeds the “critical thermal maximum”, which is thought to be between 41.6ºC
and 42ºC, life-threatening complications can ensue (eg, rhabdomyolysis) [65]. The management of
severe hyperthermia, including external cooling, is discussed separately. (See "Severe
nonexertional hyperthermia (classic heat stroke) in adults".)

There are conflicting data about the use of antipyretics and cooling in ICU patients with fever:

● In one study of 1425 patients, administration of non-steroidal anti-inflammatory agents

(NSAIDs) or acetaminophen for fever control in septic patients was associated with increased
28-day mortality (odds ratio: 2.61 NSAIDs, 2.05 acetaminophen) [62].

● A separate study of 15,818 ICU patients showed that those who received acetaminophen had
lower in-hospital mortality than those who did not (10 versus 20 percent) [66]. However,
methodologic flaws in this study may have influenced the results.

● In a randomized controlled trial of external cooling applied to patients in septic shock, a

reduction in vasopressor requirements and 14-day mortality was seen in the treatment group
(19 versus 34 percent), although this difference in outcome was not sustained at later follow-
up [67].

● Another randomized study of 698 critically ill patients with fever suspected to be due to
infection reported that compared with placebo, intravenous acetaminophen administered until
resolution of fever, cessation of antibiotics, ICU discharge, or death did not increase the
number of ICU-free days [68]. In addition, mortality was unaffected by acetaminophen,
 although this outcome was inadequately assessed.

Several ongoing randomized controlled trials should help clarify the role of antipyretics and
external cooling in critically ill patients. However, until these data are available, there is no role for
routine pharmacological treatment of fever with antipyretics or external cooling.

If an antipyretic is required, most experts choose acetaminophen rather than NSAIDs. Whether
intravenous or enteral acetaminophen should be used is unknown, although our preference is for
enteral administration, when feasible. Several studies reported that the incidence of hypotension
(systolic blood pressure ≤90 mmHg or ≥20 percent decrease from baseline) was higher after
parenteral acetaminophen compared with enteral administration [69,70].

SUMMARY AND RECOMMENDATIONS

● Normal body temperature is approximately 37ºC (98.6ºF), although this varies with the time of
day and the method of measurement used. We define a fever as a body temperature of
38.3ºC (101ºF) or higher. (See 'Definition' above.)

● Conventional means of measuring temperature in the intensive care unit (ICU) include
intravascular, intravesicular (ie, bladder), rectal, and oral. The gold standard is the thermistor
on a pulmonary artery catheter. Regardless of which method is chosen, the same method and
site of measurement should be used repeatedly to facilitate the trending of serial
measurements. (See 'Temperature measurement' above.)

● Sources of fever in the ICU may be infectious (table 1) or noninfectious (table 2). (See
'Differential diagnosis' above.)

● A review of the medical history and a full physical examination should be performed whenever
a patient develops an unexplained fever in the ICU. Blood cultures are the only mandatory
diagnostic tests in patients with a new fever. Additional investigation is generally needed, but
the exact tests that are indicated depend upon the clinical assessment. (See 'Diagnostic
approach' above.)

● Treatment of fever should be directed at its underlying cause. Perhaps the two most common
clinical decisions that need to be made when a patient develops a new fever in the ICU are
whether empiric antibiotic therapy is warranted and whether the patient’s intravenous
catheters need to be removed (see 'Management' above):
 • For ICU patients with a new fever whose clinical condition is deteriorating, who are in
shock, or who are neutropenic, we recommend the initiation of empiric antibiotic therapy
(Grade 1A).

• For ICU patients with a new fever who have a ventricular assist device, we recommend
the initiation of empiric antibiotic therapy (Grade 1B).

• For ICU patients with a new fever that is ≥38.9ºC (≥102ºF), we suggest the initiation of
empiric antibiotic therapy (Grade 2C).

• For most other ICU patients with a new fever, further diagnostic work-up with ongoing
clinical assessment prior to the initiation of antibiotic therapy is warranted.

• The management of a catheter in the setting of a possible intravascular catheter-related

infection is discussed separately. (See "Intravascular catheter-related infection:
Treatment", section on 'Catheter management'.)

● Fever itself does not generally require treatment with antipyretics (eg, acetaminophen) or
external cooling (ie, cooling blanket, ice packs). Exceptions to this are when the fever is
impairing management (eg, increasing ventilatory requirements), may be detrimental to the
outcome (eg, increased intracranial pressure), or is ≥41ºC (≥105.8ºF). (See 'Management'
above.)

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REFERENCES

1. O'Grady NP, Barie PS, Bartlett JG, et al. Guidelines for evaluation of new fever in critically ill
adult patients: 2008 update from the American College of Critical Care Medicine and the
Infectious Diseases Society of America. Crit Care Med 2008; 36:1330.

2. Fallis WM. Monitoring urinary bladder temperature in the intensive care unit: state of the
science. Am J Crit Care 2002; 11:38.

3. Giuliano KK, Scott SS, Elliot S, Giuliano AJ. Temperature measurement in critically ill orally
intubated adults: a comparison of pulmonary artery core, tympanic, and oral methods. Crit
 Care Med 1999; 27:2188.

4. Schmitz T, Bair N, Falk M, Levine C. A comparison of five methods of temperature

measurement in febrile intensive care patients. Am J Crit Care 1995; 4:286.

5. Klein DG, Mitchell C, Petrinec A, et al. A comparison of pulmonary artery, rectal, and
tympanic membrane temperature measurement in the ICU. Heart Lung 1993; 22:435.

6. Nimah MM, Bshesh K, Callahan JD, Jacobs BR. Infrared tympanic thermometry in
comparison with other temperature measurement techniques in febrile children. Pediatr Crit
Care Med 2006; 7:48.

7. Niven DJ, Gaudet JE, Laupland KB, et al. Accuracy of peripheral thermometers for
estimating temperature: a systematic review and meta-analysis. Ann Intern Med 2015;
163:768.

8. Marik PE. Fever in the ICU. Chest 2000; 117:855.

9. Romano MJ, Fortenberry JD, Autrey E, et al. Infrared tympanic thermometry in the pediatric
intensive care unit. Crit Care Med 1993; 21:1181.

10. Robinson JL, Seal RF, Spady DW, Joffres MR. Comparison of esophageal, rectal, axillary,
bladder, tympanic, and pulmonary artery temperatures in children. J Pediatr 1998; 133:553.

11. Lefrant JY, Muller L, de La Coussaye JE, et al. Temperature measurement in intensive care
patients: comparison of urinary bladder, oesophageal, rectal, axillary, and inguinal methods
versus pulmonary artery core method. Intensive Care Med 2003; 29:414.

12. Hebbar K, Fortenberry JD, Rogers K, et al. Comparison of temporal artery thermometer to
standard temperature measurements in pediatric intensive care unit patients. Pediatr Crit
Care Med 2005; 6:557.

13. Kimberger O, Cohen D, Illievich U, Lenhardt R. Temporal artery versus bladder thermometry
during perioperative and intensive care unit monitoring. Anesth Analg 2007; 105:1042.

14. Niven DJ, Laupland KB, Tabah A, et al. Diagnosis and management of temperature
abnormality in ICUs: a EUROBACT investigators' survey. Crit Care 2013; 17:R289.

15. Circiumaru B, Baldock G, Cohen J. A prospective study of fever in the intensive care unit.
 Intensive Care Med 1999; 25:668.

16. Laupland KB, Shahpori R, Kirkpatrick AW, et al. Occurrence and outcome of fever in critically
ill adults. Crit Care Med 2008; 36:1531.

17. Stocchetti N, Rossi S, Zanier ER, et al. Pyrexia in head-injured patients admitted to intensive
care. Intensive Care Med 2002; 28:1555.

18. Oliveira-Filho J, Ezzeddine MA, Segal AZ, et al. Fever in subarachnoid hemorrhage:
relationship to vasospasm and outcome. Neurology 2001; 56:1299.

19. Commichau C, Scarmeas N, Mayer SA. Risk factors for fever in the neurologic intensive care
unit. Neurology 2003; 60:837.

20. Brisinda G, Maria G, Ferrante A, Civello IM. Evaluation of prognostic factors in patients with
acute pancreatitis. Hepatogastroenterology 1999; 46:1990.

21. Bohidar NP, Garg PK, Khanna S, Tandon RK. Incidence, etiology, and impact of Fever in
patients with acute pancreatitis. Pancreatology 2003; 3:9.

22. Peres Bota D, Lopes Ferreira F, Mélot C, Vincent JL. Body temperature alterations in the
critically ill. Intensive Care Med 2004; 30:811.

23. Reaven NL, Lovett JE, Funk SE. Brain injury and fever: hospital length of stay and cost
outcomes. J Intensive Care Med 2009; 24:131.

24. Young PJ, Saxena M, Beasley R, et al. Early peak temperature and mortality in critically ill
patients with or without infection. Intensive Care Med 2012.

25. Cunha BA. Fever in the critical care unit. Crit Care Clin 1998; 14:1.

26. Cunha BA. Fever in the intensive care unit. Intensive Care Med 1999; 25:648.

27. Lucet JC, Bouadma L, Zahar JR, et al. Infectious risk associated with arterial catheters
compared with central venous catheters. Crit Care Med 2010; 38:1030.

28. Eggimann P, Pittet D. Infection control in the ICU. Chest 2001; 120:2059.

29. George DL, Falk PS, Umberto Meduri G, et al. Nosocomial sinusitis in patients in the medical
intensive care unit: a prospective epidemiological study. Clin Infect Dis 1998; 27:463.
30. Holzapfel L, Chevret S, Madinier G, et al. Influence of long-term oro- or nasotracheal
intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective,
randomized, clinical trial. Crit Care Med 1993; 21:1132.

31. Barie PS, Eachempati SR. Acute acalculous cholecystitis. Curr Gastroenterol Rep 2003;
5:302.

32. Kalliafas S, Ziegler DW, Flancbaum L, Choban PS. Acute acalculous cholecystitis: incidence,
risk factors, diagnosis, and outcome. Am Surg 1998; 64:471.

33. Laurila J, Syrjälä H, Laurila PA, et al. Acute acalculous cholecystitis in critically ill patients.
Acta Anaesthesiol Scand 2004; 48:986.

34. Kaleya RN, Boley SJ. Acute mesenteric ischemia. Crit Care Clin 1995; 11:479.

35. Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl J Med 2001;
345:1683.

36. Marik PE, Andrews L, Maini B. The incidence of deep venous thrombosis in ICU patients.
Chest 1997; 111:661.

37. Hirsch DR, Ingenito EP, Goldhaber SZ. Prevalence of deep venous thrombosis among
patients in medical intensive care. JAMA 1995; 274:335.

38. PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism.
Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA
1990; 263:2753.

39. Stein PD, Afzal A, Henry JW, Villareal CG. Fever in acute pulmonary embolism. Chest 2000;
117:39.

40. Marik PE, Zaloga GP. Adrenal insufficiency in the critically ill: a new look at an old problem.
Chest 2002; 122:1784.

41. Cooper MS, Stewart PM. Corticosteroid insufficiency in acutely ill patients. N Engl J Med
2003; 348:727.

42. Ringel MD. Management of hypothyroidism and hyperthyroidism in the intensive care unit.
Crit Care Clin 2001; 17:59.
43. Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients
with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the
emergency department. Crit Care Med 2010; 38:1045.

44. Uzzan B, Cohen R, Nicolas P, et al. Procalcitonin as a diagnostic test for sepsis in critically ill
adults and after surgery or trauma: a systematic review and meta-analysis. Crit Care Med
2006; 34:1996.

45. Tang BM, Eslick GD, Craig JC, McLean AS. Accuracy of procalcitonin for sepsis diagnosis in
critically ill patients: systematic review and meta-analysis. Lancet Infect Dis 2007; 7:210.

46. Marshall JC, Foster D, Vincent JL, et al. Diagnostic and prognostic implications of
endotoxemia in critical illness: results of the MEDIC study. J Infect Dis 2004; 190:527.

47. Marshall JC, Walker PM, Foster DM, et al. Measurement of endotoxin activity in critically ill
patients using whole blood neutrophil dependent chemiluminescence. Crit Care 2002; 6:342.

48. Póvoa P, Almeida E, Moreira P, et al. C-reactive protein as an indicator of sepsis. Intensive
Care Med 1998; 24:1052.

49. Müller B, Becker KL, Schächinger H, et al. Calcitonin precursors are reliable markers of
sepsis in a medical intensive care unit. Crit Care Med 2000; 28:977.

50. Claeys R, Vinken S, Spapen H, et al. Plasma procalcitonin and C-reactive protein in acute
septic shock: clinical and biological correlates. Crit Care Med 2002; 30:757.

51. Mackenzie I, Woodhouse J. C-reactive protein concentrations during bacteraemia: A

comparison between patients with and without liver dysfunction. Intensive Care Med 2006;
32:1344.

52. Jensen JU, Heslet L, Jensen TH, et al. Procalcitonin increase in early identification of
critically ill patients at high risk of mortality. Crit Care Med 2006; 34:2596.

53. Lobo SM, Lobo FR, Bota DP, et al. C-reactive protein levels correlate with mortality and
organ failure in critically ill patients. Chest 2003; 123:2043.

54. van Zanten AR, Dixon JM, Nipshagen MD, et al. Hospital-acquired sinusitis is a common
cause of fever of unknown origin in orotracheally intubated critically ill patients. Crit Care
2005; 9:R583.
55. Vargas F, Bui HN, Boyer A, et al. Transnasal puncture based on echographic sinusitis
evidence in mechanically ventilated patients with suspicion of nosocomial maxillary sinusitis.
Intensive Care Med 2006; 32:858.

56. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective
antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care
Med 2006; 34:1589.

57. Viscoli C, Varnier O, Machetti M. Infections in patients with febrile neutropenia: epidemiology,
microbiology, and risk stratification. Clin Infect Dis 2005; 40 Suppl 4:S240.

58. Topkara VK, Kondareddy S, Malik F, et al. Infectious complications in patients with left
ventricular assist device: etiology and outcomes in the continuous-flow era. Ann Thorac Surg
2010; 90:1270.

59. Gozzoli V, Schöttker P, Suter PM, Ricou B. Is it worth treating fever in intensive care unit
patients? Preliminary results from a randomized trial of the effect of external cooling. Arch
Intern Med 2001; 161:121.

60. Ryan M, Levy MM. Clinical review: fever in intensive care unit patients. Crit Care 2003;
7:221.

61. Schulman CI, Namias N, Doherty J, et al. The effect of antipyretic therapy upon outcomes in
critically ill patients: a randomized, prospective study. Surg Infect (Larchmt) 2005; 6:369.

62. Lee BH, Inui D, Suh GY, et al. Association of body temperature and antipyretic treatments
with mortality of critically ill patients with and without sepsis: multi-centered prospective
observational study. Crit Care 2012; 16:R33.

63. Cairns CJ, Andrews PJ. Management of hyperthermia in traumatic brain injury. Curr Opin Crit
Care 2002; 8:106.

64. Marion DW. Controlled normothermia in neurologic intensive care. Crit Care Med 2004;
32:S43.

65. Bouchama A, Knochel JP. Heat stroke. N Engl J Med 2002; 346:1978.

66. Suzuki S, Eastwood GM, Bailey M, et al. Paracetamol therapy and outcome of critically ill
patients: a multicenter retrospective observational study. Crit Care 2015; 19:162.
67. Schortgen F, Clabault K, Katsahian S, et al. Fever control using external cooling in septic
shock: a randomized controlled trial. Am J Respir Crit Care Med 2012; 185:1088.

68. Young P, Saxena M, Bellomo R, et al. Acetaminophen for Fever in Critically Ill Patients with
Suspected Infection. N Engl J Med 2015; 373:2215.

69. Kelly SJ, Moran JL, Williams PJ, et al. Haemodynamic effects of parenteral vs. enteral
paracetamol in critically ill patients: a randomised controlled trial. Anaesthesia 2016; 71:1153.

70. Cantais A, Schnell D, Vincent F, et al. Acetaminophen-Induced Changes in Systemic Blood

Pressure in Critically Ill Patients: Results of a Multicenter Cohort Study. Crit Care Med 2016;
44:2192.

Topic 1624 Version 16.0

GRAPHICS

Infectious causes of fever in the intensive care unit

Common causes Other causes

Bacteremia Cellulitis

Intravascular catheter-related infection Cholangitis

Surgical site infection Diverticulitis

Ventilator-associated pneumonia Empyema

Endocarditis

Intra-abdominal abscess

Meningitis

Myonecrosis

Necrotizing fasciitis

Pseudomembranous colitis

Septic arthritis

Sinusitis

Suppurative thrombophlebitis

Urinary tract infection

Graphic 73551 Version 1.0

Noninfectious causes of fever in the intensive care unit

Important causes Other causes

Acalculous cholecystitis Acute respiratory distress syndrome (late)

Adrenal insufficiency Burns

Benign post-operative fever Drug overdose (eg, aspirin anticholinergic drugs)

Drug fever Drug withdrawal

Pancreatitis Gout

Thyroid storm Heat stroke

Transfusion reaction Intracranial hemorrhage

Ischemic colitis

Malignancy

Malignant hyperthermia

Myocardial infarction

Neuroleptic malignant syndrome

Pheochromocytoma

Seizures

Serotonin syndrome

Thromboembolic disease

Vasculitis

Graphic 68779 Version 1.0

Risk factors for acute acalculous cholecystitis

Acute myelogenous leukemia

Acquired immune deficiency syndrome

Ampullary stenosis

Bone marrow transplantation

Burns

Cardiopulmonary resuscitation

Childbirth

Choledochal cyst

Cholesterol emboli

Coronary heart disease

Cystic duct obstruction by a percutaneous transhepatic catheter in the bile duct

Diabetes mellitus

End-stage renal disease

Heart failure

Hemobilia

Immunosuppression

Infections

Major trauma

Mechanical ventilation

Medications (eg, opiates, sunitinib)

Metastases to porta hepatis

Multiple transfusions

Nonbiliary surgery

Sepsis/hypotension

Total parenteral nutrition

Vasculitis

Graphic 82539 Version 3.0

Contributor Disclosures
Graeme MacLaren, MBBS, MSc, FRACP, FCICM Nothing to disclose Denis Spelman, MBBS, FRACP,
FRCPA, MPH Nothing to disclose Scott Manaker, MD, PhD Consultant/Advisory boards: Expert witness in
workers' compensation and in medical negligence matters [General pulmonary and critical care medicine].
Equity Ownership/Stock Options (Spouse): Johnson & Johnson; Pfizer (Numerous medications and devices).
Other Financial Interest: Director of ACCP Enterprises, a wholly owned for-profit subsidiary of ACCP [General
pulmonary and critical care medicine (Providing pulmonary and critical care medicine education to non-
members of ACCP)]. Geraldine Finlay, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
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