Management of Fever Post Head Trauma

Understanding Fever in TBI

Neurogenic fever is common in TBI patients and associated with increased risk of complications and unfavorable outcomes 1
Fever can precipitate secondary brain injury by increasing brain metabolic rate, cerebral blood flow, and intracranial pressure, regardless of whether it's caused by infection or impaired thermoregulation 1

Differentiate between neurogenic fever and infectious causes, though management should proceed regardless of source while investigation continues 1, 2
Evaluate for signs of increased intracranial pressure and risk of secondary brain injury 1

For patients with severe TBI who are sedated and ventilated, initiate controlled normothermia reactively when fever is detected 3
Target temperature range: 36.0-37.5°C 1
Utilize automated feedback-controlled temperature management devices for precise control 3, 4
Maintain temperature with minimal variation (≤ ±0.5°C per hour and ≤1°C per 24-hour period) 3, 5

Antipyretics such as acetaminophen (paracetamol) or NSAIDs have limited efficacy in controlling fever in severe TBI 3
These medications may be used as adjuncts during the induction phase but should not be relied upon as primary management 3

Continue controlled normothermia for as long as the brain remains at risk of secondary brain injury 3, 5
This is particularly important during the acute phase of TBI 1

Fever control is especially important in TBI patients with seizures or those at high risk of seizures 3
While some controlled pyrexia may be allowed during the subacute phase, uncontrolled fever requires urgent management in the acute phase 1, 3
For patients with severe TBI with impending herniation or obliterated basal cisterns, more aggressive temperature management may be needed 1

Relying solely on antipyretics is insufficient for temperature control in severe TBI 3
Failing to differentiate between central fever and infectious causes may lead to antibiotic overuse or missed treatable conditions 1
Discontinuing temperature control too early while the brain remains at risk of secondary injury 3, 5

La monitorización continua de temperatura es preferible sobre mediciones intermitentes en pacientes con lesión cerebral traumática (LCT) grave 6
Se recomienda monitorizar la temperatura central (vejiga, esofágica, cerebral) en lugar de la temperatura superficial (piel, timpánica) 6
La temperatura cerebral puede ser hasta 2°C más alta que la temperatura sistémica y puede variar independientemente según las características de la patología cerebral 7, 8

El aumento de temperatura puede provocar un incremento en el metabolismo cerebral, flujo sanguíneo cerebral y volumen sanguíneo cerebral, precipitando hipertensión intracraneal 9, 10
Se recomienda la normotermia controlada (temperatura central 36,0-37,5°C) como parte de los tratamientos de Nivel 1 y 2 según las guías SIBICC 2019 9, 10
La hipotermia terapéutica (temperatura central ≤36,0°C) debe considerarse en casos donde los tratamientos de nivel 1 y 2 han fallado en controlar la PIC 9, 10

Nivel Cero: Tratar temperatura central >38,0°C con sedación, intubación endotraqueal y ventilación mecánica 10
Nivel 1: Normotermia controlada (temperatura central 36,0-37,5°C) con titular sedación y analgesia para controlar PIC 9, 10
Nivel 2: Normotermia controlada (temperatura central 36,0-37,5°C) con objetivos individualizados de PPC 9, 10

La fiebre neurogénica (temperatura central >37,5°C) causada por desregulación neurológica es común en LCT y debe ser detectada y tratada rápidamente 11, 12
La fiebre no controlada (neurogénica o secundaria a inflamación o infección) puede precipitar lesión cerebral secundaria 11, 12

Se recomienda que la inducción rápida de hipotermia en casos de LCT se logre con dispositivos automatizados de manejo de temperatura con retroalimentación controlada 11, 12