Sepsis 3.0 produced the quick sepsis related organ failure assessment (qSOFA) score. This score is supposed to be a quick bedside tool to help predict which patients are at greatest risk of poor outcomes. The score is composed of three components: Low systolic blood pressure (≤100mmHg), high respiratory rate (22 breaths per minute), and altered mental status (Glasgow coma scale <15). As you have probably noticed, nowhere in this score is consideration for fever.
The Who and What of the Study:
- Observational cohort study from the Swedish national quality register for sepsis
- 30 ICU’s in Sweden
- Patients were divided into four temperature levels
- <37 C
- 37 – 38.29 C
- 3 – 39.5 C
- ≥39.5 C
What was there outcome measure:
- Primary: In-hospital Mortality
Who was Included:
- Enrolled in the Swedish National Quality Sepsis Register (NQSR)
- >17 years of age
- Admitted to the ICU with a diagnosis of severe sepsis or septic shock within 24 hours of arrival to the ED
What was Found:
- 2,225 adults admitted to the ICU within 24 hours of hospital arrival with a diagnosis of severe sepsis or septic shock
- Overall mortality: 25%
- In-hospital mortality decreased >5% for every increase by °C from 35°C up to >41°C
- Of the measured vital signs, temperature had the highest predictive value for in-hospital mortality followed by respiratory rate >heart rate > O2 saturation > systolic blood pressure
Study Author Conclusions:
“Contrary to common perceptions and current guidelines for care of critically ill septic patients, increased body temperature in the emergency department was strongly associated with lower mortality and shorter hospital stays in patients with severe sepsis or septic shock subsequently admitted to the ICU.”
The patients with severe sepsis and septic shock who do not have fever are the ones we must pay more attention to. Calculating the qSOFA score does not use temperature as a predictor of mortality and in this study, temperature was the vital sign that had the best prediction of in-hospital mortality.
- Sunden-Cullberg, J et al. Fever in the Emergency Department Predicts Survival of Patients with Severe Sepsis and Septic Shock Admitted to the ICU. Crit Care Med 2017. 45: 591 – 99. PMID: 28141683
Another excellent study I ran across while researching this article…
Article link here
The Absence of Fever Is Associated With Higher Mortality and Decreased Antibiotic and IV Fluid Administration in Emergency Department Patients With Suspected Septic Shock
OBJECTIVE: This study evaluates whether emergency department septic shock patients without a fever (reported or measured) receive less IV fluids, have decreased antibiotic administration, and suffer increased in-hospital mortality.
DESIGN: This was a secondary analysis of a prospective, observational study of patients with shock.
SETTING: The study was conducted in an urban, academic emergency department.
PATIENTS: The original study enrolled consecutive adult (aged 18 yr or older) emergency department patients from November 11, 2012, to September 23, 2013, who met one of the following shock criteria: 1) systolic blood pressure less than 90 mm Hg after at least 1L IV fluids, 2) new vasopressor requirement, or 3) systolic blood pressure less than 90 mm Hg and IV fluids held for concern of fluid overload. The current study is limited to patients with septic shock. Patients were grouped as febrile if they had a subjective fever or a measured temperature >100.4ºF documented in the emergency department; afebrile patients lacked both.
MEASUREMENTS AND MAIN RESULTS: Among 378 patients with septic shock, 207 of 378 (55%; 50-60%) were febrile by history or measurement. Afebrile patients had lower rates of antibiotic administration in the emergency department (81% vs 94%; p < 0.01), lower mean volumes of IV fluids (2,607 vs 3,013 mL; p < 0.01), and higher in-hospital mortality rates (33% vs 11%; p < 0.01). After adjusting for bicarbonate less than 20 mEq/L, lactate concentration, respiratory rate greater than or equal to 24 breaths/min, emergency department antibiotics, and emergency department IV fluids volume, being afebrile remained a significant predictor of in-hospital mortality (odds ratio, 4.3; 95% CI, 2.2-8.2; area under the curve = 0.83).
CONCLUSIONS: In emergency department patients with septic shock, afebrile patients received lower rates of emergency department antibiotic administration, lower mean IV fluids volume, and suffered higher in-hospital mortality.