Standardized Antipyretic Treatment in Stroke: A Pilot Study

Abstract

Background: Fever after acute cerebral injury is associated with unfavorable functional outcome and increased mortality, but there is controversy about the optimal antipyretic treatment. This study investigated an institutional standard operating procedure (SOP) for fever treatment in stroke patients including a sequence of pharmacologic and physical interventions. Methods: A 4-step antipyretic SOP was established for patients with acute cerebral ischemia or hemorrhage and a body temperature ≧37.5°C within the first 6 days after admission. Data on the course of body temperature, duration of fever and achievement of normothermia were recorded. Results were compared to a historic control group that underwent conventional treatment. Results: A total of 77 patients (mean age 70.4 ± 14.2 yeas) received 331 antipyretic interventions. Sequential administration of paracetamol (n = 219), metamizole (n = 71) and calf packing (n = 24) resulted in a significant drop in body temperature after 60 min in each instance. In 5 of 9 cases which were refractory to previous attempts, normothermia followed the infusion of ice-cooled saline. In more than 90% of cases treated per protocol, normothermia was achieved within 120 min. Compared to conventional treatment, fever burden was significantly lower within the first 4 days after admission (p < 0.001). Conclusion: This SOP may help to optimize antipyretic treatment for stroke patients.

Relationships Between Brain and Body Temperature, Clinical and Imaging Outcomes after Ischemic Stroke

“…Neither study found associations between ischemic brain temperature and admission stroke severity. The associations between CNL temperature and clinical findings parallel those found for tympanic temperature in the same patients 11 and that others have found for body temperature in other studies 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 summarized in Karaszewski et al 11 The difference in the pattern of brain temperature elevation in the ischemic lesion, combined with the different associations with clinical and imaging features, suggests that the mechanism(s) for early temperature elevation in ischemic brain are different to those which elevate temperature in normal-appearing brain and cause pyrexia. This leads to several important conclusions:

The elevated temperature in ischemic tissue is not directly related to body temperature and possibly not to progression of brain injury, and appears to have a different mechanism to that of body and normal-appearing brain temperature;

that body temperature elevation after ischemic stroke occurs secondary to the systemic (presumably inflammatory) response to brain injury and is reflected in temperature in normal-appearing brain.

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Therapeutic hypothermia in treatment of different cerebral injuries

“…В настоящее время накопился большой опыт купирования дрожи. Для этого эффективно применяются буспирон, меперидин, клонидин, дексмедетомидин, сульфат магния, причем ряд работ показал синергизм эффектов буспирона и меперидина [11]. Кроме того, часто возникают сложности при поддерживании температуры тела на желаемом уровне путем поверхностного охлаждения, в связи с чем высок риск переохлаждения [12].…”

Effective Fever Control in Acute Stroke: Still Wanted!

“…Observational studies like that of Kallmünzer et al [8] might stimulate further research in this field of high clinical significance for acute stroke care. More than 3 decades after Hindfelt's [11] recommendation 'that fever and subfebrility, irrespective of their genesis, should be intensely combated during the early stages of an ischaemic stroke' we need a proven treatment strategy for fever control.…”

“…Kallmünzer et al [8] investigated the safety of an institutional 4-step protocol using pharmacological and physical interventions in order to enforce post-stroke fever control. When body temperature was 6 37.5 ° C, treatment was started with 1 g paracetamol intravenously (level 1) and in case of nonresponse followed hourly by treatment with 1 g metamizole intravenously (level 2), calf packing (level 3) and finally intravenous infusion of 500 ml of 4 ° C cold saline solution (level 4).…”