What is the treatment for central fever in traumatic brain injury (TBI)?

Treatment of Central Fever in Traumatic Brain Injury

Immediate Management Approach

For patients with severe TBI who are sedated and ventilated, initiate controlled normothermia reactively when fever is detected, targeting 36.0-37.5°C using automated feedback-controlled temperature management devices. 1, 2

Uncontrolled fever in the acute phase of TBI requires urgent management as it precipitates secondary brain injury by increasing brain metabolic rate, cerebral blood flow, and intracranial pressure. 1, 2

Step-by-Step Treatment Algorithm

Step 1: Recognize the Urgency

• Central (neurogenic) fever is defined as core temperature >37.5°C driven by neurological dysregulation without evidence of sepsis. 3
• While investigating for infectious sources, proceed immediately with temperature control—do not delay treatment while searching for the fever source. 4
• Fever is particularly dangerous in TBI patients with seizures or those at high risk of seizures, requiring aggressive control. 1

Step 2: Primary Treatment Modality

• Use automated feedback-controlled temperature management devices as the primary intervention for rapid induction and maintenance of normothermia. 1, 2
• These devices should be used for both the induction phase and maintenance phase to achieve precise temperature control. 1
• Target temperature variation must be maintained at ≤±0.5°C per hour and ≤1°C per 24-hour period to prevent harmful temperature fluctuations. 1, 2

Step 3: Role of Pharmacological Agents

• Antipyretics such as acetaminophen (paracetamol) or NSAIDs have limited efficacy in controlling fever in severe TBI and should not be relied upon as primary management. 1, 2
• These medications may be used as adjuncts during the induction phase only, but automated devices remain essential. 1
• The ineffectiveness of antipyretics in this setting distinguishes central fever from typical febrile responses. 1

Step 4: Alternative Pharmacological Approach

• Propranolol 20-30 mg every 6 hours has been reported to reduce central fevers by at least 1.5°C within 48 hours in TBI patients with autonomic dysfunction (tachycardia, profuse sweating, decorticate posturing). 5
• This approach is particularly relevant when central fever is accompanied by signs of autonomic dysregulation. 5
• Propofol infusion can control intracranial pressure while maintaining cerebral perfusion pressure in severely head-injured patients, though bolus doses may compromise cerebral perfusion. 6

Step 5: Duration of Treatment

• Continue controlled normothermia for as long as the brain remains at risk of secondary brain injury. 1, 2
• This is particularly critical during the acute phase when the patient is still perceived to be at significant risk. 1
• Some degree of controlled pyrexia may be allowed during the subacute phase, but uncontrolled fever always requires urgent management in the acute phase. 1

Temperature Monitoring Requirements

• Use continuous central temperature monitoring (bladder, esophageal, or cerebral) rather than superficial measurements (skin, tympanic). 2
• Brain temperature can be up to 2°C higher than systemic temperature and may vary independently. 2
• Continuous monitoring is preferable to intermittent measurements for maintaining tight temperature control. 2, 4

Critical Pitfalls to Avoid

• Do not rely solely on antipyretics—this is the most common error, as they are insufficient for temperature control in severe TBI. 1, 2
• Do not use non-automated cooling methods beyond the induction phase—manual methods provide poor control and increase temperature variability. 1
• Do not discontinue temperature control prematurely—maintain treatment throughout the period of secondary brain injury risk. 1, 2
• Do not allow temperature fluctuations—variability outside the target range negatively impacts neurological outcomes. 1

Special Considerations

• In patients with impending herniation or obliterated basal cisterns, more aggressive temperature management with therapeutic hypothermia (≤36.0°C) may be needed when standard treatments fail to control ICP. 2
• When automated devices are unavailable, increase staff awareness and implement dedicated protocols for sedation, analgesia, and shivering management to minimize temperature fluctuations. 1
• The incidence of central fever in acute TBI rehabilitation settings is approximately 4%, though it is more common in the acute ICU phase. 7