Theilen H, Ragaller M
Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstrasse 74, 01307 Dresden.
Anaesthesist. 2007 Sep;56(9):949-52, 954-6. doi: 10.1007/s00101-007-1211-z.
In critically ill patients fever is associated with an increased morbidity and mortality rate. However, it remains unclear whether fever is an associated symptom of the underlying severe disease or a stimulator of specific pathophysiological cascades considered responsible for a deleterious outcome. Hyperthermia per se induces systemic changes like increased energy and oxygen demands, tachycardia, or fluid loss which might be harmful especially in septic patients due to congestion of the cardiovascular system. In this constellation a reduction of fever by antipyretic strategies might be indicated to decrease oxygen and energy demands. On the other hand the increasing body temperature obviously plays an important role in the inflammatory hemostasis during infections. Fever optimises humoral and cellular responses to infection and has some direct effects on bacteria and other microorganisms. Therefore, in severe sepsis or septic shock, fever reduction might impair the immune competency of the patients. According to the currently available evidence a body temperature higher than 40 degrees C is definitely harmful and should be treated in any case. A temperature range between 36 degrees C and 39 degrees C should be achieved for patients with severe sepsis and septic shock. At present there are no data showing the superiority of any of the different antipyrectic strategies in septic patients. Hence, external cooling with cold blankets or other devices may induce shivering of the muscles with a substantial increase of oxygen demand and is hardly tolerated in conscious patients. However, antipyretic therapy in patients with severe sepsis or septic shock should be indicated while considering the individual pathophysiology of every patient.
在危重症患者中，发热与发病率和死亡率增加相关。然而，发热究竟是潜在严重疾病的相关症状，还是被认为对有害结局负有责任的特定病理生理级联反应的刺激因素，仍不清楚。高热本身会引发全身变化，如能量和氧气需求增加、心动过速或液体流失，这可能尤其对脓毒症患者有害，因为心血管系统会出现充血。在这种情况下，可能需要采用退热策略来降低发热，以减少氧气和能量需求。另一方面，体温升高在感染期间的炎症止血过程中显然起着重要作用。发热可优化对感染的体液和细胞反应，并对细菌和其他微生物有一些直接影响。因此，在严重脓毒症或脓毒性休克中，降低发热可能会损害患者的免疫能力。根据目前可得的证据，体温高于40摄氏度肯定有害，无论如何都应进行治疗。对于严重脓毒症和脓毒性休克患者，应将体温维持在36摄氏度至39摄氏度之间。目前尚无数据表明在脓毒症患者中任何一种不同的退热策略具有优越性。因此，使用冷毯或其他设备进行外部降温可能会诱发肌肉颤抖，导致氧气需求大幅增加，且清醒患者很难耐受。然而，在考虑每位患者的个体病理生理学情况时，应对严重脓毒症或脓毒性休克患者进行退热治疗。
