The HEAT Trial – The Skeptics Guide to Emergency Medicine

I got to sit down in person with Ken Milne this week while at the great SkiBEEM conference and talk about evidence based medicine. I know – life just can’t get much better. The episode of The Skeptics Guide to Emergency Medicine that we recorded about the HEAT trial was just released today. Make sure to check it out!

The episode is: SGEM#146: The HEAT is On – IV Acetaminophen for Fever in the ICU

 

I briefly covered the HEAT trial in the October 2015 edition of articles of the month:

Turning down the heat: can acetaminophen save lives?

HEAT trial: Young P, Saxena M, Bellomo R. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. The New England journal of medicine. 2015. PMID: 26436473 [free full text]

For some reason, people just love to hate on fever. It is present when people are sick, so it must be bad, right? We better rush to treat it. This is a randomized, double blind trial of 690 adult ICU patients with a fever and suspected infection, comparing acetaminophen 1 gram IV every 6 hours to placebo. Not surprisingly (unless you actually believed treating fever was helping patients) there was no difference in the primary outcome of ICU free days. There was also no difference in mortality at 28 or 90 days.

Bottom line: Tylenol is great, but it isn’t needed for febrile patients

 

Although this brief description is sufficient for spreading the word about new evidence, I think it is incredibly important to develop and in-depth understanding of the trials you use to shape your practice. The structured critical appraisal done on the SGEM is an amazing way to dissect this evidence and learn about EBM at the same time.

The most important question I get asked: how do I used this evidence? When just looking at the HEAT trial alone, I think the SGEM conclusion is appropriate: “We would agree with the authors’ conclusion that intravenous acetaminophen to treat fever in ICU patients thought to be due to an infection did not affect the number of ICU-free days.” However, this conclusion is pretty narrow. If you try to place this trial within the context of everything else we know about treating fever, I think it is safe to say that routinely treating infectious fever is unlikely to alter any clinically important outcomes. However, acetaminophen is safe and effectively manages symptoms, so it is very reasonable to use it for symptom control. (I certainly do.)

 

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

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