Dexmedetomidine-associated fever in the intensive care unit.

Abstract

Dexmedetomidine is an intravenous, α-2 receptor agonist commonly used for the maintenance of sedation in the intensive care unit (ICU) [Hospira, 2014] (Box 1). The most recent iteration of the Society of Critical Care Medicine guidelines for pain, agitation and delirium preferentially recommend using a nonbenzodiazepine agent, such as dexmedetomidine, if a continuous-infusion sedative is required [Barr et al. 2013]. This recommendation is based on multiple trials which have demonstrated the benefits of dexmedetomidine over benzodiazepine infusions in mechanically ventilated ICU patients [Riker et al. 2009; Pandharipande et al. 2007; Jakob et al. 2012]. There is limited respiratory depression and the potential for less ICU-related delirium associated with the drug, which makes it an attractive option for ICU patients. Additionally, dexmedetomidine has demonstrated safety and efficacy outside of the mechanically ventilated patient and has been evaluated in situations such as alcohol withdrawal [Mueller et al. 2014]. Box 1. Key points about dexmedetomidine Dexmedetomidine (Precedex®, Hospira, Inc.) is a commonly used sedative agent in intensive care and operative settings for maintaining a lighter level of sedation. Although some investigators have evaluated α2-agonists as a potential target for the treatment of hyperthermia, fever has previously been reported with this agent. In our case and the previous published cases, this fever is quite impressive and may prompt investigation of causes such as neuroleptic malignant syndrome. Withdrawal of dexmedetomidine results in defervescence within a few hours of cessation of the infusion. The most commonly reported adverse effects associated with dexmedetomidine are hypotension and bradycardia, which can result in sinus arrest [Hospira, 2014]. Fever, or pyrexia, has been reported with dexmedetomidine use; however, this rate was no different than the control arm (4–5% for both dexmedetomidine and control) [Hospira, 2014]. In a more recent publication comparing midazolam or propofol with dexmedetomidine, there were no differences in the incidence of fever [Jakob et al. 2012]. Two case reports have been published describing high fevers related to dexmedetomidine [Okabe et al. 2009; Reeve et al. 2013] As fever in the ICU is commonly attributed to infections, underlying malignancy or thrombosis, development of an elevated temperature may prompt collection of multiple cultures, laboratory tests, imaging studies and other diagnostic testing. Although drug fever is typically a diagnosis of exclusion and should not subvert the need for common tests (e.g. blood cultures), timely recognition of drug-induced causes may avoid more invasive, costly or extensive interventions. In this article, we describe a patient who developed temperatures up to 40.3oC after initiation of dexmedetomidine, which completely resolved after discontinuation of the drug.