I wish blood pressure did not exist.

[Birdstrike]

A lot of times in Medicine, we're treating psychology without even realizing it.

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[Birdstrike]

Not.Even.Close.
Fevers are protective. That's why we still have them. Because our ancestors with fevers outlived those who didn't mount them.
See Fever Is Associated with Reduced, Hypothermia with Increased Mortality in Septic Patients: A Meta-Analysis of Clinical Trials

I've always thought along these lines, myself. It seems that from an evolutionary standpoint, there's a very good chance this is correct. Are our bodies reacting to infection with fevers? Are our bodies being duped by pathogens into a self destructive reaction, which is the fever?

Or are our bodies being proactive, by creating the fever response, because there's something protective about a fever?

Does a fever make the body a less hospitable place for a pathogen?
Does a fever make our body more able to fight off an infection?

I'm not sure which it is.

Either way, I'm under no delusion that when I'm treating a fever symptomatically, that I'm doing it because I must do it. I'm doing it because I'm treating psychology. Treating a fever, is good persuasion. Everyone is persuaded that things are moving in the right direction, when a fever comes down, regardless of whether it ultimately alters the course of the patient's disease, either in a positive or negative way. Does treating a fever make people get healthy quicker? Does treating a fever suppress a protective reflex generated by the human body?

I don't know. But treating a fever is powerfully persuasive, psychologically. Persuasive psychology is 99% of what physicians do. And it's 100% of lawsuits.

 

[Arcan57]

I discharged a kid home with fever, and hadn't treated him with antipyretics. Came back via ambulance 20 minutes later with a febrile seizure. I'll usually try to bring the fever down to minimize that from happening.

Even though studies have shown that scheduled max dose anti-pyretics don't reduce rates of febrile seizures?

 

[UKEMdoc]

Hypothermia in sepsis is essentially decompensation - it signals failure of the bodies standard coping mechanisms. Please note this refers to genuine hypothermia not a slightly low peripheral temperature on a cold day.

 

[Apollyon]

Does a fever make the body a less hospitable place for a pathogen?

Lice leave cold bodies (dead) and hot bodies (febrile). I recall reading somewhere maybe 20 or 25 years ago about an old practice of injecting milk subcutaneously to induce a fever to de-louse someone.

 

[deleted109597]

Well, yeah. The whole "therapeutic hypothermia" trend was proven false because it turns out that you decrease badness by reducing fevers, not by keeping people at 33C. And yet, we all have to purchast 5 figure Arctic Suns to allow people to be cold.
Again, fevers ARE good, or we wouldn't still mount them. I'm not sure why this is an argument. Normal people can't mount a pathologic fever. Abnormal people can, so checking the actual temp is still appropriate.

 

[thegenius]

Not.Even.Close.
Fevers are protective. That's why we still have them. Because our ancestors with fevers outlived those who didn't mount them.
See Fever Is Associated with Reduced, Hypothermia with Increased Mortality in Septic Patients: A Meta-Analysis of Clinical Trials

Ninja, there is nothing I wrote that merits “Not.Even.Close.” What’s up with the periods anyway?

I.made.no.comment.about.whether.fever.is.good.or.bad. just a comment about correlation between fever and possibility of bacteremia.

 

[lymphocyte]

Again, fevers ARE good, or we wouldn't still mount them. I'm not sure why this is an argument..

"Sepsis IS good. Otherwise we still wouldn't mount a septic response to infection. I'm not sure why this is an argument..."

There's about a thousand dumb ways the body responds to things. Fever is *sometimes* one of those ways, like in stroke.

 

[Brigade4Radiant]

"Sepsis IS good. Otherwise we still wouldn't mount a septic response to infection. I'm not sure why this is an argument..."

There's about a thousand dumb ways the body responds to things. Fever is *sometimes* one of those ways, like in stroke.

Uhh sepsis is not a body response...


The body is far better than modern medicine. Case in point fighting infection in someone who has a CD4 count less than 50.

Also temperature is modulated by the brain and strokes happen when the brain isn't working.

 

[Rendar5]

Uhh sepsis is not a body response...


The body is far better than modern medicine. Case in point fighting infection in someone who has a CD4 count less than 50.

Also temperature is modulated by the brain and strokes happen when the brain isn't working.

Septic shock is a body’s response. It’s just a piss poor self destructive response.

Cytokines come from us, not from the infective source.

 

[lymphocyte]

Uhh sepsis is not a body response...

Sepsis is by definition a dysregulated host response.

Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-10.

 

[Brigade4Radiant]

Yes sepsis is the body's response to an overwhelming infection but you have to have the pathogen invading the host.

And yes that paper is stating that they recommend changing the definition of sepsis to having a SOFA score of 2 or more. But it isn't like if they body didn't react with cytokines you would be okay or that the body should have no problem. The host response becomes dis-regulated because having a SOFA score that high means the infection has become so severe.

 

[lymphocyte]

that paper is stating that they recommend changing the definition of sepsis to having a SOFA score of 2 or more.

No. The paper defines sepsis as "life-threatening organ dysfunction caused by a dysregulated host response to infection." That's the international consensus definition of sepsis: in 2018, that's what sepsis is.

SOFA identifies organ dysfunction. That's all SOFA does.

Do you like blood pressure? I like blood pressure. I like that it exists.

 

[deleted109597]

No. The paper defines sepsis as "life-threatening organ dysfunction caused by a dysregulated host response to infection." That's the international consensus definition of sepsis: in 2018, that's what sepsis is.

SOFA identifies organ dysfunction. That's all SOFA does.

Do you like blood pressure? I like blood pressure. I like that it exists.

Well, without it your brain wouldn't work. But unlike increased BP for things like, ischemic stroke, which can be a harmful response, fevers actually help fight infection. And apart from cases like heat stroke, malignant hyperthermia, nor neuroleptic malignant syndrome, the body won't make a pathologic fever. 105 isn't harmful to your brain when fighting off an infection.
Fevers in stroke are completely different. That's from a damaged response, not normal.
Think high altitude pulmonary edema for a normal process that's screwed up by outside factors.

Also, septic shock isn't a normal response. It's the pathogen overwhelming the body and causing endothelial disruption and leaky capillaries.

 

[deleted109597]

Ninja, there is nothing I wrote that merits “Not.Even.Close.” What’s up with the periods anyway?

I.made.no.comment.about.whether.fever.is.good.or.bad. just a comment about correlation between fever and possibility of bacteremia.

You wrote this.

I think it has something to do with, back in the day, the lowest temp possible that correlated with septicemia. That is, the chance of having positive blood cultures below 100.4 is exceedingly rare.

It's completely wrong. Hence, it's not even close to correct. It's not an opinion, you're flat out wrong.

 

[lymphocyte]

Well, without it your brain wouldn't work. But unlike increased BP for things like, ischemic stroke, which can be a harmful response, fevers actually help fight infection. And apart from cases like heat stroke, malignant hyperthermia, nor neuroleptic malignant syndrome, the body won't make a pathologic fever. 105 isn't harmful to your brain when fighting off an infection.
Fevers in stroke are completely different. That's from a damaged response, not normal.
Think high altitude pulmonary edema for a normal process that's screwed up by outside factors.

Fever has a metabolic cost. I generally treat it in shocked patients. True, RCTs show equivocal benefit in sepsis, but a lot depends on the VO2 of the patient in front of you. There also seems to be a pretty clear benefit in AMI (it's predictive of infarct size in a really well-done cardiac MRI study, for example).

Jang WJ, Yang JH, Song YB, et al. Clinical Significance of Postinfarct Fever in ST-Segment Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study. J Am Heart Assoc. 2017;6(4)

 

[Rendar5]

I wouldn’t mind an RCT that looked at say the flu to see if letting someone have a fever or not shortened the course of the illness or viral load or viral shedding or whatnot. I’ll have to spend some time looking for one if it were published. To simply say that fever is the body’s beneficial response based on something I learned as a child (which I did) without evidence to back it up is rather dogmatic. Shouldn’t be too hard to test it for some simple viral illnesses

 

[deleted109597]

I wouldn’t mind an RCT that looked at say the flu to see if letting someone have a fever or not shortened the course of the illness or viral load or viral shedding or whatnot. I’ll have to spend some time looking for one if it were published. To simply say that fever is the body’s beneficial response based on something I learned as a child (which I did) without evidence to back it up is rather dogmatic. Shouldn’t be too hard to test it for some simple viral illnesses

There's plenty of evidence. It's the fact that we still do them. Fevers do have metabolic cost, that's clear. If they were a net negative, evolutionary pressure would have made them cease to exist by now. This isn't like cancer that develops after procreation, literally every child has multiple febrile illnesses before they have more offspring. The fact that people who don't mount fevers (or become hypothermic) have higher mortality is pretty good proof as well.

 

[deleted109597]

Fever has a metabolic cost. I generally treat it in shocked patients. True, RCTs show equivocal benefit in sepsis, but a lot depends on the VO2 of the patient in front of you. There also seems to be a pretty clear benefit in AMI (it's predictive of infarct size in a really well-done cardiac MRI study, for example).

Jang WJ, Yang JH, Song YB, et al. Clinical Significance of Postinfarct Fever in ST-Segment Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study. J Am Heart Assoc. 2017;6(4)

It's reasonable to try and decrease metabolic requirements in shocked patients. That's not the only group that gets them.
And yes, most of the 'therapeutic hypothermia' trials have found that it's not keeping patients, cool, it's preventing fever that helps. Just like the trials that show extra oxygen is also harmful. We don't need more free radicals out there. But those are, again, dysfunctional responses.
A corollary would be to argue that our clotting process is bad because people with neisseria meningits have purpura.

 

[Angry Birds]

This has turned into a pissing contest. Who's winning?

 

[Apollyon]

This has turned into a pissing contest. Who's winning?

Not me; that's clearly evident, by common consent. No RCT needed.

 

[Rendar5]

There's plenty of evidence. It's the fact that we still do them. Fevers do have metabolic cost, that's clear. If they were a net negative, evolutionary pressure would have made them cease to exist by now. This isn't like cancer that develops after procreation, literally every child has multiple febrile illnesses before they have more offspring. The fact that people who don't mount fevers (or become hypothermic) have higher mortality is pretty good proof as well.

I don’t doubt that they’re probably good for combatting illness, and your reasoning above is sound—I myself was always taught that and have no reason to really doubt it; I’m just saying it’s a bit dogmatic and I’d have to look for some proof as sometimes dogma is incorrect and we don’t realize it because it makes too much rational sense. It may be out there, I honestly don’t know. The paper cited earlier about septic patients isn’t really good proof, though. Too many confounders honestly, e.g. septic patients who are normothermic may have had delays in recognition leading to worse outcomes than those with fevers, in whom sepsis is more easily recognized. As I said, probably be useful to see some experimentation or trials in infectious disease states with a rather low mortality rate with a different end-point. Trust but verify.

 

[thegenius]

This has turned into a pissing contest. Who's winning?

Indicating who are winning and losing would further spray the piss.

It's rather ridiculous to think that treating fever in the vast majority of our mild-to-moderate infections is actually making things worse for them. Oh because it's natural and hasn't been weeded out by evolutionary forces that act over 100,000s of years...it must be good and preserved at all cost!

How many 1-2 yr old kids stop eating because their temp is 103 due of their "hyperactive immune system" turning up the temp at the mildest of provocation?

A fever might be protective, but a simple dose of plain.old.acetaminophen.allows.these.kiddos.to.feel.better.so.they.eat. (And.dont.die.)

 

[thegenius]

 

[Birdstrike]

I guess this bad boy is still up for grabs:

 

[deleted109597]

Indicating who are winning and losing would further spray the piss.

It's rather ridiculous to think that treating fever in the vast majority of our mild-to-moderate infections is actually making things worse for them. Oh because it's natural and hasn't been weeded out by evolutionary forces that act over 100,000s of years...it must be good and preserved at all cost!

How many 1-2 yr old kids stop eating because their temp is 103 due of their "hyperactive immune system" turning up the temp at the mildest of provocation?

A fever might be protective, but a simple dose of plain.old.acetaminophen.allows.these.kiddos.to.feel.better.so.they.eat. (And.dont.die.)

You sound like the combination of a nurse and a first time mom.
Not eating for one day won't hurt you.
OTOH. Effect of Antipyretic Therapy on Mortality in Critically Ill Patients with Sepsis Receiving Mechanical Ventilation Treatment
Also this.
Should we treat pyrexia? And how do we do it?

And for those who are equating this with a pissing contest, It's arguably not. It's a scientific question. One side has produced multiple papers. The other side has produced feelings and wants.

 

[thegenius]

Should we treat pyrexia? And how do we do it?

And for those who are equating this with a pissing contest, It's arguably not. It's a scientific question. One side has produced multiple papers. The other side has produced feelings and wants.

This paper does not conclude anything but “need more research.” This is the conclusion to that paper:

*************************
There is now awareness that a balance is required between the severe metabolic stress induced by pyrexia and its possible contribution to host defences. On what side the balance is can strongly vary between patient groups. The precise, safe and efficient control of temperature is now well within our ability, although analysis of the literature does not provide recommendations for preferred methods of treatment in clinical practice. Several studies have found certain techniques have some superiority over others but none have demonstrated a beneficial clinical impact of a more rapid induction or a better control of normothermia on patient outcome. Further studies are needed to determine which patients would benefit the most from control of pyrexia and by which means this should be implemented.
***************************

More pissing about!

 

[Birdstrike]

You sound like the combination of a nurse and a first time mom.

Hey, hey, hey. That was a low blow.

And for those who are equating this with a pissing contest, It's arguably not. It's a scientific question. One side has produced multiple papers. The other side has produced feelings and wants.

In other words, you're saying, "Facts don't care about your feelings."

 

[sunshinefl]

You sound like the combination of a nurse and a first time mom.
Not eating for one day won't hurt you.
OTOH. Effect of Antipyretic Therapy on Mortality in Critically Ill Patients with Sepsis Receiving Mechanical Ventilation Treatment
Also this.
Should we treat pyrexia? And how do we do it?

And for those who are equating this with a pissing contest, It's arguably not. It's a scientific question. One side has produced multiple papers. The other side has produced feelings and wants.

I’m a medical student following the thread and appreciate the discussion. This is why I try to tell my classmates there is value to SDN. But some are still scarred from pre-med forum so they stay away.

 

[deleted109597]

I’m a medical student following the thread and appreciate the discussion. This is why I try to tell my classmates there is value to SDN. But some are still scarred from pre-med forum so they stay away.

Premed can be a little blunt. We are actively working on that as moderators, but you can only change things a little at a time or people leave in droves. Thanks for sticking with it.

 

[GeneralVeers]

I'm all for science, and completely agree that fever is a natural process, and possibly shouldn't be interfered with. The only problem I would see is trying to explain to all the neurotic, poorly-educated parents why you aren't treating a fever......bring on the bundles of hospital and medical board complaints.

 

[lymphocyte]

You sound like the combination of a nurse and a first time mom.
Not eating for one day won't hurt you.
OTOH. Effect of Antipyretic Therapy on Mortality in Critically Ill Patients with Sepsis Receiving Mechanical Ventilation Treatment
Also this.
Should we treat pyrexia? And how do we do it?

And for those who are equating this with a pissing contest, It's arguably not. It's a scientific question. One side has produced multiple papers. The other side has produced feelings and wants.

Exterior cooling sucks because it also jacks your VO2. The second paper you cite actually agrees with what I'm saying. There's a gradient of benefit, and a lot of the benefit is driven by the underlying pathophysiology. Shocked or ischaemic patients should get antipyretics.

Febrile well-looking kid -- do whatever you want. Kid will honestly be fine either way.

 

[gamerEMdoc]

Febrile well-looking kid -- do whatever you want. Kid will honestly be fine either way.

For the win...

 

[Angry Birds]

In other words, you're saying, "Facts don't care about your feelings."

You're a fan of that twerp?

 

[Birdstrike]

You're a fan of that twerp?

I think you're referring to Ben Shapiro?
I'm actually not a fan. He kind of annoys me, actually. I'm surprised you don't like him, though. He's a Trump-hater. You and he should bond on that alone.

I like the quote, though. Clever and pithy. But yeah, I probably shouldn't use a quote popularized by him (not sure if it's his originally) since the automatic (false) assumption is that one must be a fan of anyone one quotes. I'm surprise anyone's heard of him.

 

[Angry Birds]

I like the quote, though. Clever and pithy. But yeah, I probably shouldn't use a quote popularized by him (not sure if it's his originally) since the automatic (false) assumption is that one must be a fan of anyone one quotes. I'm surprise anyone's heard of him.

Just asking bro!

 

[Birdstrike]

Just asking bro!

It's all good, bro.

 

[Lawpy]

I’m a medical student following the thread and appreciate the discussion. This is why I try to tell my classmates there is value to SDN. But some are still scarred from pre-med forum so they stay away.

There is a lot of awesome stuff on SDN. The premed forums unfortunately aren't great, but the specialty forums are awesome.

 

[sunshinefl]

There is a lot of awesome stuff on SDN. The premed forums unfortunately aren't great, but the specialty forums are awesome.

You’re preaching to the choir @Lawper !!! I learn so much from these forums.

 

[Birdstrike]

You’re preaching to the choir @Lawper !!! I learn so much from these forums.

You guys learn from our pissing matches?

 

[VA Hopeful Dr]

You guys learn from our pissing matches?

Honestly yes. I often have to learn a good bit to even figure out why you're arguing about something. Before last week I had no idea what a HEART score was (as a family doctor, I have no need for it). Most of it is stuff that won't change my practice at all, but its always good to learn new things.

Plus it helps to understand why other specialties do the things they do.

 

[thegenius]

Just make sure you don't get any of our piss on you.

So...what have you learned so far about us, may I ask?

 

[killerleaf]

I have learned that ya'll don't like it when a patient comes in with what they think is a high blood pressure reading that they have taken at home, but have no other symptoms.

However, couple that with weakness, worst headache ever, those type of things, and then there may be value in that score.

(did I get that right??)

 

[deleted109597]

I have learned that ya'll don't like it when a patient comes in with what they think is a high blood pressure reading that they have taken at home, but have no other symptoms.

However, couple that with weakness, worst headache ever, those type of things, and then there may be value in that score.

(did I get that right??)

Asymptomatic hypertension is not an emergency. Patients get upset with us for not doing something about it.
Weakness? As in, generalized old person no specific complaint weakness? Yeah, that's not a specific thing either, and unlikely to be caused by their essential hypertension.
Worst headache of life? Everybody has one of those at some point in their life. Exceedingly few of them are relevant. Now, sudden onset maximal intensity makes you think of subarachnoid, but other than that, plenty of studies show that headaches (and nosebleeds) actually cause the hypertension, rather thanthe other way around.
So, if they're complaining of chest pain, focal weakness, altered mental status (PRES is a thing), or any other number of specific things, then it warrants workup.

 

[killerleaf]

Dr. McNinja,
Thank you for clarifying. All my life, I have been told by the media, TV shows, and even doctors (not ED) that a sudden increase to high blood pressure was a scary thing, especially if you have a bad headache, and you need to be seen right away, or you will "stroke out". There probably needs to be communication, that high blood pressure does not mean you are going to die.

 

[deleted109597]

Yeah, almost all of us give that speech nearly every day.
It's rooted in the same sense of "don't go to sleep after a head injury because you might not wake up." Yes, 100% of those who died after head injuries were comatose, but it wasn't because they went to sleep.
Also, nearly all strokes are hypertensive during the stroke. And high BP does increase risk of stroke over a lifetime. But acutely, it's not so easy to say. Large rises in BP do put you at risk of popping an aneurysm (hence people having them on the toilet during valsalva), but if was already high your risk is the same as baseline.
Us lowering BP acutely puts you at risk of falling out though.

 

[killerleaf]

lol