From the Guidelines
For quick reduction of fever in the ER, avoiding routine use of antipyretic medications is suggested, unless the patient values comfort by reducing temperature, in which case antipyretics may be used over nonpharmacologic methods. This approach is based on the most recent guidelines from the Society of Critical Care Medicine and the Infectious Diseases Society of America, published in 2023 1. The guidelines suggest that antipyretic medications should not be used routinely for the specific purpose of reducing temperature in critically ill patients with fever, but may be considered for patient comfort.
When antipyretic medications are used, a combination of acetaminophen (Tylenol) and ibuprofen (Motrin) may be effective, although the guidelines do not specify a particular medication or dosage. For patients unable to take oral medications, IV acetaminophen may be preferred. Physical cooling measures, such as removing excess clothing or applying cool compresses, can also provide additional benefit, especially for temperatures above 103°F (39.4°C). Ensuring adequate hydration with IV fluids is also important, especially if the patient shows signs of dehydration.
It's worth noting that the guidelines emphasize the importance of investigating the underlying cause of fever, rather than just treating the symptom. This may involve performing diagnostic tests, such as chest radiographs or blood cultures, to identify the source of the infection. The goal of fever management is to improve patient comfort and decrease metabolic demands, while also addressing the underlying cause of the fever.
In terms of specific medications, the guidelines do not provide a clear recommendation, but previous studies have suggested that acetaminophen and ibuprofen may be effective in reducing fever 1. However, the most recent guidelines from 2023 should take precedence, and the decision to use antipyretic medications should be made on a case-by-case basis, taking into account the individual patient's needs and values.
Overall, the approach to fever management in the ER should prioritize patient comfort and safety, while also addressing the underlying cause of the fever. Avoiding routine use of antipyretic medications, unless necessary for patient comfort, is the recommended approach, based on the most recent guidelines from the Society of Critical Care Medicine and the Infectious Diseases Society of America 1.
From the FDA Drug Label
The safety and effectiveness of OFIRMEV for the treatment of fever in pediatric patients, including premature neonates born at ≥ 32 weeks gestational age is supported by adequate and well-controlled studies of OFIRMEV in adults, clinical studies in 244 pediatric patients 2 years and older, and safety and pharmacokinetic data from 239 patients younger than 2 years including neonates ≥ 32 weeks gestational age.
The acetaminophen (IV) can be used for the quick reduction of fever in the ER, as its safety and effectiveness for the treatment of fever are supported by clinical studies 2.
- Key points:
- Supported by adequate and well-controlled studies in adults and clinical studies in pediatric patients
- Safety and pharmacokinetic data from patients younger than 2 years, including neonates ≥ 32 weeks gestational age
- Acetaminophen (IV) can be used for the treatment of fever in pediatric patients, including premature neonates born at ≥ 32 weeks gestational age 2
From the Research
Quick Reduction of Fever in the ER
- The most effective treatment for fever in the Emergency Department (ED) is still undetermined, but a study 3 found that paracetamol 1,000 mg and the combination paracetamol 500 mg/ibuprofen 150 mg were effective in reducing fever in adult patients.
- The study 3 also found that the combination paracetamol/ibuprofen was more effective than paracetamol alone in patients with bacterial fever one hour after administration.
- Another study 4 found that early administration of acetaminophen to treat fever due to probable infection did not affect the number of ICU-free days in critically ill patients.
Treatment Options
- Paracetamol 1,000 mg is a common first-line treatment for fever in the ED 3.
- The combination paracetamol 500 mg/ibuprofen 150 mg is also an effective treatment option for fever in the ED 3.
- Acetaminophen is a common therapy for fever in patients in the intensive care unit (ICU) who have probable infection, but its effects are unknown 4.
Safety Considerations
- Ibuprofen has been associated with renal impairment, particularly in elderly patients and those with coronary artery disease 5.
- Acetaminophen has also been associated with kidney injury, with a higher reporting odds ratio and proportional reporting ratio compared to ibuprofen 6.
- Patients with liver cirrhosis should use paracetamol with caution, with a reduced dose of 2-3 g/d recommended for long-term use, and non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided due to the risk of renal impairment and hepatorenal syndrome 7.