EVIDENCE-BASED NURSING

I. Clinical Question: Among clients with hyperthermia, is tepid sponge bath more effective the taking oral antipyretic drug to relieve fever? II. Citation:

External Cooling in the Management of Fever by Kasting NW. A rationale for centuries of therapeutic bloodletting: antipyretic therapy for febrile diseases. Perspect Biol Med 1990; 33:50916. Physically Cooling of Seriously Ill Febrile Patient by Bierman W. Therapeutic use of cold. JAMA 1955;157:118992. III. Summary: Physical cooling methods are clearly indicated for the treatment of hyperthermia, but their use for the treatment of fever remains controversial because of their propensity to induce cutaneous vasoconstriction, shivering, sympathetic activation, and, perhaps most importantly, discomfort. The ultimate value of external corporeal cooling for the treatment of fever will require randomized trials that use clinically meaningful illness outcome end points, rather than mere comparisons of rates of core temperature cooling. Administration of tepid sponging for fever has been practiced for years. Formally and informally, healthcare personnel have voiced opinion for and against the practice of tepid sponging and questioned its relative effectiveness compared to other methods. A number of studies have been done to compare the efficacy of these methods. Some of them had shown that tepid sponging with antipyretic drug is more effective than only antipyretic drug while others concluded that there was no difference in temperature reduction. We observed that administration of tepid sponging and antipyretic drug resulted in rapid temperature reduction in the initial 15-30 minutes as compared to antipyretic drug alone; however, by the end of 2 hours both groups had reached the same degree of temperature. There was no difference in ultimate reduction of temperature between the two groups. Children in the tepid sponging and antipyretic group had a higher level of discomfort than only antipyretic group, although the discomfort was only mild in most cases. These findings are supported by Sharber, but certain other studies did not find any significant difference, although they used different criteria for assessing discomfort. Based on findings and review of literature, we conclude that

apart from the initial rapid temperature reduction, addition of tepid sponging to antipyretic administration does not offer any advantage in ultimate reduction of temperature and may result in additional discomfort. Outcome: The report was submitted to the requesting doctor, who decided to continue recommending tepid sponging in combination with paracetamol treatment to reduce body temperature in febrile children. Methodology: Experimental IV. Findings One hundred and fifty children were studied, 73 in the tepid sponging and antipyretic drug group and 77 children in the only antipyretic drug group. The baseline characteristics are shown in Table I. Males outnumbered females in both the groups by an approximate ratio of 2:1. Majority of children in both the groups had respiratory diseases like upper respiratory tract infection, pneumonia etc. A higher number of children in both groups had their initial body temperature between 101 F 103 F.

TABLE I
Variable Baseline Characteristics of the Study Children Tepid sponging and Only antipyretic antipyretic drug drug group group (N=77) (N=73) n % n % 30 28 15 46 27 28 32 13 41.1 38.4 20.5 63.0 37.0 38.4 43.8 17.8 30 32 15 53 24 38 28 11 38.9 41.6 19.5 68.8 31.2 49.3 36.4 14.3

Age 6 months2 years 3 years 6 years 7 years 12 years Sex Male Female Initial body temperature 101F102F 102F103F 103F104F

The mean temperature of both groups at different time intervals is depicted in the graph (Fig.1). It shows a rapid reduction of temperature in the tepid sponging and antipyretic group at 15 minutes. Only antipyretic group had slow but sustained reduction in temperature.

Mean temperature of the Tepid sponging and antipyretic drug group and Only antipyretic drug group at different time intervals.

The comparative effectiveness of the two methods was assessed based on the analysis of covariance. The results indicate that there is a difference in mean temperature over time between the treatment methods after adjusting for the initial temperature as covariate. The analysis of covariance confirms the rapid reduction of temperature in the combined tepid sponging and antipyretic group as shown in Fig.1. However, by the end of 2 hours both groups had reached the same degree of temperature. There was no difference in ultimate reduction of temperature between the two groups. The level of discomfort was higher in tepid sponging and antipyretic group than only antipyretic group. It was compared by using a chi-square test and the result showed a statistically significant value (P<0.001). The discomfort in the tepid sponging group was mostly mild.

V. Conclusion:

Although physical methods of cooling are the treatment of choice for hyperthermia, their value in the treatment of fever remains uncertain. Methods involving convection and evaporation are more effective than those involving conduction for the treatment of hyperthermia.These same methods, combined with antipyretic medication, are preferable to immersion as treatment for fever in young children but are generally not practical in adults. Febrile children treated with tepidwater sponging plus antipyretic drugs are more uncomfortable that those treated with antipyretic drugs alone, although they exhibit slightly more rapid reductions in temperature. When febrile, seriously ill patients are externally cooled and are sedated or paralyzed with drugs that suppress shivering, they may have a more rapid reduction of fever and reduced energy expenditure than if treated with antipyretic drugs alone. A risk/benefit assessment of the consequences of such treatment is not yet possible. VI. Applicability: The study is not applicable in common setting because it might be very uncomfortable for the client. It may be very disturbing to the client given the fact that they are sick. VII. Commentary:

Apart from the initial rapid temperature reduction, addition of tepid sponging to antipyretic administration does not offer any advantage in ultimate reduction of temperature; it may result in additional discomfort