In patients with hypertensive cerebral hemorrhage, fever is a sensitive and objective indicator of disease change and a common symptom in patients with hypertensive cerebral hemorrhage. The higher the body temperature, the earlier the first hyperthermia occurs, and the longer the duration of hyperthermia, the worse the prognosis of quality of life. Reasonable and effective care measures for patients with hypertensive cerebral hemorrhage and hyperthermia can help improve the prognosis and quality of life of patients with hypertensive cerebral hemorrhage, and reduce the disability and death rate.
Classification of causes:
1, pulmonary infection: is the main cause of hypertensive cerebral hemorrhage fever. Some studies have reported that it is related to the following factors:
The effect of intracranial hematoma can easily cause damage to the lower thalamus, which can lead to the release of a large amount of sympathetic substances and the release of peripheral vasoconstriction, resulting in an increase in blood pressure and the transfer of blood from the high-resistance peripheral circulation to the low-resistance pulmonary circulation, resulting in an increase in the hydrostatic pressure of fluid in the pulmonary artery and damage to the capillaries and the leakage of fluid into the alveoli, resulting in early neurogenic pulmonary edema. Recent studies have shown that neurogenic pulmonary edema is closely related to the condition of cerebral hemorrhage, with a high incidence in those with heavy bleeding and severe disease, and is caused by low blood oxygen.
②Vomiting due to unconsciousness, swallowing disorder and intracerebral hypertension can cause aspiration and lead to aspiration pneumonia.
When most patients are unconscious, the cough reflex is weakened or disappears, the back of the tongue obstructs the pharynx, nasal secretions reflux and accumulate in the larynx, so the patient is at risk of aspiration; in addition, the application of dehydrating agents reduces body fluids and makes the sputum sticky, and the secretions in the airway cannot be discharged or are poorly discharged, blocking the small airways and making the lobules incompletely inflated. This is conducive to the growth of pathogenic microorganisms, which makes it easy to complicate infection on the basis of neurogenic pulmonary edema.
④Patients are older and have decreased lung compliance, increased alveolar permeability, and poor respiratory function.
⑤ Pulmonary infections can also originate from medical infections caused by improper mechanical assisted breathing measures.
(6) Secondary infections caused by the use of adrenocorticosteroids and cross-infections caused by prolonged hospitalization.
(7) Absolute bed rest during the acute period makes sputum accumulate easily, and bronchial cilia movement is weakened, so that sputum and secretions cannot be expelled effectively, and pneumonic pneumonia occurs.
2, urinary tract infection: the incidence of urinary tract infection in patients with hypertensive cerebral hemorrhage is second only to upper respiratory tract infection. The infecting bacteria are mostly gram-negative bacilli residing in the skin mucosa. Especially for long-term indwelling urinary catheter (more than 1 week), especially for female patients, urinary catheterization can cause damage to the mucosa of the urethra, which is prone to bacterial retrograde infection. If hormonal drugs are used at the same time, the body’s anti-inflammatory capacity can be further reduced; in addition, rescue patients due to time constraints, not strictly in accordance with the principles of aseptic operation, easy to cause urinary tract infections.
3, skin infection: hypertensive cerebral hemorrhage patients are mostly elderly, dry and wrinkled skin, tissue atrophy, damage repair ability is poor, long-term friction, moisture stimulation, skin infection is very likely to occur. In addition to the acute phase of absolute bed rest, critical condition, incontinence, limb dysfunction, so that long-term pressure on the skin, diaper stimulation, prone to pressure sores and diaper dermatitis, resulting in skin infections.
4, intestinal infections:
①Eating unclean food.
② Brain hemorrhage causes a large amount of gastric acid secretion, resulting in acute damage to the gastric mucosa, bleeding, erosion, and stress ulcers.
(3) Long-term use of broad-spectrum antibiotics resulting in dysbiosis. The diagnosis of intestinal infection can be made by meeting one of the following conditions:
①Acute diarrhea. Stool routine microscopic examination of leukocytes ≥ 10 / high magnification field;
②Acute diarrhea or with fever, nausea, vomiting, abdominal pain, etc;
③ diarrhea more than 3 times a day, 2 consecutive days or a day of water diarrhea more than 5 times;
④Fecal or anal swab specimens cultured with intestinal bacteria.
5.Infection fever in the operation area
Absorption fever: Fever caused by the release of various thermogenic factors from the lysis of red blood cells in the process of blood absorption, without mesencephalic lesions or symptoms of co-infection, which occurs 3 to 10 days after the onset of the disease, with a moderate fever and low fever of about 38℃.
Dehydration fever: It is caused by excessive use of dehydrating drugs such as mannitol and tachyphylaxis and insufficient hydration, resulting in blood concentration and involvement of the intracranial regulation center. In addition, excessive dehydration can also lead to difficulty in expelling sputum due to lack of body fluid, which also increases the risk of dehydration fever.
6. Central fever: It is caused by damage to the subthalamic thermoregulatory center. Patients also have evidence of mesencephalic damage, there are two manifestations: one is the acute onset within 24 hours of the rise in body temperature, reaching 39 ℃ or more persistently, the patient coma, to the brain tonic, sweating, cold extremities, often die within a few days; the other is a persistent central fever, the patient may have coma, bilateral cone bundle signs, paroxysmal sweating, pupil size variable, unstable blood pressure fluctuations, increased blood sugar. These cytokines are endogenous pyrogens, which can stimulate the heat-sensitive neurons in the preoptic area of the anterior hypothalamus, shifting the temperature threshold upward and causing an increase in body temperature. After brainstem injury, sympathetic excitation, the release of a large number of catecholamines, can stimulate AH/JOA heat-sensitive neurons, up-regulate the “tuning point” temperature threshold, resulting in an increase in body temperature. When craniocerebral injury involves the hypothalamus, the thermoregulatory center is dysfunctional, and the temperature of the “regulating point” is shifted upward, resulting in an increase in body temperature.
7, cryptogenic infection deep intravenous tube, etc.
The difference between central fever and infectious fever.
Central fever or infectious fever can be distinguished from the following two points: First, whether the fever is sweating or not, central fever is not sweating, while the general fever is accompanied by sweating. The second is the response to drugs. Central hyperthermia is ineffective to antipyretic and analgesic drugs and hormones, while infection-induced fever is effective in reducing fever; central hyperthermia is ineffective to anti-infection treatment, while infection-induced fever is effective to sensitive antimicrobial agents. Due to the need to lower cranial pressure, large doses of dehydrating agents are applied, resulting in massive water loss, leading to dehydration fever, which can be corrected after replenishing blood volume; if the infected patient has high fever and rapid heart rate, it indicates systemic inflammatory response syndrome; if the blood pressure is low at the same time and requires vasoactive drugs to maintain, it indicates infectious toxic shock, and it is recommended to immediately make blood culture and use broad-spectrum antibiotics.
The patient’s body temperature above or equal to 39℃ is defined as hyperthermia. Infectious fever is diagnosed when there is an obvious systemic or chest inflammatory reaction, along with low blood pressure, and positive sputum culture, cerebrospinal fluid culture, and blood culture.
If the patient is insensitive to antipyretic and anti-infective drugs, the diagnosis is central hyperthermia, and bromocriptine is used, along with physical and pharmacological cooling.
After the application of a large amount of dehydrating drugs, the heart rate was accelerated, blood pressure was lowered and hyperthermia was observed. The clinical manifestation of dehydration was diagnosed as typical dehydration fever by monitoring central venous pressure.
Postoperative absorption fever can be divided into early absorption fever and late absorption fever. Early absorption fever occurs 1 to 3 d after surgery, and late absorption fever occurs 5 to 7 d after surgery. late absorption fever can be of the retention fever or tachyphylaxis type and fluctuates around 38.5 ℃, with a few cases above 39 ℃. lumbar puncture cerebrospinal fluid tests reveal a hemorrhagic cerebrospinal fluid with proportionally higher erythrocytes and leukocytes, higher protein content, normal or slightly lower sugar and chloride, and negative bacterial cultures. Aseptic meningitis is common after epidermoid cyst and cerebral nerve microvascular decompression, with fever occurring 3-7 days after surgery, temperature reaching 38-40 ℃ for 2-3 weeks or longer, positive meningeal irritation signs, decreased cerebrospinal fluid sugar and chloride, increased white blood cell count and protein content, and negative cerebrospinal fluid bacterial culture. Diagnostic criteria for intracranial infection :
① Postoperative fever with symptoms of cranial hypertension such as headache, vomiting, impaired consciousness and meningeal irritation;
(ii) Increased peripheral blood leukocytes or increased neutrophil ratio; increased cerebrospinal fluid leukocytes, increased protein, decreased sugar and chloride;
③Evidence of abscess on imaging or re-surgery to confirm abscess;
④ Positive smear culture of cerebrospinal fluid and punctured pus. If the cerebrospinal fluid smear or culture is negative, the diagnosis will be made by combining the remaining items. Judgment of local effusion: postoperative review of cranial CT shows cerebrospinal fluid collection in the tumor bed, subdural and even under the skin flap in the bone window area, and in a few cases, cerebrospinal fluid leakage may occur.
Measures.
Prevention and treatment of respiratory tract infection:
①Give early and continuous oxygen inhalation to prevent the occurrence of neurogenic pulmonary edema.
② Elevate the head of the bed by 30°, encourage patients to cough and breathe deeply frequently, and do not use a straw to drink water. For patients with obvious consciousness disorders, they should be placed in the lateral position and the corners of the mouth should be lowered. For those who are unconscious and vomiting, foreign bodies in the mouth should be sucked up with a bedside suction device after vomiting to prevent aspiration into the trachea.
To prevent nasal reflux, the speed of nasal feeding should not be too fast, and pay attention to the appropriate temperature. Before nasal feeding, sputum should be fully aspirated, and after nasal feeding, the head of the bed should be elevated by 30° for 2 hours. In case of gastric reflux, the daily amount of nasal feeding can be reduced appropriately, and in severe cases, no food should be taken for a while. A small amount of gas should be injected at the time of extubation to prevent food from falling into the trachea when the tube is withdrawn.
④Strengthen respiratory care: for those who cannot eat due to consciousness impairment, oral care must be strengthened; according to the condition, the patient should be repeatedly turned and patted on the back for 5-6 minutes each time to facilitate sputum discharge, and the color and nature of sputum should be observed; comatose patients should be regularly aspirated with a sputum aspirator, and the catheter should be changed each time the sputum is aspirated to avoid co-infection. Patients with concurrent pneumonia have a lot of sputum that cannot be thoroughly aspirated, and even a large amount of antibiotics cannot satisfactorily control pneumonia. However, it should be noted that the patient’s head should not be moved too much during the above operation. To prevent aggravation of cerebral hypoxia, the time of sputum aspiration should be strictly controlled, 10~15 seconds each time, the depth of insertion should be appropriate, the site should be accurate, and the action should be gentle; mechanical assisted breathing should be used correctly to avoid cross infection. In case of severe pulmonary infection with high body temperature, sticky sputum that cannot be easily coughed out and impaired consciousness that cannot be recovered within a short period of time, and if medication is ineffective or there is asphyxia, notify the doctor in time and consider tracheotomy to facilitate sputum removal. Endotracheal administration of drugs and mitigation of mucosal damage caused by pharyngeal aspiration, as well as tracheotomy care measures are given. Respiratory infections complicated by cerebral hemorrhage are mostly hospital-acquired pathogenic infections, with Gram-negative bacterial infections being the most common (50%-60%), such as Escherichia coli, Pneumococcus, Pseudomonas aeruginosa, etc., all accounting for 10%, and Pneumococcus less common. The room was ventilated by opening the window twice a day for 30 minutes each time. The bed unit is wet cleaned, the bedside table has one table and one cloth, the floor is scrubbed with disinfected mop, sputum specimens are taken in time for bacterial culture, and antibiotics are applied reasonably.
Prevention and treatment of urinary tract infection: To reduce urinary tract infection, catheterization should be avoided as much as possible. If catheterization is necessary, strict disinfection should be applied and a sterile closed system should be used. The urethral opening should be cleaned with 0-25% iodine twice a day, the stool should be removed in time, and the perineum should be washed after the stool. Asymptomatic bacteriuria generally does not need to be treated, so as not to cause drug-resistant bacteria to colonize. If you have symptoms, you can choose antibiotics according to the isolated pathogenic bacteria and the results of the drug sensitivity test, and give bladder irrigation twice a day. Most bacteriuria is eliminated after catheter removal or antibiotics are administered.
Prevention of skin infection: The skin has the function of protecting the body, regulating body temperature, absorption, secretion, excretion and sensation, etc. The intact skin has a natural barrier to avoid microbial invasion. Skin metabolism is rapid, its excretion of waste such as sebum and shed epidermal debris, can be combined with external bacteria and dust, adhering to the surface of the skin, if not eliminated in time, will cause skin inflammation. The sweat is acidic and stays on the skin to stimulate the skin, which reduces its resistance and destroys its barrier role, becoming a gateway for bacterial invasion and causing various infections. Preventive measures:
①Keep the bed clean and dry, clean vomit and excrement at any time.
②Establish turning card, turn regularly, massage the bone ridge, and avoid dragging and pushing when turning.
③ scrub the skin of the whole body with warm water of 40~45℃ every day in summer, especially at the skin folds, wash the perineum every day, clean it at any time after defecation, and keep the perineum dry. Cut finger (toe) nails every week.
Intestinal infection prevention and control measures: give early nutritional support: gastric mucosa needs energy to regenerate and secrete mucus to protect the mucosa. Enteral nutrition can promote the repair of gastrointestinal tract, stimulate visceral and hepatic circulation, change mucosal blood flow, and prevent acidosis and osmotic disorders in the mucosa. In patients with cerebral hemorrhage, enteral nutrition should be given early, and formula diet should be given within 24~48 hours, gradually increasing from 25ml/hour to 100ml/hour, and antioxidants such as glutathione, vitamin E and carotene should be added. Fiber intake can improve the nutrition of the colonic mucosa to prevent intestinal-derived infections, with a daily requirement of 10g or more. When oral intake is not possible, nasal feeding is given early, and fluid can be extracted from the gastric tube to observe the gastric fluid situation. If diarrhea occurs, take stool specimens for examination, clean up the stool in time, give warm water to wash and wipe dry, and change bed sheets.
Closely observe the change of body temperature to detect the aura of infection in time: at the beginning of the illness, the patient’s body temperature is basically in the normal range or slightly low. The increase in body temperature should be excluded from absorption fever, central fever and dehydration fever. Infectious fever is mostly seen in comatose patients with cerebral hemorrhage, and infection often occurs in the respiratory tract, urinary tract, oral cavity and pressure sores. The fever should be detected as early as possible, and the doctor should be informed promptly and given appropriate treatment.
Care measures for central hyperthermia: Central hyperthermia can increase the metabolic rate and oxygen consumption of brain tissue, aggravate cerebral ischemia, hypoxia and cerebral edema, and further damage brain tissue on the basis of the original brain injury and cerebral hemorrhage. Hypothermia treatment can effectively control central hyperthermia and reduce the metabolism and oxygen consumption of brain cells. Selective local cerebral hypothermia can effectively reduce the energy metabolism of brain tissue, improve the symptoms of brain tissue hypoxia and ischemia, reduce the secondary damage of brain tissue, enable patients to safely pass the dangerous period, and greatly reduce the disability and death rate of patients.
Physical cooling:
①Electronic ice cap. Use electronic ice cap head cooling, set the temperature according to the season, generally set 2 ℃ in summer, set 5 ℃ in winter, to be tolerated by awake patients. During the cooling process, the brain temperature is generally controlled in the range of 33~35℃, which is safe and has few complications. Frostbite should be avoided during cooling.
②Ice bag. Use rubber ice bags filled with crushed ice, and then add ice water to make the ice corners become rounded and smooth, so as not to damage the skin. Can also use rubber gloves or plastic bags filled with ice, placed on the body surface of the large blood vessels.
Bathing: 32 ~ 36 ℃ warm water or 30% ~ 50% alcohol bathing.
Traditional hypothermia treatment methods, including the application of cooling blankets, ice caps, ice bags, fans and alcohol baths for surface cooling and ice saline intragastric or rectal irrigation, seem to be less than satisfactory for patients with craniocerebral fever, and physical cooling methods can cause chills, electrolyte disturbances and cardiac arrhythmias. Now, a new technique, endovascular cooling, which may replace the above-mentioned cooling methods, has been introduced in clinical practice.
Pharmacological hypothermia:
①Hibernation drugs. Half the amount of Hibernation I can be used for agitated patients with high fever to inhibit their activity and reduce heat production.
②Aspirin 1・0g can be added to 100ml of ice water in an enema. This method is generally used in patients with high fever of 40℃ or more, without hypotension and with clear consciousness. Precautions for hypothermia:
①Cooling measures should be taken early, before the emergence of hyperthermia, so that the brain is in a low-temperature environment to prevent damage to brain tissue from central hyperthermia.
② The speed of cooling should not be too fast, to reduce about 2 ℃ per hour is appropriate. Too fast cooling is easy to make the patient chills, thus increasing the oxygen consumption of the brain, and aggravate the condition.
③ Cooling to 37 ℃ for more than 1 week, before all cooling items can be gradually removed, not all together, so as not to cause brain hypoxia, edema and other adverse reactions due to rapid recovery of body temperature.
④Take cooling measures to cool down the body temperature 60 minutes after the drop is more obvious, can reflect the effect of cooling more real.
The treatment of absorption fever: physical cooling can be used. Prevention and treatment of dehydration fever: For patients with unexplained fever, dry skin, decreased urine volume and increased red blood cell pressure during treatment, the possibility of dehydration fever should be considered. Firstly, adjust the dose of dehydration, and give isotonic glucose water or isotonic saline and 5% glucose solution in the ratio of 1:3, and treat effectively by intravenous drip. Physical cooling can be used.
Changes in body temperature have an important impact on the prognosis of patients with hypertensive cerebral hemorrhage. Reasonable and effective care measures for patients with hypertensive cerebral hemorrhage and hyperthermia can reduce the disability rate and death rate of patients, and help improve the quality of life of patients.