What is the treatment for a patient presenting with fever and shivering?

Treatment of Fever with Shivering

The treatment approach depends critically on the clinical context: for general fever with shivering, use acetaminophen as first-line therapy; however, if shivering occurs during targeted temperature management (post-cardiac arrest or traumatic brain injury), employ an analgesic-first approach with low-dose fentanyl, escalating to sedatives and ultimately neuromuscular blockade if needed.

Initial Assessment and Context Recognition

Before initiating treatment, determine the underlying cause and clinical setting:

• Evaluate for infection as the primary cause, particularly respiratory and wound infections, which commonly present with fever and shivering 1
• Check for sepsis indicators if temperature ≥38.0°C, as this requires prompt evaluation and potential empiric antibiotics 2
• Identify if the patient is undergoing specialized temperature management (post-cardiac arrest or traumatic brain injury), as this fundamentally changes the treatment algorithm 2

Treatment for General Fever with Shivering (Non-ICU Setting)

First-Line Pharmacologic Management

Antipyretics are the cornerstone of symptomatic fever management:

• Acetaminophen (paracetamol) is effective and well-tolerated for fever reduction 2, 3
• Intravenous ibuprofen (400 mg) or IV paracetamol (1000 mg) provide equivalent fever control within 30 minutes in emergency settings 4
• Both medications significantly improve accompanying symptoms and thermal comfort 4

Important Caveats About Physical Cooling

Avoid active physical cooling in unsedated patients with moderate fever:

• Physical cooling (cooling blankets at 15-18°C) does not reduce core temperature effectively and may be counterproductive 5, 6
• Cooling provokes shivering, increases metabolic rate by 35-40%, activates the autonomic nervous system, and causes significant thermal discomfort 6
• Cooling increases oxygen consumption and cardiovascular stress without improving fever control 6

Treatment for Shivering During Targeted Temperature Management (ICU Setting)

This applies specifically to post-cardiac arrest patients or those with traumatic brain injury undergoing controlled temperature management.

Stepwise Escalation Protocol

Phase 1: Non-Pharmacologic and Basic Pharmacologic Measures

• Initiate surface counterwarming of extremities (ears, palms, soles) as first-line non-pharmacologic intervention 2
• Administer acetaminophen as an adjunct (safe, non-sedating, but typically insufficient alone) 2
• Give magnesium sulfate (2-4 g bolus, then 1 g/h infusion) as an adjunct, keeping levels <4 mg/dL 2

Phase 2: Analgesic-First Approach

• Start low-dose fentanyl (bolus 25-100 μg, then infusion 25-200 μg/h) as the primary agent 2
• Consider meperidine (12.5-50 mg boluses) for potent anti-shivering properties, though caution is needed due to neurotoxicity risk and seizure threshold reduction 2

Phase 3: Add Short-Acting Sedative

• Add dexmedetomidine infusion (0.2-1.5 μg/kg/h) if analgesia alone is inadequate 2
• Alternative: propofol (20-60 μg/kg/min), though this carries higher hypotension risk 2

Phase 4: Neuromuscular Blockade (When Other Measures Fail)

Ensure adequate sedation depth before administering neuromuscular blockers 2:

• Cisatracurium (0.1-0.2 mg/kg bolus, then 0.5-10 μg/kg/min infusion) is preferred in renal/hepatic impairment 2
• Rocuronium (0.6-1 mg/kg bolus, then 3-12 μg/kg/min) for longer-acting effect 2
• Use short-term boluses (one or two doses) during induction phase to rapidly achieve target temperature 2
• Titrate continuous infusions to minimum dose that suppresses shivering 2

Critical Safety Considerations for ICU Shivering Management

Monitor for complications during neuromuscular blockade:

• Perform continuous EEG monitoring during NMB, as it masks clinical seizure manifestations 2
• Monitor train-of-four testing when using continuous NMB infusions 2
• Be aware that shivering increases metabolic rate, doubles oxygen consumption, and can trigger cerebral ischemia in vulnerable patients 1

Avoid common pitfalls:

• Never use physical cooling alone in unsedated patients—it worsens shivering and increases metabolic stress 6
• Do not rely on magnesium or acetaminophen alone for significant shivering—they are adjuncts only 2
• Recognize that all sedatives accumulate during hypothermia, resulting in delayed awakening 2
• Propofol and dexmedetomidine may worsen hemodynamic compromise in patients with shock 2

Special Population Considerations

For patients with labile intracranial pressure (traumatic brain injury):

• Shivering must be aggressively managed as it reduces brain tissue oxygenation and causes cerebral metabolic stress 2
• Ensure adequate sedation depth before neuromuscular blockade to prevent awareness 2
• Consider permissive hyperthermia in self-ventilating subacute TBI patients when shivering cannot be controlled with first-line treatments 2

For patients with cardiogenic shock:

• Minimize sedative doses due to hemodynamic effects 2
• Have lower threshold for neuromuscular blockade to avoid sedative-induced hypotension 2