Systemic Lupus Erythematosus and Critical Illness.

Systemic lupus erythematosus is a chronic autoimmune disorder that causes a wide range of mild to life-threatening conditions that require hospitalization and critical care. The morbidity and mortality of systemic lupus erythematosus are associated with the organ system damage caused by intermittent or chronic disease activity and with the complications of long-term and toxic immunosuppressant medication regimens. This article reviews the epidemiologic, clinical, diagnostic, and therapeutic information essential for critical care clinicians who provide care to patients with systemic lupus erythematosus.

Interprofessional Care and Teamwork in the ICU.

OBJECTIVES: We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care team, including patients and family members, and discusses quality improvement initiatives that require interprofessional collaboration for success. DATA SOURCES: Studies were identified through MEDLINE search using a variety of search phrases related to interprofessional care, critical care provider types, and quality improvement initiatives. Additional articles were identified through a review of the reference lists of identified articles. STUDY SELECTION: Original articles, review articles, and systematic reviews were considered. DATA EXTRACTION: Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles. DATA SYNTHESIS: "Interprofessional care" refers to care provided by a team of healthcare professionals with overlapping expertise and an appreciation for the unique contribution of other team members as partners in achieving a common goal. A robust body of data supports improvement in patient-level outcomes when care is provided by an interprofessional team. Critical care nurses, advanced practice providers, pharmacists, respiratory care practitioners, rehabilitation specialists, dieticians, social workers, case managers, spiritual care providers, intensivists, and nonintensivist physicians each provide unique expertise and perspectives to patient care, and therefore play an important role in a team that must address the diverse needs of patients and families in the ICU. Engaging patients and families as partners in their healthcare is also critical. Many important ICU quality improvement initiatives require an interprofessional approach, including Awakening and Breathing Coordination, Delirium, Early Exercise/Mobility, and Family Empowerment bundle implementation, interprofessional rounding practices, unit-based quality improvement initiatives, Patient and Family Advisory Councils, end-of-life care, coordinated sedation awakening and spontaneous breathing trials, intrahospital transport, and transitions of care. CONCLUSIONS: A robust body of evidence supports an interprofessional approach as a key component in the provision of high-quality critical care to patients of increasing complexity and with increasingly diverse needs.

Rectal and Bladder Temperatures vs Forehead Core Temperatures Measured With SpotOn Monitoring System.

BACKGROUND: Methods and frequency of temperature monitoring in intensive care unit patients vary widely. The recently available SpotOn system uses zero-heat-flux technology and offers a noninvasive method for continuous monitoring of core temperature of critical care patients at risk for alterations in body temperature. OBJECTIVE: To evaluate agreement between and precision of a zero-heat-flux thermometry system (SpotOn) and continuous rectal and urinary bladder thermometry during fever and defervescence in adult patients in intensive care units. METHODS: Prospective comparison of SpotOn vs rectal and urinary bladder thermometry in eligible patients enrolled in a randomized clinical trial on the effect of acetaminophen on core body temperature and hemodynamic status. RESULTS: A total of 748 paired temperature measurements from 38 patients who had both SpotOn monitoring and either continuous rectal or continuous bladder thermometry were analyzed. Temperatures during the study were from 36.6°C to 39.9°C. The mean difference for SpotOn compared with bladder thermometry was -0.07°C (SD, 0.24°C; 95% limits of agreement, ± 0.47°C [-0.54°C, 0.40°C]). The mean difference for SpotOn compared with rectal thermometry was -0.24°C (SD, 0.29°C; 95% limits of agreement, ± 0.57°C [-0.81°C, 0.33°C]). Most differences in temperature between methods were within ± 0.5°C in both groups (96% bladder and 85% rectal). CONCLUSIONS: The SpotOn thermometry system has excellent agreement and good precision and is a potential alternative for noninvasive continuous monitoring of core temperature in critical care patients, especially when alternative methods are contraindicated or not available.

Effects of IV Acetaminophen on Core Body Temperature and Hemodynamic Responses in Febrile Critically Ill Adults: A Randomized Controlled Trial.

OBJECTIVE: To determine the effects of IV acetaminophen on core body temperature, blood pressure, and heart rate in febrile critically ill patients. DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: Three adult ICUs at a large, urban, academic medical center. PATIENTS: Forty critically ill adults with fever (core temperature, ≥ 38.3°C). INTERVENTION: An infusion of acetaminophen 1 g or saline placebo over 15 minutes. MEASUREMENT AND MAIN RESULTS: Core temperature and vital signs were measured at baseline and at 5-15-minute intervals for 4 hours after infusion of study drug. The primary outcome was time-weighted average core temperature adjusted for baseline temperature. Secondary outcomes included adjusted time-weighted average heart rate, blood pressure, and respiratory rate, along with changes-over-time for each. Baseline patient characteristics were similar in those given acetaminophen and placebo. Patients given acetaminophen had an adjusted time-weighted average temperature that was 0.47°C less than those given placebo (95% CI, -0.76 to -0.18; p = 0.002). The acetaminophen group had significantly lower adjusted time-weighted average systolic blood pressure (-17 mm Hg; 95% CI, -25 to -8; p < 0.001), mean arterial pressure (-7 mm Hg; 95% CI, -12 to -1; p = 0.02), and heart rate (-6 beats/min; 95% CI, -10 to -1; p = 0.03). Changes-over-time temperature, blood pressure, and heart rate outcomes were also significantly lower at 2 hours, but not at 4 hours. CONCLUSIONS: Among febrile critically ill adults, treatment with acetaminophen decreased temperature, blood pressure, and heart rate. IV acetaminophen thus produces modest fever reduction in critical care patients, along with clinically important reductions in blood pressure.

Body temperature and mortality in patients with acute respiratory distress syndrome.

BACKGROUND: Little is known about the relationship between body temperature and outcomes in patients with acute respiratory distress syndrome (ARDS). A better understanding of this relationship may provide evidence for fever suppression or warming interventions, which are commonly applied in practice. OBJECTIVE: To examine the relationship between body temperature and mortality in patients with ARDS. METHODS: Secondary analysis of body temperature and mortality using data from the ARDS Network Fluid and Catheter Treatment Trial (n = 969). Body temperature at baseline and on study day 2, primary cause of ARDS, severity of illness, and 90-day mortality were analyzed by using multiple logistic regression. RESULTS: Mean baseline temperature was 37.5°C (SD, 1.1°C; range, 27.2°C-40.7°C). At baseline, fever (≥ 38.3°C) was present in 23% and hypothermia (< 36°C) in 5% of the patients. Body temperature was a significant predictor of 90-day mortality after primary cause of ARDS and score on the Acute Physiology and Chronic Health Evaluation III were adjusted for. Higher temperature was associated with decreased mortality: for every 1°C increase in baseline temperature, the odds of death decreased by 15% (odds ratio, 0.85; 95% CI, 0.73-0.98, P = .03). When patients were divided into 5 temperature groups, mortality was lower with higher temperature (P for trend = .02). CONCLUSIONS: Early in ARDS, fever is associated with improved survival rates. Fever in the acute phase response to lung injury and its relationship to recovery may be an important factor in determining patients' outcome and warrants further study.