How is central fever managed and treated?

Management and Treatment of Central Fever

Central fever should be managed as a diagnosis of exclusion after ruling out infectious and other non-infectious causes, with treatment focused on symptomatic relief using antipyretic medications when patients desire comfort, while avoiding routine temperature reduction in the absence of symptoms. 1, 2

Diagnostic Confirmation Required First

Central fever is defined as core temperature >37.5°C driven by neurological dysregulation without evidence of sepsis or clinically significant inflammatory processes. 1 This diagnosis can only be made after systematic exclusion of other causes:

Mandatory Initial Workup

• Chest radiograph for all ICU patients with new fever 3, 1, 2
• Blood cultures (at least two sets, 60 mL total) collected before any antimicrobial therapy 1, 4
• Simultaneous central and peripheral blood cultures if a central venous catheter is present 3, 1
• CT imaging for patients with recent thoracic, abdominal, or pelvic surgery 1, 2
• Lumbar puncture for patients with neurological symptoms if not contraindicated 1

Temperature Monitoring Standards

• Use central temperature monitoring (pulmonary artery catheters, bladder catheters, or esophageal thermistors) when available 3, 1, 2
• When central monitoring unavailable, use oral or rectal temperatures rather than unreliable tympanic or axillary measurements 3, 1, 2
• Avoid temporal artery thermometers as they are influenced by environmental temperature and sweating 3

Treatment Approach Once Central Fever Confirmed

Primary Management Strategy

Antipyretic medications are recommended over non-pharmacologic cooling methods for patients who desire symptomatic relief. 3, 1, 2 However, routine use of antipyretics solely for temperature reduction is not recommended in critically ill patients, as fever management reduced body temperature but did not improve 28-day mortality, hospital mortality, or shock reversal. 3, 1

Pharmacologic Options

When treatment is warranted, three medications have anecdotal evidence supporting their use specifically for central fever:

• Bromocriptine: Dosing strategies and duration vary significantly across case reports 5
• Propranolol: Has demonstrated ability to restore normothermia in case reports 5
• Baclofen: Anecdotal evidence supports use, though exact mechanism not fully elucidated 5

The significant heterogeneity in dosing strategies and lack of comparative data makes a definitive treatment strategy elusive. 5 Each medication has demonstrated ability to restore normothermia, but variation in underlying causes prevents establishing clear protocols. 5

Special Considerations for Neurologic Patients

Uncontrolled neurogenic fever can precipitate secondary brain injury in patients with neurological conditions. 1 For patients with acute ischemic stroke, prompt fever treatment is recommended to prevent worse outcomes. 1 Central fever is strongly associated with subarachnoid hemorrhage, cerebral trauma, and ischemic or haemorrhagic stroke. 6

Key Clinical Pitfalls

• Do not treat the thermometer reading rather than the patient's symptoms and comfort 2
• Recognize that elderly patients and those on immunosuppressive medications may not mount typical fever responses despite having infections 1, 2
• Monitor for infection signs beyond temperature, as certain populations have blunted fever responses 1
• Avoid delaying infectious workup even when central fever is suspected, as approximately 50% of ICU fevers are infectious 4, 7
• Distinguish fever from hyperthermia, as antipyretics are ineffective in hyperthermia 7

Monitoring During Treatment

• Continue surveillance for infectious causes even after diagnosing central fever 1
• Reassess if fever persists beyond expected timeframe or patient condition deteriorates 3
• Monitor for development of new symptoms suggesting alternative diagnoses 1, 6
• Track response to any pharmacologic interventions attempted 5