Anti-pyretic Therapy in Critically Ill Adults

Assessment of the Safety of Anti-pyretic Therapy in Critically Ill Adults

The impact of fever and its management in different medical and surgical populations of critically ill patients has not been explained to date. The current study aims to assess the safety and efficacy of treatment of critically ill patients with a permissive versus aggressive fever treatment strategy.

Study Overview

• Status: Completed
• Conditions: Fever
• Intervention / Treatment: Other: Aggressive Fever Treatment; Other: Permissive Fever Treatment

Detailed Description

The impact of fever and its management in different medical and surgical populations of critically ill patients has not been explained to date. Clinical trials in critically ill surgical patients have demonstrated null or potentially harmful effects of treatment of moderate degrees of fever. However, the pathophysiological effects of fever treatment are not well defined according to different patient populations, and clinical trial results are questionably generalized to medical ICU patients. This may relate to different mechanisms of fever in these populations and merits further investigation. There is also very little known about the exact timing of expression of the diverse pro and anti-inflammatory mediators involved in inducing, maintaining and eventually abrogating the fever response. Treating on the sole basis of an elevated temperature may lead to detrimental effects if the anti-inflammatory cascade naturally regulating this response is active, demonstrating the importance of understanding the normal pattern of regulation of these diverse mediators. The current study aims to assess the safety and efficacy of treatment of critically ill patients with a permissive versus aggressive fever treatment strategy. In addition, the effect of anti-pyretic therapy on markers of inflammation in neurologically intact critically ill adults will be evaluated.

The study population will be neurologically intact febrile adults (≥18 years) admitted to the Peter Lougheed Center (PLC) or Foothills Medical Center (FMC) ICU over a 12-month period in Calgary, Alberta, Canada. Consenting patients that fulfill enrolment criteria will be randomly allocated to either the permissive or aggressive treatment group (see Interventions section for details). Randomization will be concealed using the consecutively numbered sealed opaque envelope technique. Samples of blood will be collected from study patients at enrolment and subsequently at 12, 24 and 48 hours for assessment of inflammatory mediators.

Markers of feasibility will include the rate of enrolment, adherence of patients to assigned treatment regimen/protocol violation, acceptance of the protocol by staff, and facility and maintenance of random allocation technique. Markers of safety will include potential adverse events such as 28-day survival, nosocomial infection rate, and evidence of myocardial ischemia, or hepatocellular inflammation during the febrile episode.

• Study Type: Interventional
• Enrollment (Actual): 26
• Phase: Phase 2

Contacts and Locations

Study Locations

• Canada
  • Alberta
    • Calgary, Alberta, Canada, T1Y 6J4
      • Intensive Care Unit, Peter Lougheed Center
    • Calgary, Alberta, Canada, T2N 2T9
      • Intensive Care Unit, Foothills Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Age ≥18 years old
• Fever (two consecutive measurements ≥ 38.3°C at least 2 hours apart or a single temperature measurement ≥ 39.5°C)
• Admitted to ICU with an expected length of stay at least 48 hours related to critical illness
• Attending physician approval

Exclusion Criteria:

• Admission to ICU for support for specific procedure (e.g. endoscopy, acute dialysis, bronchoscopy)
• Acute brain injury due to any etiology
• Acute myocardial ischemia
• Documented hepatitis with elevated alanine aminotransferase (ALT) more than twice the upper limit of normal, or chronic hepatic failure (defined by evidence of cirrhosis on available imaging or known varices, ascites, hepatic encephalopathy, hepatorenal syndrome, and/or hepatocellular carcinoma)
• Hyperthermia syndromes (malignant hyperthermia, heat stroke, neuroleptic malignant syndrome, serotonin syndrome, or endocrine causes including thyrotoxicosis, pheochromocytoma, and adrenal crisis)
• Refractory shock with lactic acidosis >4 mmol/L (at the time of screening for study enrollment) despite supportive therapy or need for paralytic treatment to reduce metabolic demand
• Requirement for use of anti-pyretic agents (acetaminophen or NSAIDs) for indications other than treatment of fever
• Receipt of anti-pyretic pharmacotherapy within 6-hours of expected study enrollment (650mg acetaminophen, 800mg ibuprofen, or 325mg acetylsalicylic acid)
• Contraindications to esophageal temperature monitoring
• Pregnancy (all women of child-bearing potential need to have a pregnancy test performed prior to enrollment)
• Time from onset of fever in the ICU to consideration for study enrollment is > 12 hours

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: NONE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Aggressive Fever Treatment	Other: Aggressive Fever Treatment; Patients assigned to the aggressive fever treatment protocol will receive acetaminophen 650 mg enterally every 6 hours for fever ≥ 38.3°C and external cooling will be initiated for temperatures ≥ 39.5°C. Acetaminophen and external cooling will be discontinued once core temperature is less than 38.3°C and 39.5°C respectively.
ACTIVE_COMPARATOR: Permissive Fever Treatment	Other: Permissive Fever Treatment; Patients assigned to the permissive treatment strategy will not receive anti-pyretic therapy until the temperature reaches 40.0°C at which point they will receive acetaminophen 650mg every 6 hours. External cooling will be initiated for temperatures ≥ 40.5°C. Acetaminophen and external cooling will be discontinued once core temperature is less than 40.0°C and 40.5°C respectively.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
28-day survival	28-day

Secondary Outcome Measures

Outcome Measure	Time Frame
Feasibility of randomizing critically ill patients to different fever management strategies	12 months
Consumption of anti-microbials	Maximum 28-days from enrollment
Incidence of nosocomial infection	Maximum 28-days from enrollment
The effect of anti-pyretic treatment of fever on markers of inflammation	48 hours
Incidence of myocardial infarction during treatment of fever	Maximum 28-days from enrollment
Incidence of hepatocellular inflammation related to acetaminophen use	Maximum 28-days from enrollment

Collaborators and Investigators

• Sponsor: University of Calgary
• Collaborators: Canadian Intensive Care Foundation
• Investigators: Principal Investigator: Kevin Laupland, MD MSc FRCPC, Faculty of Medicine, University of Calgary; Principal Investigator: Henry T Stelfox, MD PhD FRCPC, Faculty of Medicine, University of Calgary

Publications and helpful links

General Publications

• Niven DJ, Stelfox HT, Leger C, Kubes P, Laupland KB. Assessment of the safety and feasibility of administering antipyretic therapy in critically ill adults: a pilot randomized clinical trial. J Crit Care. 2013 Jun;28(3):296-302. doi: 10.1016/j.jcrc.2012.08.015. Epub 2012 Oct 24.
• Niven DJ, Leger C, Kubes P, Stelfox HT, Laupland KB. Assessment of the safety and feasibility of administering anti-pyretic therapy in critically ill adults: study protocol of a randomized trial. BMC Res Notes. 2012 Mar 16;5:147. doi: 10.1186/1756-0500-5-147.

Study record dates

Study Major Dates

• Study Start: August 1, 2010
• Primary Completion (ACTUAL): January 1, 2012
• Study Completion (ACTUAL): January 1, 2012

Study Registration Dates

• First Submitted: July 28, 2010
• First Submitted That Met QC Criteria: July 29, 2010
• First Posted (ESTIMATE): August 2, 2010

Study Record Updates

• Last Update Posted (ESTIMATE): February 23, 2012
• Last Update Submitted That Met QC Criteria: February 21, 2012
• Last Verified: February 1, 2012

More Information

Terms related to this study

• Keywords: Safety; ICU; Fever; Acetaminophen; Inflammatory mediators
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Critical Illness
• Other Study ID Numbers: E-23090