For a patient 20 days post‑hemorrhagic stroke with an axillary temperature of 98.8 °F (37 °C), is this temperature considered fever and should acetaminophen (paracetamol) be administered every 6 hours?

Is 98.8°F Axillary Temperature a Fever Requiring Acetaminophen in Post-Hemorrhagic Stroke Day 20?

No, an axillary temperature of 98.8°F (37°C) does not constitute fever and does not require scheduled acetaminophen every 6 hours in a patient 20 days post-hemorrhagic stroke. This temperature is normal, and axillary measurements systematically underestimate core temperature by 1–2°C, making this reading even less concerning. 1

Temperature Measurement Considerations

• Axillary temperatures are unreliable and should not be used for fever detection. Electronic axillary measurements have a sensitivity of only 46% for detecting fever, with mean differences of 1.17°C below oral and 1.81°C below rectal temperatures. 1

• Central temperature monitoring methods (pulmonary artery thermistors, bladder catheters, esophageal thermistors) are preferred when accurate measurements are critical; oral or rectal temperatures are suggested over axillary measurements. 2

• In this patient, the axillary reading of 98.8°F (37°C) likely corresponds to a true core temperature of approximately 37.5–38°C (99.5–100.4°F), which still does not meet fever thresholds. 1

Fever Definition in Hemorrhagic Stroke

• Fever in stroke patients is typically defined as core temperature ≥38°C (100.4°F). 3

• The American Heart Association recommends treating fever aggressively with antipyretics in intracerebral hemorrhage patients because fever is associated with worse prognosis, increased intracranial pressure, and prolonged fever duration independently predicts poor functional outcome. 3

• However, prophylactic antipyretic therapy (treating before fever develops) has not been shown to improve functional outcomes. The PAIS-1 trial showed no benefit from prophylactic paracetamol in stroke patients including those with ICH (adjusted OR 1.20,95% CI 0.96–1.50). 3

When to Administer Acetaminophen in Hemorrhagic Stroke

Acetaminophen should be administered reactively when fever (≥38°C core temperature) is detected, not prophylactically in normothermic patients. 3

Treatment Algorithm:

1. Obtain accurate core temperature measurement (oral or rectal preferred; avoid axillary). 2, 1

2. If temperature ≥38°C (100.4°F):

   • Initiate acetaminophen as first-line antipyretic (typical dosing 1000mg every 6 hours, maximum 4g/24 hours). 4, 3
   • Simultaneously investigate and treat infectious sources (chest radiograph, aspiration screening, appropriate cultures). 2, 3
   • Monitor temperature response within 4 hours (acetaminophen may lower temperature by mean 0.26°C). 4

3. If temperature <38°C (100.4°F):

   • Do not administer routine antipyretics. 2
   • Continue temperature monitoring.
   • Reserve antipyretics for patient comfort if requested. 2

Critical Warnings for This Patient

• At post-stroke day 20, fever is more likely infectious (aspiration pneumonia, urinary tract infection) than neurogenic. Fever occurs in >30% of hemorrhagic stroke patients, especially with intraventricular extension. 3

• Routine use of antipyretics without documented fever is not recommended in critically ill patients. 2

• If fever develops, acetaminophen's effectiveness may be limited—patients with temperatures >38°C may be relatively unresponsive to treatment. 4

• Target normothermia (36–37°C), not hypothermia. Deep hypothermia (32–34°C) carries high complication rates including coagulopathy (each 1°C drop reduces clotting factor activity by ~10%), pulmonary complications, and rebound intracranial hypertension. 3

Bottom Line for This Case

This patient's axillary temperature of 98.8°F does not warrant acetaminophen administration. Obtain a reliable core temperature measurement (oral or rectal), and only initiate antipyretic therapy if true fever (≥38°C) is documented. 2, 3, 1 Scheduled antipyretics every 6 hours in a normothermic patient are not evidence-based and may expose the patient to unnecessary medication without benefit. 2, 3