How to manage fever in a patient on day 2 post right Middle Cerebral Artery (MCA) infarct due to atrial fibrillation?

Management of Fever in Post-MCA Infarct Patient

Fever should be actively treated with antipyretic medications in patients with acute ischemic stroke, as elevated body temperature is strongly associated with worse neurological outcomes and increased mortality. 1

Rationale for Fever Treatment

Fever in the acute stroke setting worsens outcomes through multiple mechanisms 1:

• Increased metabolic demands on injured brain tissue
• Enhanced release of excitatory neurotransmitters
• Increased free radical production
• Meta-analysis data demonstrates marked increases in both morbidity and mortality with post-stroke fever 1

Immediate Management Steps

1. Identify and Treat the Fever Source

The underlying cause of fever must be identified and treated concurrently with temperature reduction. 1 Common sources in day 2 post-stroke include:

• Aspiration pneumonia (particularly with right hemisphere strokes affecting swallowing)
• Urinary tract infection
• Deep vein thrombosis
• Central fever from stroke itself

2. Pharmacological Temperature Control

Acetaminophen (paracetamol) is the first-line antipyretic agent 1:

• Dosing: 1000 mg every 6 hours (6000 mg total daily dose) 2, 3
• This high-dose regimen produces a 0.3-0.4°C reduction in body temperature within 24 hours, even in normothermic patients 2, 3
• Treatment should be initiated promptly and continued for at least 5 days 2, 3

Important caveat: While the PAIS-1 trial (which included 11% ICH patients) did not show overall benefit with prophylactic acetaminophen, this does not contradict treating established fever 1. The American Stroke Association guidelines specifically recommend treating fever when present, not prophylactic administration 1.

3. Physical Cooling Measures

If pharmacological measures are insufficient 1:

• Cooling blankets
• Ice packs to groin and axillae
• Catheter-based cooling systems (in ICU settings, though evidence is limited for routine use) 1

Target Temperature

Maintain body temperature <37.5°C (99.5°F), with oxygen saturation ≥95% 1. Monitor temperature at 2-hour intervals during acute phase 2.

Special Considerations for This Patient

Atrial Fibrillation Management

This patient's stroke etiology (atrial fibrillation) requires concurrent attention 1:

• Cardiac monitoring for arrhythmias is essential, as right hemisphere strokes increase arrhythmia risk 1
• Anticoagulation decisions should follow standard stroke protocols (typically delayed 24-48 hours post-infarct depending on infarct size)

Avoid These Pitfalls

• Do not use NSAIDs (ibuprofen) as first-line agents - while one ED study showed efficacy for bacterial fever 4, ibuprofen has not been adequately studied in acute stroke and may interfere with antiplatelet therapy
• Do not delay treatment waiting for fever >38.3°C - even modest temperature elevations worsen outcomes 1
• Do not use prophylactic hypothermia - this remains investigational and is not recommended outside clinical trials 1

Monitoring Protocol

• Temperature every 2 hours for first 24 hours of fever, then every 6 hours 2
• Continuous cardiac monitoring given atrial fibrillation history 1
• Pulse oximetry with supplemental oxygen if saturation <95% 1
• Assess swallowing function before oral intake given aspiration risk 1