What is the treatment for central fever?

Treatment of Central Fever

Central fever should be treated with antipyretic medications when symptomatic relief is desired, but routine use of antipyretics solely for temperature reduction is not recommended. 1

Definition and Diagnosis

Central fever is defined as core temperature >37.5°C driven by neurological dysregulation without evidence of sepsis or clinically significant inflammatory processes 2. It is a diagnosis of exclusion that should be considered only after infectious and other non-infectious causes have been ruled out, particularly in patients with central nervous system disorders 3.

Key characteristics of central fever include:

• Persistent temperature elevations without a cyclic pattern 2
• More likely to occur within 72 hours of admission to the neurologic ICU 4
• Common in patients with traumatic brain injury, subarachnoid hemorrhage, intraventricular hemorrhage, or brain tumors 4
• Often accompanied by other signs of autonomic dysfunction (tachycardia, profuse sweating) 5

Diagnostic Approach

Before diagnosing central fever, a thorough workup should be performed:

• Chest radiograph (recommended for all ICU patients with new fever) 1
• Blood cultures (at least two sets, 60 mL total) 1
• If central venous catheter is present, simultaneous collection of central and peripheral blood cultures 1
• Consider CT imaging for patients with recent thoracic, abdominal, or pelvic surgery 1
• For patients with neurological symptoms, consider lumbar puncture if not contraindicated 1

A combination of negative cultures, absence of infiltrate on chest radiographs, diagnosis of subarachnoid hemorrhage/intraventricular hemorrhage/tumor, and onset of fever within 72 hours of admission strongly suggests central fever (probability of 0.90) 4.

Treatment Options

First-line Treatment:

• For patients who desire symptomatic relief, antipyretic medications are recommended over non-pharmacologic cooling methods 1
• Acetaminophen is commonly used but should be discontinued if fever persists beyond 3 days without identified cause 6

Second-line Pharmacologic Options:

• Bromocriptine, propranolol, and baclofen have shown anecdotal success in case reports 7
• Propranolol (20-30 mg every 6 hours) has been reported to reduce central fever by at least 1.5°C within 48 hours in traumatic brain injury patients 5

Important Considerations:

• Routine use of antipyretics solely for temperature reduction is not recommended in critically ill patients 1
• Fever management reduced body temperature but did not improve 28-day mortality, hospital mortality, or shock reversal in non-neurocritically ill patients 1
• Uncontrolled neurogenic fever can precipitate secondary brain injury in patients with neurological conditions 2
• For patients with acute ischemic stroke, prompt fever treatment is recommended to prevent worse outcomes 1

Monitoring and Follow-up

• Use central temperature monitoring methods when available (pulmonary artery catheters, bladder catheters, esophageal thermistors) 1, 8
• When central monitoring is unavailable, oral or rectal temperatures are preferred over less reliable methods like axillary or tympanic measurements 1, 8
• Monitor for other signs of infection despite normal temperature, as certain patient populations may have blunted fever responses 8
• If antipyretic therapy fails to control central fever, consider consultation with neurology or critical care specialists for alternative pharmacologic approaches 7

Pitfalls and Caveats

• Central fever is a diagnosis of exclusion - always rule out infectious causes first 3, 9
• Elderly patients and those on immunosuppressive medications may not mount typical fever responses 8
• Temperatures between 102°F-106°F (38.9°C-41.1°C) are more likely to be due to infection, while temperatures <102°F or >106°F are usually due to non-infectious causes 9
• When propranolol is used for central fever, abrupt discontinuation may lead to fever recurrence 5
• Distinguish fever from hyperthermia, as antipyretics are ineffective in the latter 9